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Carotid Angiography: Information Quality and Safety

Carotid Angiography: Information Quality and Safety. Michael J. Cowley, M.D., FSCAI. Carotid Angiography. Essential Cognitive Knowledge. Indications and contraindications Non-invasive methods of vascular evaluation and their utility/appropriateness Potential complications & management

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Carotid Angiography: Information Quality and Safety

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  1. Carotid Angiography: Information Quality and Safety Michael J. Cowley, M.D., FSCAI

  2. Carotid Angiography Essential Cognitive Knowledge Indications and contraindications Non-invasive methods of vascular evaluation and their utility/appropriateness Potential complications & management Ability to assess risk / benefit

  3. Essential Cognitive Knowledge Carotid Angiography • Cerebrovascular pathology: • Atherosclerosis • - Typical disease states and appearance • Unusual forms of disease • Aneurysms • AVM’s • Bleed • Tumor

  4. Vascular Access Arch Angiography Selective angiography: Extracranial vessels Intracranial vessels Carotid Angiography Technique

  5. Vascular Access Arch Angiography Selective angiography: Extracranial vessels Intracranial vessels Carotid Angiography Technique

  6. Femoral approach whenever possible Better angle of entry to arch vessels Allows forming of complex curve catheters Brachial access is possible but: requires more advanced skills higher complication rates Catheter Access

  7. Access Arch Angiography Selective angiography: Extracranial vessels Intracranial vessels Carotid Angiography Technique

  8. To evaluate access to great vessels Identify Type of arch Identlfy ; anatomic variants (anomalies) 5 or 6F Pigtail catheter 30-40 degree LAO view Field of view: origin of great vessels extending to the carotid bifurcation Patient’s head should be straight with chin turned upward Hand or power injection 15-20 ml/sec for 2 seconds Aortic Arch Angiography

  9. Conventional Arch Courtesy of Mark Burket, M.D.

  10. Aortic Arch Angiography Anatomic Features 65-70%: Usual pattern 20-25%: Bovine arch (Left CCA from brachiocephalic) 3%: Separate origin of left vertebral 5%: Various patterns, including right subclavian from distal arch

  11. It’s Not Just The Arch That Gets Longer! Tortuous Right Common Carotid LEFT

  12. Aortic Arch Types

  13. Access Arch Angiography Selective angiography: Extracranial vessels Intracranial vessels Carotid Angiography Technique

  14. Ipsilateral oblique and lateral views (additional views may be necessary) Contralateral carotid (Circle of Willis, collaterals, etc) 5 or 6 F with appropriate curve Intracranial angiography also important Carotid Angiography

  15. Carotid Angiography Key Information for Carotid Stenting

  16. Simple Curve Catheters Have only a primary (distal) curve Do not need to be formed May not be adequate in tortuous anatomy Complex Curve Catheters Have a primary and secondary curve Must be formed Often will not track over standard wires Catheter Shapes

  17. Simple Curved Catheters ‘Coronary catheters’ IMAModified AR1 JR 4 Consider using dedicated catheters!!!

  18. First choice for most selective angiography Wide variety of catheters available, chose one and perfect its use Glide catheters provide improved tracking over softer wires Chose a catheter that will be less traumatic and still allow selection of the arch vessels Primary Curve Catheters

  19. H1 or Vertebral Artery Catheter These catheters work well for flat aortic arches

  20. Complex Curved Catheters Simmons 1, 2, and 3 curves VTK

  21. Simmons Catheter:A Closer Look • Ideal for Type II-III arch • Technique Tip: Re-shape in subclavian artery with an exchange wire to avoid arch manipulations

  22. Selective Catheter Choice Vitek, Simmons 1,2,3 Catheters

  23. Allow for access proximally displaced vessels (Type 2 & 3 Arch or bovine arch Can be formed by placing the primary curve in the left subclavian artery and advancing the secondary curve toward the ascending aorta Avoid forming in the ascending aorta whenever possible Do not track well over most wires May require exchange length wires to change to a simple curve catheter after access is obtained Complex Curve Catheters

  24. Engaging a Simmons II Catheter

  25. Dx catheter engages innominate and road map of carotid bifurcation done Stiff angled 0.035’ guide wire advanced into distal CCA or ECA under roadmap guidance Catheter advanced over guidewire into CCA Guidewire removed Angio performed in ipsilateral oblique and lateral views (and other views if necessary) Carotid Angiography Right Common Carotid Artery

  26. Carotid Angiography Views Extracranial: - Ipsilateral oblique - Lateral - AP Intracranial: - AP cranial (Townes view) - Lateral - Ipsilateral oblique, caudal

  27. Pass angled guidewire into CCA using road map image Avoid advancing wire across diseased segment Fix wire and advance catheter over wire Position catheter tip in porox 1/3 of CCA Remove wire slowly from catheter Right Carotid Artery

  28. Using roadmap, retract catheter from Asc Aorta with clockwise rotation Position catheter close to origin of L CCA and turn counter- clockwise to engage CCA Pass angled guidewire into CCA using road map image; avoid advancing across diseased segment Fix wire and advance catheter over wire Position catheter tip in porox 1/3 of CCA Remove wire slowly from catheter Carotid Angiography Left Carotid Artery

  29. Dx catheter engages innominate and road map of carotid bifurcation done Stiff angled 0.035’ guide wire advanced into distal CCA or ECA under roadmap guidance Catheter advanced over guidewire into CCA Guidewire removed Carotid Angiography Right Common Carotid Artery

  30. Anterior cerebral circulation viewed by PA cranial (15-20 degrees) and lateral views Important to visualize both arterial and venous phases: - Intracerebral disease - Collateral circulation - Presence of AVM, aneurysm, isolated hemisphere - Missing arterial phase vessels (allows identification of embolization post CAS) Intracerebral Angiography

  31. Non-ionic contrast preferred Minimize contrast volume used Use lower risk catheter curves when possible Minimize catheter manipulations Carotid Angiography Avoiding Complications

  32. AvoidExcessive catheter manipulation

  33. Severe Atheroma of the Aorta

  34. Clinical status: Symptomatic vs Asx Technical challenges: - Duration of catheter dwell time - Number of catheter exchanges - Contrast volume, fluoro time High risk anatomic features (not high risk clinical features) Carotid Access Issues Complications Complication Risk determined primarily by case selection

  35. High quality baseline angiography is essential for optimal carotid stenting Understanding necessary elements and anatomic variations assures quality imaging Intracranial and extracranial angiography is essential for pre and post intervention Proper catheter selection and careful technique insures safest possible angiography Carotid Angiography Summary

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