Interventional radiography Flashcards
1
Q
What is this describing?
General term referring to radiologic examination of vascular structures after the introduction of a contrast medium
A
Angiography
2
Q
What is Arteriography?
A
Imaging of the arteries
3
Q
What is Venography?
A
Imaging of the veins
4
Q
Who are the people present on the angiography team?
A
-Interventional Radiologist
-Scrub Technologist, Nurse, or Certified Surgical Technologist (CST)
-Circulating Technologist
5
Q
What are the technologists’ responsibilities in angiography?
A
-Equipment Operation
-Inventory Management
-Patient Prep
-Scrub Tech!!
-Circulating Tech!!
-Documentation
-Sterile Tray Preparation
-Adding catheters and wires to tray as requested
6
Q
What equipment is present in an angiography suite?
A
1.Digital Flouro (Single or Biplane)
2.Anaesthesia Equipment (O2, Blood Pressure, HR, ECG)
3.Monitor: Over sedation, Hemorrhage, Anaphylaxis
4.Ultrasound
5.Infusion Devices – IVAC pump or IV poles (heparinized saline)
6.Power Injector
7
Q
Why do we have a kettle in the angiography suite?
A
Have to shave catheter and will have to put it under the steam
8
Q
What are the 2 types of digital fluoro equipment?
A
- Single Plane
- Biplane Fluoro
9
Q
T/F
Most angio suites have single plane flouro equipment
A
True
10
Q
What type of detector does a single plane flouro machine have?
A
Flat panel detector
11
Q
What are the advantages of using Biplane Fluoro?
A
-Acquire AP and lateral images simultaneously
-Safer for patient because less contrast needed
-Doesn’t save dose but saves time
-Multiple runs with just one contrast injection-Better for the kidneys
12
Q
What type of flouro machine do most neuro suites have?
A
Bi-plane flouro machines
13
Q
How long is a single plane flouro machine?
A
16”
14
Q
T/F
A single plane flouro machine has everything other than the head.
A
True
15
Q
T/F
A single plane flouro machine can go around 360 degrees
A
True
16
Q
What machine is this showing?
A
An automatic injector
-Has to be primed
A: 100% contrast
B: Why is there two?: Cannot use 100% so we can mix the contrast
-i.e. half contrast half saline
17
Q
Most Diagnostic Angiography has been replaced with what?
A
CTA
-An example is a GI bleed
18
Q
How does CTA and angiography work together? (don’t memorize, just understand)
A
Once the pathology has been found using CTA, the patient is brought to the angio suite for intervention (embolization to stop the bleed)
19
Q
What are the benefits of interventional angiography?
A
-Less expensive than traditional surgical procedures
-Less invasive than traditional surgical procedures
-Shorter hospital stays
-Shorter recovery time
-Alternative for nonsurgical candidates
20
Q
What are the indications for interventional angiography?
A
-Identify anatomy (anomalies) or pathology of the blood vessels
-Stenosis
-Occlusion
-Aneurysm
-AVM = Arterial Venous Malformation
-Bleeds
-Tumours
21
Q
What is stenosis?
A
narrowing of a vessel; usually due to atherosclerosis
22
Q
What is an occlusion?
A
blockage of a vessel; often caused by atherosclerosis
23
Q
Why is Right renal stenosis more common?
A
More common because it is longer
24
Q
What are the treatments for tumours within the vessels?
A
- Chemoembolization
- Pre-op surgical removal of tumour
25
What is Chemoembolization?
Catheter right to a tumour filled with chemo
26
What equipment is needed for sugeries of the cerebrovascular system?
Needles
Sheaths
Wires
Catheters
Dilators
27
# T/F
The smaller the gauge, the bigger the needle
True
28
What percentage of an inch is an 18g needle?
18g = 1/18 of an inch
29
For vascular structures, what gauge is used?
18-19g typically
30
What needle method is used for venous access?
Single wall for venous access
31
What needle method is used for arterial access?
Double walled for arterial access (inner stylet)
32
What is a Micro puncture?
