Angiographic Facilities Research Articles

1040-71 Interhospital transfers are costly, cause delays and do not address the imbalance of access to revascularization: The case for more angiographic facilities? Results from the global registry of acute coronary events

1040-71 Interhospital transfers are costly, cause delays and do not address the imbalance of access to revascularization: The case for more angiographic facilities? Results from the global registry of acute coronary events

Optimal Resources for the Examination and Endovascular Treatment of the Peripheral and Visceral Vascular Systems: AHA Intercouncil Report on Peripheral and Visceral Angiographic and Interventional Laboratories

In 1969 the Intersociety Commission for Heart Disease Resources was established through a contract with the American Heart Association under Public Law 89-239. Its responsibility was to produce guidelines defining optimal medical resources and care for the prevention and treatment of cardiovascular disease, including guidelines for radiologic facilities (1). This resource guideline was revised in 1976 (2) and again in 1983 (3). The Intersociety Commission was disbanded shortly thereafter, but a joint ad hoc task force of the American Heart Association and the American College of Cardiology continued this work with “Guidelines for Cardiac Catheterization and Cardiac Catheterization Laboratories” (4), published in 1991. The task force concluded that “. . . while noncardiac diagnostic and therapeutic procedures are growing in number . . . guidelines for these services are beyond the scope of this document.” These documents have charted the evolution of cardiac catheterization from a procedure performed in a few highly specialized laboratories for cardiovascular research to one performed in a number of interventional cardiac laboratories. The documents also have provided useful optimal resource guidelines. In the 1983 report similar standards for angiographic facilities were implied but never specifically stated, with the emphasis always on the heart. Nevertheless, the report mentioned angiographic facilities and considerable involvement by radiologists. Just as cardiac catheterization has evolved, so too have peripheral and visceral angiography. Diagnostic angiography proliferated in the 1960s and the 1970s, and interventional radiology emerged in the 1980s. Nevertheless, optimal resource standards have never been promulgated except in an abbreviated form (5). In 1989 the Council Affairs Committee of the AHA approved the formation of a committee on peripheral vascular disease under the auspices of the Council on Cardiovascular Radiology. In 1992 an ad hoc task force was created, with members from the Councils on Cardiovascular Radiology, Cardio-Thoracic and Vascular Surgery, Clinical Cardiology, and Kidney in Cardiovascular Disease, to develop guidelines for peripheral and visceral angiographic and interventional laboratories. Task force members are Eric C. Martin, MD, chair; William J. Casarella, MD (Council on Cardiovascular Radiology); Barry T. Katzen, MD (Council on Cardiovascular Radiology); Gerald M. Dorros, MD (Council on Clinical Cardiology); Gary S. Roubin, MD (Council on Clinical Cardiology); James A. DeWeese, MD (Council on Cardio-Thoracic and Vascular Surgery); and John H. Laragh, MD (Council on Kidney in Cardiovascular Disease). The task force is grateful for the contributions of the following consultants: John F. Cardella, MD; Joel E. Gray, PhD; Victoria M. Marx, MD; Edward L. Nickoloff, ScD; Michael J. Pentecost, MD; and David C. Levin, MD.

Availability of diagnostic facilities in the Netherlands for patients with suspected pulmonary embolism

Pulmonary embolism remains a complex diagnostic problem. Although accurate and cost-effective, the ‘Dutch consensus’ strategy is not widely applied. We assessed the availability and investment plans of the different facilities used in this strategy. Furthermore, the current and future availability of new diagnostic modalities was investigated. A questionnaire was sent to all Dutch hospitals. The questionnaire contained separate sections with questions for the hospital management and the medical practitioners at the departments of radiology, nuclear medicine, internal medicine and pulmonology. Five hundred and eighty-four questionnaires were sent out (response rate 68%). Forty-three percent of the hospitals had no nuclear medicine facility, 11% had no pulmonary angiography facility, and 59% had no spiral CT scan (SCTA). Forty-six percent of the responding hospitals had a nuclear medicine facility; and 5% used Technegas for ventilation studies. Strategies with SCTA were available in about 27% of the hospitals. Due to future investments this number will increase to approximately 55%. Strategies with Technegas were available in 2.4% of the hospitals, this number might increase to 25% if Technegas is proven accurate. The ‘Dutch consensus’ strategy is available in two-thirds of the hospitals. All other strategies were less feasible. Several equivalent strategies for diagnosing pulmonary embolism should be developed. These strategies should be accurate, widely available and accepted.

