Interventional Radiology Flashcards
Femoral arterial access technique
The common femoral artery begins inferior to the inguinal ligament. From lateral to medial, the mnemonic NAVL helps to localize the femoral nerve, artery, vein, and lymphatics.
The ideal position to acces the femoral artery is the inferomedial margin of the femoral head, for two reasons. First, the femoral head provides a hard surface to press against to provide adequate hemostasis. Second, at the level of the femoral head, the femoral artery and nerve are side by side. If arterial puncture is performed too low, the femoral vein may be traversed with possible formation of arteriovenous fistula.
Hematoma
A hematoma may be superficial or retroperitoneal. A superficial subcutaenous hematoma has a generally benign clinical course, while a retroperitoneal hematoma carries a risk of fatal hemorrhage.
There is increased risk of retroperitoneal hematoma with a high (more cranial) arterial puncture above the pelvic brim.
Pseudoaneurysm
Pseudoaneurysm formation occurs in approximately 1% of arterial punctures. On color Doppler, a pseudoaneurysm appears as a swirling yin-yang with high-velocity flow at the site of communication with the femoral artery.
Watchful waiting can be performed for a small pseudoaneurysm <1 cm in size. Ultrasound-guided thrombin injection is the treatment of choice for a pseudoaneurysm >1 cm. Less commonly, ultrasound-guided compression of the neck of the pseudoaneurysm can be performed to thrombose the pseudoaneurysm.
Arteriovenous fistula (AVF)
An arteriovenous fistula (AVF) is an anomalous connection between an artery and a vein. AVFs are usually asymptomatic but may enlarge and ultimately cause high-output cardiac failure.
There is increased risk of developing an iatrogenic AVF with a low (inferior/distal) femoral arterial puncture. The femoral vein often passes deep to (instead of medial to) the femoral artery distal to the standard puncture site.
On Doppler ultrasound, an AVF demonstrates arterial flow within a vein and there is loss of normal triphasic waveform in the artery. Increased diastolic flow is often seen in the artery proximal to the fistula.
Air embolism
Air embolism is a rare but potentially life-threatening complication of vascular procedures.
The most dangerious portion of a venous access procedure is the insertion of the catheter into the peel-away sheath.
If air embolism is suspected (e.g., if the patient becomes acutely hypoxic as the catheter is inserted intot he peel-away sheath), the patient should be immediately placed in the left lateral decubitus (left side down) so that the air bubble remains antidependent in the right heart. 100% oxygen should be administered. If practial, fluoroscopy can be used to identify the air bubble. Catheter aspiration can be considered if the air bubble is large.
Injection rates
The terminology for injection rates for angiographic runs is “cc/sec for total cc”. For instance “25 for 50” means an injection rate of 25 cc/sec for a total of 50 cc.
The diameter in mm of a vessel is a rough guide to the injection rate (in cc/sec), and the total volume of cotnrast injection depends on the intravascular volume of the vascular bed.
Aortogram (aortic arch): 20 for 30.
Abdominal aorta: 20 for 20.
Inferior vena cavogram: 20 for 30.
Mesenteric artery 5 for 25.
Renal artery 5 for 15.
Distal artery: 3 for 12.
Percutaneous transluminal angioplasty (PTA)
Percutaneous transluminal angioplasty (PTA) is the first-line technique for treatment of a stenosis, where a balloon is inflated across the stenosis to create a controlled stretch injury adn increase the luminal cross-sectional area.
When treating a stenosis caused by atherosclerotic plaque, angioplasty widens the luminal diameter due to disruption of the intima and extension of the plaque into the media.
Most balloons are non-compliant. That is, they have a fixed diameter that does not expand no matter the air pressure. If a non-compliant balloon is inflated above its rated maximum pressure, the balloon will burst.
In general, a balloon should be selected that is 10-20% larger than the vessel diameter.
Balloons are sized by diameter in millimeters and lenght in centimeters. For instance a 10 x 6 balloon is 10 mm in diameter and 6 cm in length.
Risks of angioplasty include distal emboli, vessel rupture, and dissection. Anticoagulation (typically heparin) should always be used with angioplasty.
Stents
The two broad categories of stents are balloon-expandable and self-expandable stents.
In general, balloon-expandable stents have a higher radial force upon deployment but will not rebound if crushed. Thus, balloon-expandable stents are suboptimal for sites prone to external compression, such as around joints or the adductor canal in the leg.
Self-expandable stents are more flexible and trackable through the vessels than balloon-expandable stents. Their use is favored when the route to the lesion is tortuous or when the anatomy is prone to external compression.