A 21 gauge or less needle injected which reduces the vessel trauma
33
What are the types of non vascular needles:
Chiba
Spinal needle
Biopsy
34
Describe a chiba needle:
Thin walled with inner stylet
35
What is the gauge used for a chiba needle?
18-25g
36
How long is a chiba needle?
10-20 cm long
37
Describe a Spinal Needle:
Thicker wall and smaller inner lumen
38
Describe a Biopsy needle:
Has a loaded gun, increased capability of cutting
39
How many millimeters are the sheath's inner diameter of a biopsy needle?
0.33 mm=1 FR (inner diameter)
40
When are sheaths used?
Used when multiple catheter exchanges are expected to protect the tissue and clot formation
41
What is the size of a sheath determined by?
Determined by the inner diameter (5 French sheath is used with a 5 French catheter)
42
How long is a sheath in cm?
10-90 cm in length
43
What is the purpose of the backbleed valve in a sheath?
To prevent blood loss during catheter or wire manipulation
44
What is used in the back bleed to prevent clot formation?
Herborized saline in the back bleed valve-to prevent clots
45
How many drips per minute of saline is given into the back bleed?
15-20 drips per minute
46
What structure is positioned before the catheter is inserted? Why?
Guide wire positioned first-reduces possibility of complications
47
What structure is inserted over the guide wire?
Catheter inserted over guidewire
48
How long should the guide wire be?
Should be at least 10 cm longer than catheter for exchanges
49
What are the three types of guide wires?
-Steerable
-non-steerable
-hydrophilic (slippery)
50
How do you know you are in the femoral artery?
If the blood is spurting out quickly (pulsatile)
51
How do we get the J wire to go through the guide wire?
Push the blue to the tip and it straightens the J
52
Once you are in right femoral artery, what happens when the J wire gets through the needle?
It becomes a J again and will bounce off the wall and not puncture
53
What happens if the straight needle goes through the femoral wall?
Creates a dissection
54
What are the four Puncture methods into the femoral artery?
1.Seldinger (Percutaneous)
2.Modified Seldinger
3.Cut Down Method
4.Translumbar
55
What puncture method is used currently?
Modified seldinger
56
When is the cut down method used?
Used by vascular surgeons for the abdomen aneurysm-EVARs (endovascular aneurysm repair)
## Footnote
Should not see this method unless you are in the OR
57
# T/F
The translumbar method is not commonly done
True
58
Describe the Seldinger Technique
1.Vertical needle and puncture through both the anterior and posterior wall of the femoral artery
2.Pull back until they get blood squirting out
59
# T/F
The Femoral artery or vein can be used with the Modified Seldinger Technique
True
(Easily palpated and accessible. Relatively large and compressible-femoral head below puncture site)
60
What type of approach is most common when using the Modified Seldinger Technique?
Retrograde approach most common for artery
61
Where is the femoral vein located in relation to the femoral artery?
Femoral vein is 0.5 cm medial to the femoral artery
62
Where do you palpate for the femoral vein and artery?
Both are found by palpating at the crease of the hip
63
What artery is becoming the norm for cardiac catheterization?
Radial artery
64
What happens if you let go of the guide wire with the femoral artery?
It pushes back out
65
What happens if you let go of the guide wire with the femoral vein?
It goes to the right side of the heart and is pulled inwards
66
Watch the following video:
https://www.youtube.com/watch?v=LChKL2E95jE
67
**Describe the Procedure for the Modified Seldinger technique**:
1.Groin is prepped and draped
2.Modified Seldinger technique with needle (puncture femoral artery)
3.Stylet of the needle is removed
4.J-wire is pushed through needle into vessel-Wipe the wire
5.Needle pulled out leaving wire in vessel
6.Sheath inserted over wire to protect vessel during multiple catheter exchanges
7.Sheath connected to heparinized saline
8.J-wire removed and replaced with specific wire to get into desired structure or leave that one in
9.Catheter placed over wire
10.Wire removed
11.Injection performed of vessel
68
Who preps the patient's groin in a modified Seldinger technique?
Done by the dirty tech
69
Who preforms the iodine and chlorohexidine rub in a modified Seldinger technique?
Clean tech
70
What degree of insertion is the needle at for a modified seldinger technique?
