VERTEBRAL ARTERIOGRAPHY: AN EVALUATION OF METHODS.

Abstract

WHAT IS the best means of angiographic demonstration of a terminal basilar artery aneurysm, a small angioma of the occipital lobe, or posterior displacement of the basilar artery by a clivus meningioma? In the last thirty years, a battery of methods has been proposed. These have included needle injections in the subclavian artery (1), direct puncture of the vertebral arteries (6,9, 10), catheterization of the vertebral (8) and the subclavian (7) arteries, as well as retrograde injections of contrast material in the brachial vessels after cannulation (3, 4). We are of the opinion that in the adult either direct puncture of the vertebral artery or catheterization of this vessel should be carried out. The purpose of this report is directed primarily toward an assessment of these two methods. The survey has been made from the standpoint of radiological information achieved, and the technical drawbacks and patient complications of each procedure are enumerated. Material and Technics A series of 119 consecu tive direct puncture vertebral angiographic studies at St. George's Hospital, London, England, during 1962 was surveyed. All these examinations were carried out under general anesthesia. The vertebral artery was entered, usually at the level of C-3, C–4 via an anterior neck approach, the puncture being made just below the horizontal ramus of the mandible. The needle3 used had a trocar point with a side-hole. A film series when adequately completed consisted of a lateral, anteroposterior, and, usually, one oblique projection. Hand injections of 7–8 cc Hypaque 45 per cent were made for each projection. Results of vertebral artery catheterization carried out or attempted in 40 consecutive instances at the Hospital of the University of Pennsylvania in 1963 and 1964 were studied. The percutaneous Seldinger method was employed, and femoral puncture with retrograde manipulation of the catheter through the aorta into the left subclavian artery was the route of choice. Installation of the catheter in the origin of the vertebral artery was facilitated by the use of a preformed right angle in the distal 1 cm of the catheter. A gentle arc in the distal aspect of the catheter, approximately 8 cm in length and conforming to the curve in the subclavian artery, was also helpful in promoting vertebral catheterization. If femoral catheterization could not be undertaken because of arteriosclerotic changes in the lower extremities, or catheterization of the left vertebral artery was not accomplished (due to arteriosclerotic alteration of the left subclavian artery or aorta, hypoplasia of the left vertebral artery, or aortic origin of the left vertebral artery), a right axillary puncture was made. The catheter tip was then placed in the most proximal segment of the right vertebral artery (Fig. 1). To prevent reduced flow of blood and contrast material caused by plugging of the vertebral artery by the catheter, a 3 cc test injection was made.