In general, a stent should be selected that is 1-2 cm longer than the stenosis, with a diameter that is 1-2 mm wider than the unstenosed vessel lumen. A rule of thumb is 10% oversizing of an arterial stent and 20% oversizing of a venous stent.
Most stents are fenestrated and provide only a scaffolding-like support; however, covered stents are employed for treatment of pseudoaneurysm, dissection, and TIPS.
Embolic materials
The two main categories of embolic materials are premanent (coils, particles, glue, and sclerosing agent) and temporary (absorbable gelatin sponge and autologous clot).
Coils create thrombosis by inducing vascular stasis. The main advantage of coils is the ability for precise and quick placement, without distal embolization. The primary disadvantage is sacrifice of distal access: Once a vessel is coiled, it cannot be re-accessed for retreatment. When using coils for embolization of a specific lesion, the general technique is to first coil distal to the lesion, the proximal to it. This prevents recurrent bleeding from retrograde collaterals.
Particles flow distally to occlude the small capillaries. Two types of particles are trisacyl gelatin microspheres (Embospheres, BioSphere Medical) and polyvinyl alcohol.
Adsorbable gelatin sponge (Gelfoam, Pfizer) is the most commonly used temporary embolic agent, lasting 2-6 weeks. Of important note, because Gelfoam is dissolved foam, post-procedural CT imaging can show numerous gas locules in the embolized organ. This appearance can mimic abscess and careful clinical observation is necessary to prevent unnecessary interventions.
Sodium tetradecyl sulfate is a sclerosing agent used for vascular malformations adn varices.
Cyanoacrylate is a special glue that rapidly hardens when it comes in contact with blood.
Complications of embolization
Post-embolization syndrome usually occurs within the first day after embolization and clinically presents with pain, cramping, fever, and nausea/vomiting, thought to be due to release of endovascular inflammatory modulators by infarcted tissue. Treatment is NSAIDS, opoids when appropriate, and IV fluids.
Non-target embolization is unintentional embolization of structures other than the target. For instance, during uterine fibroid embolization there is a risk of non-target embolization of the ovaries. During bronchial artery embolization, there is a risk of non-target embolization to the brain causing stroke and to the spinal arteries causing paralysis.
Catheter sizing
Catheters are sized in French (Fr), where 1 Fr = 0.33 mm. For instance, a 6 Fr catheter has an external diameter of 2 mm. The luminal diamter will be slightly smaller.
Sheath versus catheter: A sheath has a defined luminal diameter; however, the overall diameter of the catheter will be slightly larger. For instance, a 6 Fr sheath can by definition fit a 6 Fr catheter inside, but will be a 7 or 8 Fr in external diameter
High-flow catheters
High-flow (also known as flush) catheters have multiple sideholes and may be coiled (most commonly; known as pigtail/omniflush catheter), curved, or straight.
High-flow catheters are used for large vessel angiography, such as the aorta adn vena cava.
Selective and superselective catheters
Selective and superselective catheters have a single hole at the end of the catheter. There are numerous shapes of the distal portion, each tailored towards a specific situation or general purpose use.
C2 and SOS are reverse curved-tip catheters; and Berenstein is an angled-tip catheter.
Wires
Wires are sized in inches, with a standard wire measuring 0.035” in diameter and a microwire measuring 0.018” in diameter.
Standard wires have a floppy tip or J-tip, which allows the wire to be safely inserted blindly (although once in teh vesself the course should be followed on fluoroscopy).
A Bentson wire is a typical floppy tip wire; Rosen is a J-tip wire.
Hydrophilic wires are used to cross a stenosis or for initial cannulation of an indwelling device, as would be performed for a routine check and change.
Roadrunner (Cook) and Glidewire (Terumo) wires are hydrophilic.
Stiff wires are used when structural rigidity is required. For instance, a devices that dilates the subcutaneous tissues (such as a sheath, biliary drain, nephrostomy tube, etc.) needs to be inserted over a stiff wire.
An Amplatz (Boston Scientific) wire is a commonly used superstiff wire.
Giant cell arteritis
Giant cell arteritis (GCA) is a medium and large-vessel vasculitis that has overlapping imaging findings with Takayasu arteritis. GCA tends to affect older patietns (typically greater than 50 years of age) compared to Takayasu arteritis.
The medium-sized upper extremity arteries are most commonly affected in GCA, including the subclavian, axillary, and brachial arteries. The aorta is rarely involved, unlike in Takayasu arteritis. GCA typically produces long smooth stenoses and occlusions.