–Needle on 45 degree angle
71
# T/F
The J wire should be able to flow free inside a good distance initially.
True
72
What modality is used for the modified seldinger?
Ultrasound guidance with the Modified Seldinger
73
What room preparation is done prior to the patient's arrival for an interventional proceedure?
1.Enter patient demographics
2.Check crash cart supplies / O2 and suction
3.Set exposure technique
4.Load injector if needed
5.Obtain and setup sterile procedure tray /catheters, guidewires, and sheath
74
What is the patient prep starting the night prior for an interventional procedure?
NPO
75
What is the patient prep prior to an interventional procedure?
1.History taken
2.Procedure explained in detail
3.Consent signed with knowledge of risks
4.Patient connected to ECG, O2, SAT
5.Shave groin area before prepping skin
6.Iodine and Chlorhexidine wash
7.Drape patient and equipment
8.CLEAN TECH > scrub in, prep & drape site
9.DIRTY TECH > ready to image / assist as needed (get supplies)
76
What history needs to be taken from the patient prior to an interventional procedure?
Meds, allergies, renal function, clotting Creatinine, INR(international normalized ratio), PTT (Partial thromboplastin time)
77
# T/F
In an interventional procedure, we may image all phases (arterial, capillary, venous)
True
78
What phase; arterial or venous phase, requires a faster frame rate?
Arterial phase requires faster frame rate
79
How long is the frame rate for an arterial phase in cerebral imaging?
Typically requires 7-10 seconds for cerebral imaging (mask before contrast + all 3 phases)
80
What are the branches that come off the aortic arch?
BCT, then LCC then L SC
81
What are the complications of angiography in interventional radiography?
1.Infection at site
2.Anaphylactic Shock
3.Dissection of vessel
4.Hemorrhage
5.Thrombus
6.Contrast Induced Nephropathy (CIN)
7.DEATH !!
82
What is a dissection of a vessel?
–False aneurysm-blood runs through the wall of the vessel instead of the center
–Could cause death
83
# T/F
Vasospasm increases transit time in angiography
True
84
# T/F
AVM increases transit time in angiography.
False; AVM decreases transit time in angiography
85
# T/F. Why or why not?
Imaging starts prior to contrast injection in angiography.
True; so that mask can be applied for DSA
86
What is the Transit time?
Time it takes to get from arterial to venous circulation
87
**What is the procedure for post angiogram-Femoral access?**
1.Pressure on site (min 20 minutes for femoral art.)
2.Check for pedal pulses
3. PACU or day surgery
4.Lie flat at least 4 hours to ensure clot/seal
5.Vascular closure devices
88
Why we check pedal pulse after a femoral artery procedure?
To make sure the vessel is not compromised
89
# T/F
If you don’t compress the femoral artery properly it can bruise and take longer
True
90
How do you demonstrate the aortic arch?
-45° LAO or RPO
-C-arm obliqued rather than patient
91
What is the top left phase showing?
Phase 1: Arterial phase
92
What is the top right phase showing?
Phase 2: Capillary phase
93
How long is the exposure for an angiogram?
Exposure for 7-10 seconds
94
What is the bottom left phase showing?
Phase 3: Venous stage
95
What intracrainial pathologies does Cerebral Angiography investigate?
Aneurysms
Vasospasm
AVMs
Tumours
Stenosis / occlusion
96
What arteries are being shown here?
The anterior and middle cerebral arteries
97
What view is shown here?
AP/PA (Ruggles) for the anterior circulation of the brain
98
How do you demonstrate the right anterior circulation following injection into the internal carotid?
Do the 3 views (Ruggles, lateral, modified oblique Caldwell) specifically in RAO
99
What projection is this?
AP oblique RAO modified Caldwell
100
What side is this demonstrating?
Demonstrating the right side
101
Describe the pathway of blood through the Right Anterior Circulation to the brain starting with the femoral artery:
1. Femoral Artery
2. External iliac artery
3. Common iliac artery
4. Abdominal aorta
5. Thoracic aorta
6. Aortic arch
7. Brachiocephalic trunk
8. Right common carotid artery
9. Right internal carotid artery
102
Describe the pathway of blood through the Left Anterior Circulation to the brain starting with the femoral artery:
1. Femoral Artery
2. External Iliac Artery
3. Common Iliac Artery
4. Abdominal Aorta
5. Thoracic Aorta
6. Aortic Arch
7. Left common carotid
8. Left internal carotid artery
103
What views have been done here? What are we imaging?
