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Cardiology
Peripheral Vascular Angiography Step-Wise Approach to Detailed Diagnostic Imaging in Patient
Built from Cardiovascular Catheterization and Intervention: A Textbook of Coronary, Peripheral, and Structural Heart Disease
What’s inside
6 sections · 94 slides
General principles
- PAD = atherosclerosis of major non-coronary beds Aorta and aortic arch vessels involved Mesenteric and renal circulation involved Upper extremity and iliac segments involved Femoral, popliteal, tibio-plantar circulation Multilevel disease is the usual pattern
- Global prevalence of PAD rising Expected 15% rise in Western countries Expected 30% rise in developing countries Rise driven by accumulating comorbidities PAD carries higher morbidity and mortality
- Endovascular therapy now a front-line approach Adopted by vascular surgery, radiology, cardiology Bypass excellent in well-selected patients Many PAD patients unfit for surgical bypass Device and technique innovation drives growth
- Confirm clinical examination findings Confirm noninvasive physiological testing Define vessel patency at every level Pave the way for revascularisation planning Argued as the gold standard for patency
- Diabetes falsely elevates ankle-brachial index Normal ABI may mask significant arterial disease CT angiography limited in small-calibre vessels Severe tibial calcification degrades CT accuracy MR angiography avoided in advanced renal disease
- Digital subtraction superior to non-subtracted images Automated injectors preferred over hand injection ACIST system delivers contrast in closed circuit Operator controls volume, pressure and rise time Auto-detection of air is a built-in safety check
- Diabetes and CKD both raise PAD risk Contrast-induced nephropathy a major concern Typical diagnostic angiogram needs 150-200 cc Staged diagnosis then therapy limits total contrast CLI patients often have coexisting CKD
- CO2 is a nontoxic, compressible gas Long-established alternative contrast agent No contrast nephropathy and no allergic reaction Used for aorto-iliac and femoral segments Limited accuracy at popliteal level and below
- Carbon dioxide angiography of the aorta and superficial femoral artery
- Diluted contrast versus carbon dioxide below the knee
- Contrast-sparing angiographic protocol
- Multilevel, multivessel disease needs full assessment All interventions staged in the authors' practice Diagnostic-only study advised in carotid disease Diagnostic-only study advised in critical limb ischaemia CLI needs 1.9-2.4 procedures for full revascularisation
- US guidance lowers access complication rates US guidance improves puncture accuracy Evidence spans arterial and central venous access Author's view: US should be the gold standard Applies to any vascular conduit accessed
- Access outcome data in critical limb ischaemia
- Common catheters and wires used in peripheral angiography
Upper extremity arterial anatomy
- Inflow from right and left subclavian arteries Left subclavian is third arch vessel, direct origin Right subclavian from brachiocephalic bifurcation Arch vessel takeoff has multiple named patterns Aberrant right subclavian from aorta in under 1%
- Aortic arch angiogram showing the three great vessels
- Extends to lateral border of the first rib Three segments defined by scalenus anterior muscle First segment carries the important branches Branches: vertebral, internal mammary, thyrocervical Vertebral arises from proximal subclavian artery
- One vertebral artery is typically dominant Dominance may be right or left sided Left vertebral may arise directly from arch Direct arch origin occurs in under 5% Variant origin alters selective catheter choice
- Subclavian continues as axillary artery Axillary spans first rib to humeral head Beyond humeral head vessel is brachial artery Brachial once standard for left heart catheterisation Radial access has largely replaced brachial
- Selective right subclavian and axillary angiogram
- Brachial gives radial and ulnar arteries Bifurcation begins at the neck of the radius Ulnar bifurcates medially, usually the dominant vessel Ulnar gives interosseous artery, runs laterally Ulnar passes through pisiform region into the hand
- Selective right brachial angiogram with forearm bifurcation
- Radial and ulnar arteries with the profunda brachii branch
- Radial artery smaller, runs to radial styloid Ulnar artery supplies the deep palmar arch Radial artery supplies the superficial palmar arch Common digital arteries arise from both arches Digital vessels usually spared by atherosclerosis