Definitive diagnosis is with temporal artery biopsy. Treatment is steroids.
Congenital anomalies of the superior vena cava (SVC)
Normally, the embyrologic left anterior cardinal vein regresses and the right anterior cardinal vein develops into the SVC.
Left-sided SVC is due to persistence of the embryological left anterior cardinal vein and regression of the right anterior cardinal vein. The left SVC usually drains directly into the coronary sinus -> right atrium. Rarely, the left SVC drains directly into the left atrium causing a left to right shunt. Left-sided SVC is weakly associated with congenital heart disease (CHD). Left SVC is an incidental finding in 0.5% of the population but is seen in 4% of patients with CHD.
A duplicated SVC is due to persistance of both the right and left anterior cardinal veins.
SVC obstruction
Acute obstruction of the SVC causes SVC syndrome, which clinically presents as facial and upper extremity edema and cyanosis. Acute SVC syndrome is a vascular emergency.
In contrast to acute SVC syndrome, chronimc occlusion or stenosis of the SVC may be asymptomatic. If symptoms are present, facial edema that improves with standing is characteristic.
The most common causes of SVC obstruction are compression by thoracic malignancy, cathether-associated thrombosis, and mediastinal fibrosis after histoplasmosis exposure.
A classic cross-sectional abdominal imaging finding in SVC obstruction is increased enhancement of hepatic segment IVa due to collateral opacification of the vein of Sappey. The vein of Sappey drains the liver in the region of the falciform ligament and communicate with internal thoracic veins, which act as collateral vessels in the setting of SVC occlusion.
Combined internal jugular and femoral approaches may be necessary for treatment of SVC occlusion. Stenting is often necessary.
Pulmonary artery angiography technique
Before performing a pulmonary angiogram, it is essential to evaluate an EKG to ensure that a left bundle branch block (LBBB) is not present. If the pulmonary artery catheter were to cause temporary right bundle branch block in the presence of a LBBB, the lack of left-sided conduction may cause complete heart block, which can be fatal. A temporary pacer should be placed prior to pulmonary arteriography in the presence of a LBBB.
Normal right-sided pressures: Right atrium: 0-8 mm Hg. Right ventricle: 0-8 mm Hg diastolic; 15-30 mm Hg systolic. Pulmonary artery: 3-12 mm Hg diastolic; 15-30 mm Hg systolic.
Pulmonary arteriovenous malformation (AVN)
A pumonary arteriovenous malformation (AVM) is an abnormal connection between the pulmonary artery and pulmonary veins, causing a right to left shunt.
Patients with hereditary hemorrhagic telangiectasia (HHT), also known as Osler-Weber-Rendu syndrome, may have multiple pulmonary AVMs. HHT can clinically present with brain abscess, stroke, or recurrent epistaxis (due to nasal mucosa telangiectasia).
Coils must be used to embolize a pulmonary AVM. Particles are contraindicated as teh right to left shunt would cause brain emboli and infarction.
Most pulmonary AVMs have a single feeding artery and coiling of this inflow artery (via a pulmonary arterial approach) is usually sufficient treatment. Note that the treamtent of peripheral (e.g. in a limb) AVM generally requires elimination of the entire nidus, which is often fed from multiple arterial branches.
An asymptomatic lesion with a feeding artery size >3 mm or a symptomatic lesion (i.e., prior infarct or brain abscess) is an indication for treatment.
Bronchial artery embolization for hemoptysis
Massive hemoptysis (hemoptysis of >300 mL/24 h) has a very high mortality, most commonly due to asphyxiation. The vast majority (90%) of cases of hemoptysis involve the bronchial arteries, with the pulmonary arterial circuluation, the subclavian, internal mammary, inferior phrenic, and celiac arteries may be involved, so if a patient continues to bleed after evaluation of the bronchial and pulmonary arterial circulation, the subclavian, internal mammary, inferior phrenic, and celiac arteries should be evaluated as well.
Chronic inflammation can lead to hypertrophied bronchial arteries and subsequent hemoptysis. In the USA, cystic fibrosis and thoracic malignancy are the most common causes of hemoptysis. Worldwide, tuberculosis and fungal infection are more common.
The bronchial artereis arise from the thoracic aorta at T5-T6, although the arterial anatomy is quite variable. There are usually one or two bronchial arteries on each side.