-AP and lateral
-Imaging the posterior circulation of the brain
104
Looking the post circulation, the petrous ridges appear at the top of the orbits. What would you do?
Use more angle on the C arm to be able to project them (increase that angle)-Caudad
| Need the petrous ridges higher than the orbits
105
What is the Route to get to RT Vertebral Artery starting at the femoral artery?
1. Femoral Artery
2. External Iliac Artery
3. Common Iliac Artery
4. Abdominal Aorta
5. Thoracic Aorta
6. Aortic Arch
7. BCT
8. Right subclavian artery
9. Right vertebral artery
106
What is the Route to get to LT Vertebral Artery starting at the femoral artery?
1. Femoral Artery
2. External Iliac Artery
3. Common Iliac Artery
4. Abdominal Aorta
5. Thoracic Aorta
6. Aortic Arch
7. Left subclavian artery
8. Left vertebral artery
107
If checking out the posterior circulation use CTA, what artery would they inject into; The right or the left? When would they inject into the opposite artery?
-The left
-If something was blocking the left side they would use the right
108
What tunk vessels supply blood to the brain?
1.Rt an Lt common carotid (2)
2.Rt and Lt vertebral arteries?
109
When do the common carotid arteries branch into internal and external carotid artery?
At C4
110
Where does the Internal carotid enter the skull through?
Through the carotid foramen
111
Where does the internal carotid artery exit?
Exits near the foramen lacerum right near the circle of willis
112
What vessels supply the anterior and middle circulation of the brain?
-Rt and Lt vertebral arteries
113
What do the vertebral arteries travel through?
Travel superiorly through transverse foramen of C-spine
114
What structure do the vertebral arteries enter through?
Enter skull through foramen magnum
115
What do the Internal Carotid arteries bifurcate into?
The anterior & Middle Cerebral
116
What do the anterior and middle cerebral arteries supply blood to?
Arteries supplying their respective hemisphere
117
What views are does in cerebral angiography to image the Anterior Circulation?
1.AP/PA (Ruggles)
2.Lateral
3.AP/PA axial oblique (modified Caldwell)
118
How do you demonstrate the anterior right arteries of the brain?
RAO demonstrates the right side (with the tube under the table)
119
What do the Vertebral Arteries unite to form?
The basilar artery
120
What do the Basal Arteries bifurcate into?
The RT & LT Posterior Cerebral Arteries
121
What arteries supply the posterior aspect of the brain?
The Rt and Lt posterior cerebral arteries
122
What views are done to image the posterior circulation of the brain
1.AP/PA – more caudad angle to project the supraorbital margin ¾” below the petrous ridges
2.Lateral
123
List all the ways the Circle of Willis protects the patient from having a stroke:
1.Anterior communicating artery-Provides a right to left shunt (or left to right side)
2.Posterior communicating artery-Provides a front to back shunt (or posterior to anterior)
3.Vertebral arteries combine to form 1 basilar artery
124
What is shown here?
Post-op Aneurysm Repair
125
What treatment is shown here?
Aneurysm coiling
126
What is done now days for prevention of aneurysm rupture?
Aneurysm coiling
127
How does aneurysm coiling work?
| Don't memorize-just understand
-Have to get a catheter right up into the aneurysm
-Push a coil in and burn it to detach it from the end of a wire, and then do another one
-Coil has a coating which swells up and forms a clot which prevents blood from going in there. This prevents blood from entering and eventually rupturing.
128
What treatment is shown here?
1-Pre-embolization
2.Post-embolization
129
What do they do to stop the active bleed?
Coiled it so that no blood could come through
130
Read over the following Embolization Agents
## Footnote
Don’t need to know this for the exam, just understand and read over it. Understand the term embolization and what it is used for.