Survey on the use of pulmonary scintigraphy, spiral CT and conventional pulmonary angiography for suspected pulmonary embolism in the British isles

AIM: To determine current clinical practice in the radiological diagnosis of acute pulmonary embolism and assess the use of spiral volumetric computed tomography. METHOD: A survey of 327 acute hospitals including cardiothoracic and orthopaedic tertiary referral centres was undertaken to assess current utilization of lung scintigraphy, spiral computed tomography and pulmonary angiography in the investigation of suspected pulmonary embolism. Responses were received from 215 327 (66%) centres. RESULTS: Lung scintigraphy was provided by 208 hospitals (144 on-site and 64 off-site). Spiral CT services were provided by 111 (52%) hospitals (on- or off-site), 142 (66%) units had access to angiography facilities. Sixty-three centres out of 215 (29%) offered both on-site lung scintigraphy and spiral CT while only 41 215 (19%) hospitals were able to undertake all three tests on-site. On average, 501 perfusion (Q) or ventilation-perfusion (V/Q) scintigrams were performed per hospital per year with 26 spiral CT studies and just 4.6 pulmonary angiograms. CONCLUSION: These data suggest that lung scintigraphy is frequently the only imaging test in patients other than chest radiography, despite the large number of indeterminate results reported in most series.

Review of Emergency Department thrombolytic therapy and changes in inpatient mortality of acute myocardial infarction on the NSW Central Coast 1986 to 1994-96.

To examine changes in inpatient mortality of acute myocardial infarction (AMI) from 1986 to 1994-96 and to review the Emergency Department (ED) use of thrombolytic therapy (TT) for AMI on the NSW Central Coast. A retrospective review of medical records of patients presenting to the EDs of Gosford and Wyong Hospitals with a discharge diagnosis of AMI (ICD9 code 410.x) from 1 January 1986 to 31 December 1986 and 1 January 1994 to 31 December 1996. Data were collected on patients' age, sex, duration of symptoms on arrival at the ED, ECG changes and presence of positive ECG criteria for thrombolysis, agent used, contraindications to TT, and inpatient mortality. The main measure of outcome was inpatient mortality. There were 423 admissions for AMI in 1986 and 1,220 admissions in 1994-96. The overall inpatient mortality has declined from 18.9% in 1986 to 9% in 1994-96 (p<0.0001). The mean age of patients has increased from 67.5 years to 68.1 years (p=0.35). The proportion of patients over age 75 years has increased significantly from 24.6% to 30.3% (p<0.0001). Presentation times from onset of symptoms have not changed significantly from a median time of two hours in 1986 to 2.5 hours in 1994 to 1996 (p=0.52). The overall proportion of patients with ECG criteria for TT was 53.2% in 1994-96. TT was administered to 42.9% of patients with a mean door to needle time of 67 minutes (median 45 minutes). The Australasian College for Emergency Medicine benchmark door to needle time of 60 minutes was achieved in 71.3% of patients. Streptokinase was the predominant agent given in 78%, while recombinant tissue plasminogen activator accounted for 15.7% of patients. Patients not receiving TT due to negative ECG criteria showed a decline in mortality from 18.6% to 6.7% (p<0.0001). Patients who underwent mechanical revascularisation (by bypass graft or angioplasty) increased from 8.7% to 17.4% (p<0.0001). Inpatient mortality has declined for all age groups, for both sexes, and for all sites of AMI. There have been significant declines in inpatient mortality of patients with AMI on the Central Coast. TT has had a significant impact on this decline but has an eligibility rate of less than half. Significant declines in mortality have also been seen in patients ineligible for thrombolysis. These patients have benefited from other therapies introduced or more widely used in the last decade. The results achieved on the Central Coast compare favourably with published reviews in Australia and overseas despite the lack of facilities for coronary angiography, coronary angioplasty and cardiothoracic surgery.

