Carotid Angiography: Information Quality and Safety

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Carotid Angiography Information Quality and
Safety

• Michael J. Cowley, M.D., FSCAI

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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
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Carotid Angiography
Essential Cognitive Knowledge

• Cerebrovascular pathology
• Atherosclerosis
• - Typical disease states and appearance
• Unusual forms of disease
• Aneurysms
• AVMs
• Bleed
• Tumor

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Carotid Angiography
Technique

• Vascular Access
• Arch Angiography
• Selective angiography
• Extracranial vessels
• Intracranial vessels

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Carotid Angiography
Technique

• Vascular Access
• Arch Angiography
• Selective angiography
• Extracranial vessels
• Intracranial vessels

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Catheter Access

• 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

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Carotid Angiography
Technique

• Access
• Arch Angiography
• Selective angiography
• Extracranial vessels
• Intracranial vessels

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Aortic Arch Angiography

• To evaluate access to great vessels
• Identify Arch Type
• Identify variant anatomy (Anomalies)
• 5 or 6F Pigtail catheter
• 30-40 degree LAO view
• Hand or power injection
• 15-20 ml/sec for 2 seconds

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Aortic Arch Angiography

• 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
• Patients head should be straight with chin
  turned upward
• Hand or power injection
• 15-20 ml/sec for 2 seconds

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Aortic Arch Angiography

• To evaluate access to great vessels
• 5 or 6F Pigtail catheter
• 30-40 degree LAO view
• Field of view origin of great vessels extending
  to the carotid bifurcation
• Patients head should be straight with chin
  turned upward
• Hand or power injection
• 15-20 ml/sec for 2 seconds

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Conventional Arch
Courtesy of Mark Burket, M.D.
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Aortic Arch Angiography
Anatomic Features

• Variations in Arch Anatomy
• Configuration Arch Type
• Anomalous Vessel Origins
• Angulation of the arch vessels and the carotid
  bifurcation angle between the ICA and ECA
  increases with age

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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
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Its Not Just The Arch That Gets Longer!
Tortuous Right Common Carotid
LEFT
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Aortic Arch Types
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Carotid Angiography
Technique

• Access
• Arch Angiography
• Selective angiography
• Extracranial vessels
• Intracranial vessels

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Carotid Angiography

• 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

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Carotid Angiography
Key Information for Carotid Stenting
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Catheter Shapes

• 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

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Simple Curved Catheters
Coronary catheters
IMAModified AR1 JR 4
Consider using dedicated catheters!!!
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Primary Curve Catheters

• 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

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H1 or Vertebral Artery Catheter
These catheters work well for flat aortic arches
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Complex Curved Catheters
Simmons 1, 2, and 3 curves
VTK
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Simmons CatheterA Closer Look

• Ideal for Type II-III arch
• Technique Tip Re-shape in subclavian artery with
  an exchange wire to avoid arch manipulations

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Selective Catheter Choice
Vitek, Simmons 1,2,3 Catheters
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Complex Curve Catheters

• 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

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Complex Curve Catheters

• 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 facilitate
  placement of a simple curve catheter once access
  is obtained

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Engaging a Simmons II Catheter
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Carotid Angiography
Right Common Carotid Artery

• 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)

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Carotid Angiography Views
Extracranial - Ipsilateral oblique -
Lateral - AP
Intracranial - AP cranial (Townes view) -
Lateral - Ipsilateral oblique, caudal
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Right Carotid Artery

• 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

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Carotid Angiography
Left Carotid Artery

• 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

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Carotid Angiography
Right Common Carotid Artery

• 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

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Intracerebral Angiography

• 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)

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Intracerebral Angiography
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Carotid Angiography
Avoiding Complications

• Non-ionic contrast preferred
• Minimize contrast volume used
• Use lower risk catheter curves when possible
• Minimize catheter manipulations

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Avoid Excessive catheter manipulation
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Severe Atheroma of the Aorta
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Carotid Access Issues
Complications

• 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)

Complication Risk determined primarily by case
selection
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Carotid Angiography
Summary

• 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