-Liquid agents
-Glue (Onyx)
-Ethanol
-Detachable metal coils
-Particulate agents
-Gelfoam-It is temporary
-Detachable balloons
131
What proceedure has been done here?
Percutaneous Transluminal Angioplasty
132
What vessel is the balloon in?
Left coronary artery
133
What symptoms would this patient be experiencing?
Angina-specific pain associated with coronary vessels
134
What do they call angina in the legs?
Claudication
135
When is Aneurysm Clipping done?
-Before Interventional radiography
136
If the skull flap is removed with aneurysm clipping, where can it be placed until full recovery?
It can be placed into the subcutaneous tissues of the abdomen and re-attached to skull at a later date
137
# T/F
Aneurysm clippings require long hospital stays
True
138
Where is Aneurysm Coiling performed?
Performed with IR
139
How long is the stay in the hospital with aneurysm coiling?
Stay in hospital for 1 night
140
What is the alternative for aneurysm clipping?
Aneurysm coiling
141
Watch the following video on aneurysm coiling
http://www.youtube.com/watch?v=1vvqoxK4oIk
142
What is the purpose of Embolization?
1.To stop active bleeding
2.To control blood flow to diseased or malformed vessels (tumours or AVMs)
3.Stop or reduce blood flow to an area prior to surgical resection
143
What type of treatment is done for AVM’s or Tumours? How does this work?
-Embolization
-Occlude the blood flow to a specific pathology
144
What can stenotic vessels cause?
TIA’s or Mini strokes if stenotic vessels in brain or neck
or strokes
145
What treatments are done to increase flow in these in vessels diseased from stenosis?
PTA (Percutaneous Transluminal Angioplasty)
146
What is another name for PTA (Percutaneous Transluminal Angioplasty)?
Often called balloon angioplasty
147
How does PTA (Percutaneous Transluminal Angioplasty) treat stenotic vessels?
Balloon inflated with diluted contrast for 15 to 45 seconds (site and pathology dependent)
148
What type of lesions can balloon angioplasty be performed on
Lesions less than 10 cm
149
What vessels can balloon angioplasty be performed on?
Cardiac, renal, peripheral vessels
150
What is the drawback from balloon angioplasty?
Drawback – may be temporary
151
Describe the procedure of balloon angioplasty step by step:
1.Guidewire is passed through stenosis
2.Catheters are placed over the wire until the balloon part is in the stenotic area
3.Wire is removed
4.Balloons are inflated
5.Process may be repeated until the results are satisfactory
152
How do you know where the balloon is on the catheter with balloon angioplasty?
Radiopaque markers on either end of the balloon
153
What is shown here?
Stents
154
Where is this stent?
Internal carotid artery
155
Label 1-5
156
When would someone experience stable angina?
When they are moving
157
When would someone experience unstable angina?
All the time
158
What would they do if they kept experiencing angina?
Put a stent in
159
If PTA was temporary what would be done?
Could consider stents
160
How do stents work?
Once in place, balloon is used to “inflate” the stent
161
What is Thrombolysis?
-Chemical treatment for breakdown (lysis) of blood clots
162
What does Thrombolysis treat?
-PE, Myocardial Infarction, CVA or Stroke
163
What is the purpose of Anticoagulants such as Coumadin or heparin?
Reduces the growth of the clot
164
What are the thrombolytics used for clot busting? (list them)
-TPA (Tissue Plasminogen Activator)
-Streptokinase
-Urokinase
165
Where do the coronary arteries supply blood to?
The myocardium of heart
166
What are the very first things that come off the ascending aorta?
The coronary arteries
167
What modality is required for imaging of the coronary arteries?
Cinefluoroscopy is required
168
What is the frame rate of cinefluoroscopy?
30 – 60 rates/sec
169
Why would we do a venous puncture?
When looking for a pulmonary embolism to get to the pulmonary arteries
170
What is the highest dose seen in angiography?
Cardiac imaging
171
Where does the arterial puncture take place for the Left Heart or Coronary Arteries prior to catheter insertion?
Radial, Brachial or Femoral artery puncture
172
Where does the puncture take place for the right Heart or Pulmonary arteries prior to catheter insertion?