Cost-effectiveness of Noninvasive Diagnostic Aids in Suspected Pulmonary Embolism

Noninvasive instruments such as plasma D-dimer measurement (DD) and lower-limb compression ultrasonography (US) are being increasingly advocated to reduce the number of necessary angiograms in patients having suspected pulmonary embolism (PE) and a nondiagnostic lung scan. We therefore designed a decision analysis model (1) to evaluate the cost-effectiveness of combining these noninvasive diagnostic aids with lung scan and angiography in the diagnosis of PE and (2) to determine the optimal sequence and combination of tests taking into account the clinical probability of PE. We performed a cost-effectiveness analysis based on literature data, including data from a management study in our institution. Six diagnostic strategies were compared with the reference, ie, lung scan followed when nondiagnostic (low or intermediate probability) by angiography. In all strategies, PE was ruled out by a normal or near-normal scan, a negative DD (plasma level below 500 micrograms/L), or a negative angiogram. Pulmonary embolism was diagnosed and anticoagulant treatment was undertaken in the presence of a high-probability lung scan, deep vein thrombosis showed by US, or a positive angiogram. In case of a nondiagnostic scan (low or intermediate probability), patients could be either treated or not treated, or undergo other tests, according to the selected strategy. Under baseline conditions (prevalence of PE, 35%), strategies combining DD and US with lung scan, angiography being done only in case of an inconclusive noninvasive workup (DD level > 500 micrograms/L, normal US, and nondiagnostic lung scan), were most cost-effective. This approach yielded a 9% incremental cost reduction and a 37% to 47% decrease in the number of necessary angiograms compared with the reference strategy (scan +/- angiography). For patients with a low clinical probability of PE (< or = 20%), withholding treatment from those with a low-probability lung scan without performing an angiogram proved safe and highly cost-effective (30% cost reduction), provided US showed no deep vein thrombosis. The DD test and US are cost-effective in the diagnostic workup of PE, whether performed after or before lung scan, thus allowing centers devoid of lung scanning and/or angiography facilities to screen patients with suspected PE and avoid costly referrals. In patients with a low clinical probability, a low-probability lung scan, and a normal US, treatment may be withheld without resorting to angiography.

Cardiologists' use of clinical information for management decisions for patients with unstable angina: a policy analysis.

Previous studies of management of unstable angina have revealed substantial differences in management between different hospitals, especially with respect to the use of coronary angiography. Physicians in a hospital with angiography facilities were more inclined to perform angiography than were physicians in hospitals without these facilities, even when differences in patient populations were taken into account. The authors compared the management strategies of 18 cardiologists, working in hospitals with and without angiography facilities, using a series of paper-case summaries, in order to assess the contribution of individual variability between physicians to practice differences. Physicians who worked in a hospital with in-house angiography facilities were more inclined to request angiography in similar case summaries, but the inter-individual variation exceeded the between-hospital variation. The variation in individual policies with respect to the decision to initiate coronary angiography could be associated with differences in weighting clinical information. These results confirm that practice variations may have many causes: variability in patients' characteristics, variations in how physicians react to these, differences in the availability of services, and variability in thresholds for action.

Coronary angiography in the outpatient with angina pectoris

Coronary angiography remains the only definitive diagnostic procedure to assess the severity and extension of coronary artery disease. We discuss some technical aspects and the place of angiography in the risk stratification of the coronary patient comparing conservative and invasive strategies. It is suggested that a progressively more important role will be played by the general practitioner regarding indication, interpretation and therapeutic decision, sharing responsibilities with the cardiologist and the patient. With increased facilities for coronary angiography and increased ad hoc angioplasties, observed at present, the GP should also be responsible for proper selection of the reference cardiologists and hospitals.

Variations in the Utilization of Coronary Angiography for Elderly Patients with an Acute Myocardial Infarction

This article reports a study of variations in the utilization of angiography for Medicare recipients who had an acute myocardial infarction. The study cohort consisted of 1987 Medicare beneficiaries who had a recent acute myocardial infarction. Variations were examined from three perspectives: patient characteristics, regional practice patterns, and on-site availability of the procedure. Factors associated with variation within and among states were incorporated into the analysis using hierarchical logistic regression models. The probability of angiography during the first 90 days after an acute myocardial infarction was estimated as a function of patient age, gender, race, and comorbidity for patients in 51 states (including the District of Columbia). Interstate differences were examined in relation to geographic region and on-site availability of angiography. Observed rates of angiography ranged between 13.8% and 38.3% (median, 24.7%). Variation was nearly threefold based on estimated state probabilities of angiography for a patient with characteristics set at the national average. Observed and estimated rates were lower in northeastern states than in other parts of the United States. States with more extensive onsite availability of angiography tended to have higher angiography rates after adjusting for patient characteristics and geographic region. Adjusted angiography rates were on average higher for younger patients, males, and nonblacks. There was substantial interstate variation in race differences, with states in the Southeast generally having the largest differences. The adjusted black-to-nonblack odds ratio ranged from a low of 0.41 to a high of 0.94. Interstate variation in age and gender differences was moderate. The work reported in this article illustrates the potential of hierarchical regression modeling as a framework for the analysis of variations and some methodologic issues connected with its implementation. Our results show that large variations in the utilization of procedures can exist, despite uniform insurance coverage and a relatively homogeneous patient cohort. Aggressive use of angiography was highly variable across states as was the degree of access to the procedure for blacks and nonblacks. The state rate of on-site availability of angiography facilities was an important predictor of utilization. Increased on-site availability of angiography, however, was not associated with a reduction of differences in access to the procedure.