- Palmar arch disease in end-stage renal disease
Upper extremity angiography technique
- Upper limb access reserved for planned intervention Diagnostic study performed from lower CFA access Common femoral access obtained under ultrasound Aortic arch angiogram is the first acquisition Operator must recognise all vessels and branches
- Digital subtraction eliminates bony interference Requires a still patient holding their breath Cardiac contraction still produces motion artefact Left anterior oblique 25-30 degrees recommended LAO view separates the great vessel origins
- Inject 15 cc per second for 2 seconds Total contrast volume 30 cc for the arch Use a closed catheter, for example a pigtail Maintain closed system for constant monitoring Preferred aortogram pressure 800-1,000 psi
- Better defines the true degree of disease Reduces total contrast volume required Allows arterial pressure measurement by segment Visual assessment overestimates intermediate lesions Haemodynamics give conclusive lesion significance
- Pressure gradient assessment across a stenosis
- Simple tip bends: Judkins Right, DAV, vertebral Complex arches need Simmons or Vitek catheters Injection volume ranges 6 to 12 cc Confirm an adequate pressure waveform first Wall injection risks dissection or perforation
- Ostial left subclavian is a common disease site Ostial lesions may progress to total occlusion Occluded subclavian reconstitutes via collaterals True occlusion length poorly defined from the arch Retrograde radial injection defines the distal cap
- Occluded ostial left subclavian artery on arch angiography
- Retrograde radial angiogram defining the distal occlusion cap
- Dual injection showing true chronic total occlusion length
- Radial and ulnar occlusion in end-stage renal disease
- Digital and hand ischaemia: two different problems
Lower extremity arterial anatomy
- Aorta bifurcates at third or fourth lumbar vertebra Divides into right and left common iliac arteries Suprarenal aortogram shows mesenteric and renal vessels Infrarenal position used for iliac imaging Selective renal or mesenteric runs only if indicated
- Suprarenal abdominal aortogram
- Common iliac passes anteriorly through the pelvis Divides into external and internal iliac arteries Internal iliac divides in two in most patients Supplies bladder, rectum, reproductive organs Occlusion causes gluteal claudication, impotence
- Internal iliac gives superior and inferior gluteal branches Gluteal branches are major collateral pathways Supply the ipsilateral limb in iliac occlusion Also cross-fill the contralateral limb Preserve internal iliac flow where possible
- Anteroposterior aortogram with overlapping iliac bifurcation
- Angled projection separating the internal iliac origin
- External iliac runs anteriorly through the pelvis Becomes common femoral at the inguinal ligament CFA divides into superficial femoral and profunda Bifurcation below mid femoral head in 98% Occasional bifurcation above the femoral head
- Common femoral bifurcation on angiography
- Aim for a compressible puncture site Avoid puncture above the inguinal ligament Inferior epigastric origin marks the ligament High puncture site is non-compressible Non-compressible puncture risks retroperitoneal bleed
- High sheath insertion into the external iliac artery
- Gives medial and lateral circumflex femoral branches Runs laterally, perforators to thigh muscles Described as the lifeline of the leg Main collateral supply when the SFA occludes Ostium diseased in CFA disease, body usually spared
- SFA supplies knee, leg and foot Becomes popliteal artery in the adductor canal Adductor canal junction most affected by atheroma Segment under constant stretch, torsion and twisting Most SFA occlusions reconstitute below this segment
- Chronic total occlusion of the superficial femoral artery
- Superficial femoral arteries coursing through the thigh muscles
- Infrapopliteal arterial branching
- Popliteal runs posterior to distal third of femur Then along posterior surface of tibial plateau Gives branches to the calf muscles Divides into anterior tibial and tibioperoneal trunk AT crosses interosseous membrane to front of leg
- Tibioperoneal trunk gives posterior tibial and peroneal Both descend in the posterior compartment Peroneal links to AT via anterior communicating artery Peroneal links to PT via posterior communicating artery Peroneal terminates above the ankle joint