Venous puncture
–Radial
–Brachial
–Axillary
–Jugular
–Subclavian
–Femoral
173
# T/F
With catheter insertion both diagnostic and therapeutic treatment may be done in a single procedure
True
174
Watch the following video on catheters:
http://youtu.be/N7nghr9TpSU
175
What is the most common puncture site for coronary arteries?
-Using the radial artery a lot now
176
What anatomy is this showing?
left coronary
177
What anatomy is this showing?
Right coronary artery
178
What modailty is this showing
Abdominal Aortography
179
If the surgeons are trying to get into the Celiac trunk, SMA or IMA, what would you do to position with the tube?
Turn the C-arm to the lateral position (because vessels come off the anterior part of the aorta)
180
What modality is done to image the abdominal aorta?
Flush Arteriogram
“Map” of vessels
For localization
181
What does the common hepatic artery become?
-The hepatic artery proper
182
Where does the hepatic artery branch to?
Goes directly to the liver and the gastroduodenal artery
183
What does the gastroduodenal artery supply blood to?
Supplies the superior part of the duodenum with oxygenated blood
184
What is the First main branch of the abdominal aorta?
The celiac trunk
185
What does the celiac trunk bifricate into?
Left Gastric A., Splenic A., and Common Hepatic A.
186
What does the SMA supply blood to?
Supplies blood to small bowel, and cecum to splenic flexure
187
What percentage of blood to the liver is supplied by the haptic artery proper?
30%
188
Where does Renovascular hypertension occur? What is done to treat it?
-In the renal arteries
-PTA or balloon
angioplasty
189
Where does the IMA supply blood to?
Descending colon to proximal rectum
190
What is the first branch off the IMA?
Superior rectal artery is
branch of IMA
191
What is done to treat an Abdominal aneurysm?
EVAR (EndoVascular Aneurysm Repair)
192
When is EVAR done?
When Aneurysms are greater than 5 cm
193
Watch the following video on EVAR
http://youtu.be/qUpXJBoAoWI
194
# T/F
EVAR is Individualized to the patient
True
195
What is the advantage of using uncovered stent?
Less risk of stent migration (When they put it in it stays there)
196
What is the Disadvantage of using an uncovered stent
Stenosis within the stent from the tissue coming through
197
What type of stent needs to be put in for an abdominal aneurysm?
A covered stent
Blood has to be able to get through the renal arteries.
198
Why would the femoral arteries have to be repaired after EVAR?
They are using the cut down method
199
Why is it that prior to hip and knee replacement surgery, they will proactively put in an IVC filter?
Because there is a long period of time where they will not be walking and are more prone to DVT
200
What prevents DVT?
-Walking, blood thinners
201
What is the purpose of IVC filters?
They trap potentially fatal emboli from deep vein thrombosis from lower extremities when blood thinners are contraindicated
-Prevents PE
202
Where is an IVC filter inserted through?
The femoral vein
203
What IV proceedure is used for End-stage liver disease – cirrhosis?
TIPS-Transjugular Intrahepatic Portosystemic Shunt
204
What causes varices in the vessels from end stage liver disease?
An increase in portal hypertension causes blood to flow through collateral vessels leading to varices in these vessels
205
What shunt is created with TIPS?
Shunt between portal vein and hepatic vein
206
What pathologies benefit the most from a TIPS procedure?
Esophageal variceal bleeds and ascites
207
Watch the following videos:
-http://youtu.be/LovvJiLJ7Gw
-http://www.youtube.com/watch?v=O2u4_hF3234
208
What percentage of the blood to the liver is supplied by the portal vein?
70% of the blood to the liver is supplied by portal vein
209
How is a berry aneurysm in the brain treated?
-Coils are packed into the aneurysm
210
How is an AVM, bleed, or tumour treated?
-Embolization
211
What is frequently the cause of angina?
-Stenotic coronary arteries
212
What treatment options are available to treat stenotic vessels?
-Balloon angioplasty
-Stents
-CABG, using the great saphenous vein or the internal thoracic or mammary artery
213
A patient presents with persistent stenosis/occlusion even after balloon angioplasty. What other interventional procedure may help?
-Stent placement