On-site catheterization laboratory and prognosis after acute myocardial infarction. Israeli Thrombolytic Survey Group

Since the introduction of thrombolytic therapy for patients with acute myocardial infarction, the use of coronary angiography has substantially increased. We sought to determine whether the presence of on-site coronary angiographic facilities influenced the utilization of coronary procedures in patients with acute myocardial infarction hospitalized in Israel's coronary care units. A prospective survey was conducted in January and February 1992 in the 25 coronary care units operating in Israel, 15 of which had on-site catheterization facilities. Data on demographics, clinical features, thrombolytic therapy, and the type of coronary diagnostic or therapeutic procedures performed during the current in-hospital stay were recorded. Mortality, both in-hospital and 1 year after discharge, was assessed for all patients in the survey. One thousand fourteen consecutive patients with acute myocardial infarction were hospitalized during the survey, 307 (30%) of whom were admitted to 10 coronary care units without and 707 of whom were treated in hospitals with on-site coronary angiography facilities. Demographic and baseline characteristics were similar in both groups. Thrombolytic therapy was provided equally (46%) to patients admitted to hospital with and without catheterization laboratories. Patients admitted to hospitals with these laboratories underwent coronary angiography (26%) and percutaneous transluminal angioplasty and/or coronary artery bypass grafting (12%) in greater numbers than counterparts admitted to hospitals without such laboratories (10% and 5%, respectively). Hospital and cumulative 1-year mortality rates were 11% and 18%, respectively, in patients admitted to hospitals with on-site catheterization facilities vs 10% and 17%, respectively, in the patient group admitted to the other hospitals. Patients receiving thrombolytic therapy had similar hospital mortality rates unrelated to the availability of coronary catheterization laboratories. This national survey showed that the availability of invasive coronary facilities led to increased use of diagnostic and therapeutic coronary procedures among patients with acute myocardial infarction. There was no difference in hospital or 1-year mortality rates in patients admitted to hospitals with or without on-site coronary angiographic facilities.

On-Site Catheterization Laboratory and Prognosis After Acute Myocardial Infarction

Since the introduction of thrombolytic therapy for patients with acute myocardial infarction, the use of coronary angiography has substantially increased. We sought to determine whether the presence of on-site coronary angiographic facilities influenced the utilization of coronary procedures in patients with acute myocardial infarction hospitalized in Israel's coronary care units.A prospective survey was conducted in January and February 1992 in the 25 coronary care units operating in Israel, 15 of which had on-site catheterization facilities. Data on demographics, clinical features, thrombolytic therapy, and the type of coronary diagnostic or therapeutic procedures performed during the current in-hospital stay were recorded. Mortality, both in-hospital and 1 year after discharge, was assessed for all patients in the survey.One thousand fourteen consecutive patients with acute myocardial infarction were hospitalized during the survey, 307 (30%) of whom were admitted to 10 coronary care units without and 707 of whom were treated in hospitals with on-site coronary angiography facilities. Demographic and baseline characteristics were similar in both groups. Thrombolytic therapy was provided equally (46%) to patients admitted to hospital with and without catheterization laboratories. Patients admitted to hospitals with these laboratories underwent coronary angiography (26%) and percutaneous transluminal angioplasty and/or coronary artery bypass grafting (12%) in greater numbers than counterparts admitted to hospitals without such laboratories (10% and 5%, respectively). Hospital and cumulative 1-year mortality rates were 11% and 18%, respectively, in patients admitted to hospitals with on-site catheterization facilities vs 10% and 17%, respectively, in the patient group admitted to the other hospitals. Patients receiving thrombolytic therapy had similar hospital mortality rates unrelated to the availability of coronary catheterization laboratories.This national survey showed that the availability of invasive coronary facilities led to increased use of diagnostic and therapeutic coronary procedures among patients with acute myocardial infarction. There was no difference in hospital or 1-year mortality rates in patients admitted to hospitals with or without on-site coronary angiographic facilities.