Embolization is performed with a distal embolic agent, most commonly particles. Initial angiography should carefully evaluate for the rare presence of a left to right shunt prior to particle embolization to prevent inadvertent cerebral embolization. Embolization is usually performed to near-stasis. Because rebleeding after treatment is common, coils are rarely used to treat hemoptysis. Because coils prevent repeat access, the use of coils would preclude retreatment.
A potentially devastating complication is nontarget embolization of the spinal cord via the anterior spinal artery or smaller tributaries arising from bronchial and intercostal arteries. A complete neurological exam should be documented prior to the procedure.
Osseous landmarks for abdominal and pelvic angiography
Celiac artery: Arises from the aorta at the level of T12 vertebral body.
Superior mesenteric artery (SMA): Arises at the level of the T12-L1 disk space.
Renal arteries: Arise at the level of the L1-L2 disk space.
Inferior mesenteric artery (IMA): Arises to the left of the midline at the L2-L3 disk space.
Celiac axis anatomy
The anatomy of the celiac axis and abdominal viscera is highly variable.
Approximately 75% of the time the celiac artery demonstrates normal arterial anatomy with three main branches: The left gastric, the common hepatic, and the splenic artery.
The left gastric artery may be the source of bleedin in esophageal Mallory-Weiss tear.
The left gastroepiploic artery arises from the splenic artery and anastomoses with the right gastroepiploic artery along the greater curvature of the stomach. The right gastroepiploic artery arises from the gastroduodenal artery.
Hepatic arterial anatomy and variants
Most commonly (75%), the proper hepatic artery supplies blood to the liver. The proper hepatic artery is the continuation of the common hepatic artery after the takeoff of the gastroduodenal artery. The proper hepatic artery divides into the right and left hepatic artereis. The cystic artery arises from the right hepatic artery to supply the gallbladder.
A replaced right hepatic artery (RRHA) is present in 10-18% of patients, where the right hepatic artery arises from the SMA. An RRHA may become clinically significant in the setting of SMA disease or during abdominal surgery.
An accessory right hepatic artery is an artery arising from the SMA that supplies the right hepatic lobe in the presence of a normal right hepatic artery (arising from the proper hepatic artery).
A replaced left hepatic artery (RLHA) is present in 11-12% of patients, where the left hepatic artery arises form the left gastric artery.
An accessory left hepatic artery is an artery arising from the left gastric artery that supplies the left hepatic lobe in the presence of a normal left hepatic artery (arising from the proper hepatic artery).
Superior mesenteric artery (SMA)
The superior mesenteric aretery (SMA) arises from the anterior aorta at about the level of T12-L1 to supply the distal duodenum, the entire small bowel, and the proximal large bowel from the cecum to the mid-transverse colon.
The inferior pancreaticoduodenal artery is the first branch of the SMA. The inferior pancreaticoduodenal artery forms collaterals with the celiac artery.
The middle colic artery arises from the SMA and supplies the transverse colon. The middle colic artery anastomoses with the marginal artery of Drummond.
The right colic artery courses retroperitoneally, where it supplies the right colon and hepatic flexure.
The terminal artery of the SMA is the ileocolic artery, which sends arterial branches to the terminal ileum, cecum, and appendix.
Inferior mesenteric artery (IMA)
The inferior mesenteric artery (IMA) originates at the left anterior aspect of the aorta at L3-L4.
The IMA gives off the left colic artery to supply the descending colon.
The sigmoid arteries are variable in number. They run in the sigmoid mesocolon to supply the sigmoid.
The IMA terminates as the superior rectal (hemorrhoidal) artery, which supplies the upper rectum.
Internal Iliac branches
The anterior division of the internal iliac artery supplies most of the pelvic viscera. The branches of the anterior division include the inferior/middle rectal artery (anastomoses with the IMA via the pathway of Winslow), the uterine artery, the obturator artery, adn the inferior gluteal artery.
The posterior division of the internal iliac artery supplies the musculature of the pelvic and gluteal regions. The branches of the posterior division include the lateral sacral artery, the iliolumbar artery (anastomoses with external iliac via the deep circumflex iliac artery), and the superior gluteal artery.
External iliac branches
The inferior epigastric artery anastomoses with the superior epigastric artery.
The deep circumflex iliac artery anastomoses with the internal iliac via the iliiolumbar artery.
The femoral artery continues distally to supply the leg.
Abdominal artery anastomoses
The arc of Buhler is an uncommon short-segment direct connection between the celiac artery and the SMA. It is a persistent embryologic remnant and not an acquired collateral pathway.