- PT passes posterior to the medial malleolus Divides into medial and lateral plantar branches Gives medial calcaneal branch to medial heel Peroneal supplies lateral calcaneal branch All three tibials supply the calf muscles
- Tibial and plantar vessels with collateral filling
- Plantar branches of PT and DP form the pedal loop DP connects to lateral plantar via tarsal branch Metatarsal branches arise from the loop Digital branches to the toes arise from metatarsals Loop patency underlies forefoot wound healing
- Anteroposterior view of the pedal loop
- Lateral view of the pedal loop
Lower extremity angiography technique
- Retrograde common femoral access is preferred Allows navigation of difficult anatomy Most devices designed for retrograde CFA use Applies to catheters, balloons, stents, atherectomy Upper extremity access used in selected cases
- Catheter placed as distal as possible in target limb Selective imaging essential for treatment planning Authors compared duplex with both techniques Selective angiography correlated better with duplex Confirms what is commonly advocated in practice
- Fellows taught to image wire through the needle Confirms the true puncture site fluoroscopically Removes ambiguity about access level Ipsilateral 30 degree view, no cranial or caudal tilt Perform access site angiogram routinely
- Access wire through the needle on fluoroscopy
- Angiographic versus fluoroscopic assessment of antegrade access
- Antegrade access preferred in difficult aorto-iliac anatomy Also used after prior aorto-iliac bypass surgery Ultrasound guidance now the preferred strategy Author: US should be gold standard for any conduit US shows depth, calcium and adjacent vein
- Ultrasound-guided common femoral access in both directions
- Used frequently in advanced PAD and CLI Not advocated for purely diagnostic purposes If required, place a low-profile sheath Inject slowly, no more than 4-6 cc contrast Tibial injection is uncomfortable for the patient
- Retrograde tibial access revealing missed runoff
- Advance catheter to the suprarenal position Start with an anteroposterior projection LAO 20-30 degrees defines the renal ostia Catheters: pigtail, Omni Flush, Rim Closed catheter system preferred
- Total 30 cc of contrast per acquisition Rate 15 cc per second for 2 seconds Recommended pressure 800-1,000 psi Same positions apply to CO2 angiography Catheter pulled to infrarenal for iliac imaging
- Pull catheter to infrarenal position for iliacs Must separate internal from external iliac origin Contralateral projection at 20-25 degrees Add 15 degree caudal orientation Then image the proximal superficial femoral arteries
- Bolus chase and static acquisition compared
- Advance catheter into the limb in question Create a roadmap to advance over a wire Catheters: Omni, Rim, Judkins right, multipurpose Also NaviCross, Glide and TrailBlazer catheters Confirm waveform with any open-end catheter
- Fluoroscopic roadmap with the catheter engaged in the iliac artery
- Inject 12 cc at 6 cc per second for 2 seconds AP projection adequate for SFA and popliteal Ipsilateral 30 degree view for tibial vessels Lateral view identifies plantar circulation AP foot view uses 30-40 degree cranial angle
- Step-wise sequence of a diagnostic peripheral angiogram
Disease patterns and conclusions
- Common iliac disease tends to affect both ostia Both vessels often treated in the same setting SFA occlusion begins after the profunda takeoff Reconstitution at proximal popliteal artery Reconstitution follows the adductor canal segment
- Tibial disease patterns vary considerably Peroneal artery usually remains patent Peroneal feeds distal AT and PT via communicators AT usually occludes after its takeoff Occludes again after crossing the interosseous membrane
- Anterior tibial occlusion and the mimicking collateral
- Desert foot: no flow within the plantar vessels DVA directs arterial flow into plantar veins Veins and venules become the delivery conduit Gaining acceptance in advanced critical limb ischaemia Achieves healing and salvage in many CLI patients
- Venous pedal loop after deep vein arterialisation
- Angiography defines anatomy and disease level Remains the gold standard for peripheral assessment Findings must be read with the clinical presentation A uniform protocol ensures consistent image quality Alternative access can change the therapeutic plan
- References
- References (continued)
- References (continued)
- Cardiovascular Catheterization and Intervention: A Textbook of Coronary, Peripheral, and Structural Heart Disease
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