Vascular radiology in the Netherlands in 1992: A quantitative approach

A survey was held into methods and extent of vascular radiology in the Netherlands. For the year 1992, quantitative data on the number of patients, vascular radiological examinations and characteristics of angiography facilities were obtained from more than 80% of the Dutch hospitals with angiography rooms (120). The following estimates have been inferred: approximately 50 600 patients were referred for non-cardiac vascular radiology, including 32 100 patients for intra-arterial arteriography, 8900 for intravenous DSA arteriography, 4600 for phlebography and 5000 for interventional radiology. On average about two vascular examinations were carried out per patient referred for arteriography. In interventional radiology, the number of patients and the number of examinations are quite similar. The total number of angiography rooms in the Netherlands was 136. The average age of angiography X-ray systems was 7.1 years, of imaging equipment 5.7 years. In 56% of the hospitals, the X-ray tube was normally applied in the undercouch position, in 40% in overcouch position and in 4% there was no preferred position. An additional survey of occupational exposure conditions in angiography rooms (19 hospitals) showed that, in most hospitals, protective lead aprons of 0.5 mm Pb-equivalent were in use. Thyroid collars were used rather infrequently.

Thrombolytic therapy: impact on coronary care in a district general hospital.

The introduction of routine thrombolytic therapy in the Cardiac Care Unit (CCU) of a District General Hospital has resulted in an increased demand for admission particularly in the 70+ age group. Complications and side effects of such treatment have been similar to those reported in several large multicentre trials. The percentage of patients with myocardial infarction receiving thrombolysis has increased to 60% with the commonest reason for withholding of such treatment being the lack of ECG changes. Mortality rates have fallen and there has been an increased referral rate for urgent angiography. To maximise benefit CCU's should encourage early direct admission and ensure that, if not present on site, facilities for angiography can easily be arranged.

Panvenography and Pulmonary Angiography in the Diagnosis of Deep Venous Thrombosis and Pulmonary Thromboembolism

In summary, high-quality pulmonary angiography remains the most accurate and reliable means of diagnosing pulmonary embolism. It can be performed with relative safety, and the inherent mortality risks with pulmonary angiography (in the range of 0.2 to 0.5 per cent in active angiography laboratories) must be weighed against the significant risks incurred with inaccurate diagnosis obtained without pulmonary arteriography. Pulmonary arteriography and transvenous catheter embolectomy can be of great benefit in sudden cardiovascular collapse due to massive pulmonary embolism. Transvenous catheter embolectomy has survival rates at least as good as those of open embolectomy, and it has the advantage that it can be performed in any hospital with angiographic facilities and trained personnel, thus allowing more expeditious management of massive pulmonary embolism in hospitals that do not have cardiopulmonary bypass capabilities.

Percutaneous Angiographic Embolization: A Procedure of Increasing Usefulness. Review of a Decade of Experience

Summary During the past decade percutaneous therapeutic vascular occlusion was performed on 152 occasions in 124 patients. The primary indication for vaso-occlusive therapy was acute or recurrent bleeding. Upper gastrointestinal bleeding from arterial sources was controlled in 92 percent of patients and acute variceal bleeding in 83 percent. Renal embolization was performed for palliation of severe pain and hematuria from unresectable renal primary or secondary malignancies, to decrease blood loss and facilitate surgery in operable renal tumors, and for ablation of renal function to control chronic protein loss or severe hypertension. Our encouraging experience convinces us that transcatheter embolization is a useful, safe and effective procedure in selected patients. It seems certain that the technique of therapeutic embolization will be improved, its indications extended and its application become commonplace whenever angiographic skills and facilities exist.

Percutaneous transluminal angioplasty: general principles.

The introduction and availability of balloon catheters has been responsible for the recent popularity of percutaneous transluminal angioplasty (PTA) in the United States. Available balloon catheters are either double-lumen or coaxial systems. Most balloons are made of polyvinyl but one manufacturer has produced an angioplasty catheter made of specially treated polyethylene, which exhibits higher tensile and yield strength in comparison to polyvinyl. Automatic pressure injectors are necessary for the coaxial balloon system. They are not used with single catheters and larger balloons. Devices monitoring balloon inflation pressures are now available and they should be used. There is no consensus on the use of anticoagulant therapy in conjunction with PTA. Complications of PTA are few and easy to manage. Noninvasive hemodynamic studies (Doppler and pulse volume recordings) are necessary during PTA and for evaluation of long-term patency. PTA should be performed by experienced angiographers in hospitals with adequate angiographic and vascular surgical facilities. Decisions about PTA and subsequent patient management are best made in consultation with the patient's primary physician, a vascular radiologist, and a vascular surgeon.

