Carotid Digital Subtraction Angiography Research Articles

Evaluation of the level of carotid bifurcation and the morphology of extracranial internal carotid artery in patients with carotid stenosis by color doppler ultrasound and digital subtraction angiography

Objective: To evaluate the value of color Doppler ultrasound and digital subtraction angiography (DSA) in evaluating the level of carotid bifurcation and the morphology of extracranial internal carotid artery in patients with atherosclerotic carotid stenosis. Methods: The carotid artery examination data of 186 patients with atherosclerotic carotid stenosis who underwent carotid DSA and color Doppler ultrasound in Shanghai Changzheng Hospital from July 2017 to June 2019 were retrospectively analyzed, including 154 males and 32 females, with ages ranging from 36 to 84 (66±8) years old. The correlation between the position of carotid bifurcation and the level of cervical spine, the distance from the position of carotid bifurcation to mandibular angle, the correlation of the level of bifurcation with the length of neck, and the incidence of carotid distortion were analyzed. Results: DSA showed that the most common position of carotid bifurcation was at C3 level on the left [37.3% (56/150)], and at C3-C4 level on the right [33.6% (42/125)], and the highest position was at C2 level on the left, and at C2-C3 levels on the right, while the lowest level on both sides was at C5 level. The incidence of high bifurcation of left carotid artery (C3 and above) was 46% (69/150), which was higher than that of right carotid artery [21.6% (27/125), P<0.001]. The incidence of high carotid bifurcation in men and women was 33.2% (76/229) and 43.5% (20/46), respectively, with no significant difference (P = 0.182). Carotid ultrasound showed that the distance between the left carotid bifurcation and the mandibular angle was (3.0±1.3) cm, which was shorter than that on the right [(3.4±1.2) cm] (P<0.001). The distance between carotid bifurcation and mandibular angle in men and women was (3.2±1.2) cm and (3.3±1.0) cm, respectively, with no significant difference (P = 0.093). There was no significant correlation between carotid bifurcation level and carotid length (right: r = 0.02, P = 0.091; left: r = 0.01, P = 0.927). The incidence of carotid artery distortion was 28.1% (9/32) in women and 15.6% (24/154) in men, with no significant difference (P = 0.091). The incidence of right carotid artery distortion in high bifurcation group was 59.3% (16/27), which was higher than that in non-high bifurcation group [3.1% (3/98)] (P<0.001). Likewise, the incidence of left carotid artery distortion in high bifurcation group was 30.4% (21/69), which was higher than that in non-high bifurcation group [2.5% (2/81)] (P<0.001). Conclusions: The bifurcation position of left carotid artery in patients with atherosclerotic carotid stenosis is higher than that of the right. Patients with high bifurcation of carotid artery are more likely to be complicated with carotid distortion. Preoperative color doppler ultrasound combined with DSA can evaluate the distortion of extracranial carotid artery, thereby providing reference for the selection of surgical methods.

Prevalence and Clinical Outcomes of Asymptomatic Carotid Artery Stenosis in Patients Undergoing Concurrent Coronary and Carotid Angiography.

PurposeThe prevalence and clinical outcomes of asymptomatic carotid artery stenosis (CAS) in patients with coronary artery disease (CAD) have not been thoroughly studied. We examined the prevalence and predictors of asymptomatic CAS detected by carotid angiography and determined the impact of concomitant CAS on prognosis in patients undergoing coronary angiography (CAG) due to CAD.Materials and MethodsBetween January 2013 and July 2015, 395 patients who underwent carotid digital subtraction angiography to screen for CAS during CAG were analyzed. The presence of CAS was defined as angiographically significant stenosis (≥50%). Major adverse cardiac and cerebrovascular event (MACCE) rates were compared between patients with and without CAS. MACCEs included a composite of cardiac death, cerebrovascular death, acute myocardial infarction, and stroke.ResultsOf the 395 patients, 101 (25.5%) patients had significant CAS. The independent predictors of CAS were age, male sex, hypertension, diabetes, and multi-vessel disease. In patients with CAD, the presence of CAS was as an independent predictor for MACCEs after adjusting for confounding factors (hazard ratio 2.47, 95% confidence interval 1.16–5.24, p=0.018).ConclusionAsymptomatic CAS was documented in up to 25% of patients with CAD. The presence of CAS in patients with CAD was associated with a higher rate of MACCEs. Therefore, detection of CAS by carotid angiography during CAG may be important for risk stratification for CAD patients, particularly those with multi-vessel disease.