The inferior pancreaticoduodenal artery is the first SMA branch. It forms a rich collateral network with the celiac about the pancreatic head, called the pancreatic cascade.
The arc of Barkow connects the SMA to the celiac axis via the right and left epiploic arteries.
The marginal artery of Drummond is the major SMA IMA anastomosis. It lies in the peripheral mesentery of the colon, adjacent to the mesenteric surface of the colon. The marginal artery of Drummond is comprised of branches from the ileocolic, right, middle, and left colic arteries. Normally, the marginal artery of Drummond is small in caliber, but it may become prominent in the setting of IMA or SMA disease.
The arc of Riolan is an inconstant SMA IMA anastomosis. The arc of Riolan also runs through the colonic mesentery, but more medial compared to the marginal artery of Drummond.
The Cannon-Bohm point is the point of transitional blood supply to the colon between the SMA (proximal) and IMA (distal), at the splenic flexure. This watershed zone is susceptible to ischemia in case of systemic arterial insufficiency.
External iliac thoracic aorta: The inferior epigastric artery arises from the external iliac artery and anastomoses with the thoracic aorta via the internal mammary artery.
External iliac internal iliac: The deep circumflex iliac artery arises from the external iliac artery and anastomoses with the posterior division of the internal iliac artery via the iliolumbar artery.
Internal iliac IMA: the inferior/middle rectal arteries arise from the internal iliac artery and anastomose with the IMA via the superior rectal artery. This collateral pathway is the path of Winslow (rectal arcade).
Polyarteritis nodosa (PAN)
Polyarteritis nodosa (PAN) is a systemic necrotizing vasculitis of small and medium-sized arteries that causes multiple small visceral aneurysms. P-ANCA is usually elevated.
The differential diagnosis of multiple renal artery aneurysms includes multiple septic emboli, speed kidney (due to chornic methamphetamine abuse), and Ehlers-Danlos.
PAN typically affects renal, hepatic, and mesenteric end-arterioles.
PAN is associated with several medical conditions remembered with the mnemonic CLASH (cryoglobulinemia, leukemia, rheumatoid arthritis, Sjogren syndrome, and hepatitis B).
Treatment of PAN is with steroids, not procedures.
Splenic artery aneurysm
Splenic artery aneurysm is teh most common visceral aneurysm. Multiparous females and patients with portal hypertension are at increased risk of developing splenic artery aneurysms. Splenic artery aneurysms have an increase risk of rupture during pregnancy.
A splenic artery pseudoaneurysm may be the result of trauma or pancreatitis.
Indications for treatment of a splenic artery aneurysm include presence of symptoms (such as left upper quadrant pain), aneursym size >2.5 cm, and prior to expected pregnancy.
Endovascular coil embolization is the preferred approach. Coils are first placed distal to the aneurysm neck (to exclude retrograde collateral flow), then placed proximally.
Hepatic artery aneursym
Hepatic artery aneursym is the second most common visceral aneurysm.
Embolization of the right hepatic artery distal to the cystic artery (which arises from the right hepatic artery) is preferred, as embolization proximal to teh cystic artery increases the risk of ischemic cholecystitis, which may be seen in up to 10% of cases.
Cirrhosis
The classic angiographic finding of liver cirrhosis is corkscrewing of the hepatic artery branches, caused by liver fibrosis. A hypervascular mass in a cirrhotic liver may represent hepatocellular carcinoma.
Mesenteric ischemia overview
Mesenteric ischemia is inadequate blood supply to the bowel. It is seen most commonly in the elderly and has multiple causes, including acute arterial embolism, chronic arterial stenosis, venous occlusion, and low-flow states. For the purposes of interventions, the etiologies can be divided into acute or chronic.
Acute mesenteric ischemia
Acute mesenteric ischemia typically presents as catastrophic abdominal pain, often with lactic acidosis. Acute mesenteric ischemia is most commonly caused by SMA embolus.
An SMA embolism distal to the middle colic artery carries the highest risk of intestinal ischemia, as there are few native distal collaterals. The middle colic artery anastomoses with the IMA via the marginal artery of Drummond and the arc of Riolan.
In most patients with acute mesenteric ischemia, treatment is surgical revascularization (embolectomy or bypass), direct inspection of bowel, and resection of necrotic bowel.
In select patients with acute embolic mesenteric ischemia (patients without peritoneal signs or clinical findings suggestive of bowel necrosis), endovascular therapy with thrombolysis or suction embolectomy may be performed.