Report of the Inter-Society Commission for Heart Disease Resources (ICHD) Radiology Study Group

In order to comply with Section 907 of Public Law 89–239, the ICHD established guidelines for the prevention and treatment of cardiovascular disease. Two controversial sections of this 1965 report (physician staffing and the location and administration of angiographic facilities) led to the reinstitution of the ICHD Radiology Study Group. Cardiologists with special expertise in angiography were asked to join the Committee. Three major principles were established: (a) angiography may be performed by properly trained cardiologists who meet the Committee's standards; (b) a radiologist has the right to act as medical director of a cardiac catheterization laboratory; and (c) the laboratory should function as a core facility, jointly operated by radiologists and cardiologists. The full Committee report will appear in the December 1975 issue of Circulation.

Arteriography in the assessment of renal trauma. The impact of arteriographic diagnosis on preservation of renal function and parenchyma.

The efficacy of arteriographic triage of patients who sustained renal trauma into two groups, one optimally handled by early surgical intervention and one in whom conservative management guarantees maximal preservation of renal parenchyma, is discussed, based on a study of 190 patients. A substantial increase in the number of patients managed conservatively (73%) is attributable to use of arteriographic selection criteria. A very low rate of complications (2%) appears to substantiate the validity of the criteria on which the selection was based. Similarly, arteriographic criteria made possible substitution of hemi- or partial nephrectomy in almost 42% of patients who would otherwise have been treated by nephrectomy. A very low rate of complications resultant from this procedure justifies its use in these cases. The very low mortality rate (1.6%) of the present series suggests a bonus contribution of arteriography toward the management of associated intra-abdominal injuries. The safety of angiography and the now general availability of angiographic facilities and skilled personnel on a round-the-clock basis, and the policy-determining information derived from these studies, recommend widespread deployment of this method for the assessment of renal injury.

Angiography in the general practice of radiology.

The need and demand for extracardiac angiography are increasing in our community hospitals. Since angiography is a special radiographic procedure, more satisfactory examinations will be possible if our radiologists prepare themselves to accept full responsibility as angiographers (1). A few relatively inexpensive additions to existing equipment will enable any radiology department to undertake peripheral vascular angiography. It has been shown that, once the equipment and a radiologist-angiographer become available, case material grows continuously. In St. Paul, the demand for these examinations has shown a considerable increase during the author's two-year experience. From Jan. 1, 1961, to Nov. 12, 1962, 587 angiographic procedures were personally performed in similarly equipped hospitals having an average daily census of 60, 200, 230, 250, and 300 patients (Table I). The angiographic facilities and technics developed for use in these community hospitals form the basis of this report. Automatic Equipment Owing to the prohibitive cost, none of the community hospitals covered by this report is equipped with an automatic rapid film changer. These machines are a convenience in angiography, but they are not a prerequisite to accurate extracardiac diagnosis. With suitable catheters and contrast media, most extracardiac examinations can be performed with a hand injection, though efficiency is enhanced when the speed of injection and the timing of exposures are automatically controlled. The Amplatz (2) injector2 provides these features and is particularly useful for studies above the diaphragm and in some patients with hypertension. One such injector was available and was transported from hospital to hospital. Manual Equipment The additions to existing manual equipment can be obtained at a cost of $400.00 or less. Most of the materials can be constructed in a hospital maintenance shop. These removable additions should be designed for use with a fluoroscopy table so that the position of the catheter tip can be checked under direct vision by a small test dose of contrast medium. The rear of the table Bucky slot should be opened. The usual Bucky tray is removed and a 17 × 52-inch metal or plywood tray is inserted in the fashion of the Paessler-Wentzlik table.3 This tray will hold three 14 × 17-inch or four 10 × 12-inch film cassettes. The tray is successively advanced to film-centering markers which are placed along its edge. Film fogging is eliminated by horizontal 5-inch strips along both sides of the table top. In addition, an 18-inch vertical wood or rod support is clamped to both sides of the table, and lead aprons are draped to overlap the horizontal lead strips (Fig. 1). Brachiocephalic and Abdominal Studies: Brachiocephalic and abdominal studies can be performed with the arrangement described above, and films can be obtained without motion at one-second intervals with exposures of two-tenths of a second or less. This filming rate has proved adequate for mapping collateral channels and rate of blood flow where there is occlusion of carotid, innominate, subclavian, celiac, hepatic, or renal arteries.