Nonocclusive mesenteric ischemia (NOMI) is a highly lethal (70-100% mortality) form of acute mesenteric ischemia. NOMI is also known as “intestinal necrosis with a patent arterial tree” and features spasm and narrowing of multiple branches of the mesenteric arteries. Direct arterial infusion of the vasodilator papaverine (60 mg bolus, then 30-60 mg/h) is the treatment of NOMI.
Chronic mesenteric ischemia
Chronic mesenteric ischemia is usually caused by atherosclerosis. The classic clinical presentation is postprandial abdominal pain out of proportion to the physical exam.
Mesenteric angiography shows ostial narrowing of the mesenteric vessels, often with post-stenotic dilation. The lateral aortogram is the most useful view to evaluate the origins of the celiac and superior mesenteric arteries.
Because mesenteric collaterals are so extensive, at least two of three mesenteric arteries (celiac, SMA, and IMA) must be diseased to produce symptoms in chronic disease.
Chronic mesenteric ischemia can be treated endovascularly with angioplasty and stenting.
Role of interventional radiology in gastrointestinal (GI) bleeding
Gastrointestinal (GI) bleeding can be classifed as upper GI (bleeding source proximal to the ligament of Treitz), lower GI (bleeding source distal to the ligament of Treitz), and variceal. Variceal bleeding is due to portal hypertension and is treated by reducing portal pressure.
Endoscopy is the best initial procedure for acute upper GI bleeding. Endoscopy can be both diagnostic and therapeutic.
For lower GI bleeding, a hemodynamically stable patient should first be evaluated by mesenteric CT angiogram or nuclear medicine tagged red blood cell scan to localize the bleed, as these tests are thought to be more sensitive than angiography. A bleeding rate of 0.5 to 1.0 mL/min is generally required to be angiographically positive. A tagged red blood cell scan cand detect bleeding rate as low as 0.2 to 0.4 mL/min. Many institutions now favor mesenteric CT angiography as the first test for evaluation of acute lower GI bleeding because CT is rapid, easy to perform, and readily available. On CTA, acute bleeding is seen as contrast extravasatio. CTA may be able to detect bleeding rates as low as 0.35 mL/min.
A hemodynamically unstable patient with clinical evidence of current GI bleeding may go straight to angiography.
Due to the copious collaterals between the celiac axis and the SMA, it is often reasonalbe to perform empirical (in absence of visualized extravasation) embolizations of the left gastric artery in upper GI bleeding. However, lower GI collaterals are much less well developed and there is a significant risk of bowel infarct with indiscriminate lower GI embolization.
Intraarterial infusion of vasopressin (antidiuretic hormone) can often control active lower GI bleeding, but there is very high rebleeding rate once the infusion is stopped. Vasopressin is most useful in cases of bleeding from antimesenteric vessels, which are more difficult to reach directly by catheter. Major complications of vasopressin are seen in up to 20% including arrhythmia, pulmonary edema, and hypertension. Vasopressin is directly infused into the SMA or IMA. The dose of vasopressin is 0.2-0.4 units per minute (100 units mixed in 500 mL saline given at 1 mL/minute), given as a continous infusion for up to 24 hours.
Vasopressin can only be used for 24 hours before tachyphylaxis (lack of further response) develops.
Normal arterial anatomy of the leg vasculature
The femoral artery is the continuation of the external iliac artery distal to the inguinal ligament.
The femoral artery branches include: Deep femoral artery, the terminal branch to supply the deep muscles of the thigh. Superficial circumflex artery. Superficial femoral artery (SFA), which continues to supply the leg and foot.
After passing posteriorly through the adductor hiatus, the SFA becomes the popliteal artery. From medial to lateral, the branches of the popliteal arteyr are: Posterior tibial artery (most medial). Peroneal artery (arises from the tibioperoneal trunk, along with the posterior tibial artery) Anterior tibial artery (most lateral; the only anterior artery of the lower leg). It is easy to remember that the anterior tibial artery is lateral because the only muscle bulk of the anterior lower leg is the lateral compartment and that muscle is the anterior tibialis.
Normal vascular anatomy of the upper extremity
The basilic vein, located medial and superficial to the brachial veins, is the first choice for peripherally inserted catheter (PICC) placement The cephalic vein adds an extra curve as it joins the axillary/subclavian vein, but is generally the second choice if the basilic is not available. There is risk of damaging the median nerve with placement in a brachial vein as the median nerve lies superficial to the brachial veins.
A PICC should not be placed in a patient with chronic renal failure who may need a fistula in the future. Central acess using the neck veins should be used instead.