Carotid Angiographic Profile in Patients with Coronary Artery Disease

Background: This study was conducted with an aim of assessing the angiographic incidence of carotid artery stenosis (CAS) in patients undergoing coronary angiography for the diagnosis of coronary artery disease (CAD). Methods: This single centre study included 50 patients with stable CAD or acute coronary syndromes, undergoing coronary angiography for diagnostic or therapeutic indications, who gave consent for concomitant carotid digital subtraction angiography (DSA). Significant CAD was defined as ≥ 50% diameter stenosis in at least one major coronary artery or its first order branches, and was categorized as single vessel disease (SVD), double vessel disease (DVD), or triple vessel disease (TVD) according to number of vessels involved. Significant CAS was defined as a diameter stenosis of ≥50% in the common carotid artery, the carotid bifurcation, or the internal carotid artery. For statistical analysis, patients were divided into two groups i.e. patients without or with CAS. Patient characteristics in these groups were then analysed and compared to each other. Results: The mean age of study group was 58.72 ± 9.03 years. Out of 50 patients studied 33 (66%) were males and 17 (34%) were females. Risk factors included hypertension, smoking, diabetes mellitus and dyslipidemia in 82%, 50%, 48% and 28% patients respectively. CAD was present in 62% patients; with 24%, 14% and 24% patients having SVD, DVD and TVD respectively. CAS was present in 10 (20%) patients, all of whom had TVD on coronary angiography (p≤0.0001). Patients with CAS were more likely to be older than those without CAS (p=0.065). Additionally, 80% of patients with CAS were males and all of them were hypertensive. Conclusion: Significant CAS is found in substantial proportion of patients with CAD, especially multi vessel disease. A strategy of concomitant carotid DSA at the time of coronary angiography may allow superior risk stratification and better planning of management in these patients. Key words: Carotid artery stenosis, Carotid angiography, Coronary Artery Disease.

Variations in the Circle of Willis in the New Zealand White Rabbit

Purpose The New Zealand White rabbit (NZWR) serves an important role as an experimental model for vascular research, specifically in the area of stroke. Here the authors document vascular variations in the circle of Willis (COW). Materials and Methods Subselective internal carotid digital subtraction angiography was performed in 100 NZWRs. Results Important variations include hypoplasia in 36%, duplication of the middle cerebral artery in 29%, asymmetries of the posterior region in 19%, and multiple variations in 28%. The complete classical symmetric COW without significant variation is present in fewer than 30% of animals. Conclusions With recognition of the variations, the NZWR becomes an improved research model.

Carotid-Cavernous Fistula Caused by Rupture of Persistent Primitive Trigeminal Artery Trunk Aneurysm-Case Report-

A 60-year-old female presented with a carotid-cavernous fistula (CCF) manifesting as left abducens nerve palsy. Left internal carotid digital subtraction angiography showed a persistent primitive trigeminal artery (PPTA) near the CCF. Super-selective angiography showed direct shunt flow between the PPTA trunk aneurysm and the left cavernous sinus. The aneurysm was successfully occluded with detachable coils. The CCF disappeared and the PPTA was preserved. The abducens nerve paralysis had disappeared 6 months later. CCF caused by a PPTA trunk aneurysm is extremely rare. We speculate that the PPTA trunk aneurysm formed and then ruptured due to hemodynamic stress caused by hypoplasia of the basilar artery.

Intra-Arterial Thrombolysis for Left Middle Cerebral Artery Embolic Stroke During Coronary Angiography

Cerebral thromboembolism is an uncommon but serious complication of cardiac catheterization. Early diagnosis and rapid treatment by reperfusion techniques have been shown to prevent long-term neurological morbidity. We report 2 consecutive cases of successful local intra-arterial thrombolysis (LIT) for embolic stroke of the middle cerebral artery (MCA) during diagnostic coronary angiography that resulted in complete neurological recovery. A 77-year-old woman with severe valvular aortic stenosis was admitted to our catheterization laboratory for a preoperative coronary angiography. Performed from the femoral approach, it showed a normal angiographic pattern. Immediately after the procedure, the patient became stuporous with right hemiplegia and global aphasia. She was hemodynamically stable. The left carotid digital subtraction angiography that was performed immediately revealed total occlusion of the M2 part of the left MCA. There was no extravasation of contrast (Figure 1). We decided to administer selective intra-arterial urokinase infusion. After systemic heparinization (bolus of 5000 UI), a 6F Amplatz Right Guide catheter was placed in the left internal …

Value of the CT angiography in the diagnosis of common carotid artery bifurcation disease: CT angiography versus digital subtraction angiography and color flow Doppler

Objective: assessment of the degree of stenosis is the central point in the treatment of carotid stenosis. The purpose of our study was to assess whether invasive CT angiography (CTA) is a feasible alternative to the current invasive gold standard carotid digital subtraction angiography (DSA) and the current non-invasive gold standard color flow doppler. Subjects and methods: about 178 patients with cerebrovascular disease underwent digital subtraction angiography (DSA), CFD and CTA. CTA was performed on a Somatom plus 4 (Siemens, Erlangen Germany). CT was performed with 2/3/2 (collimation/table feed/reconstruction interval) or 2/3/1 mm, start delay 15–20 s, flow 2.5–3.0 ml/s, using 120 ml non-ionic contrast medium (300 mg J/ml). Quantification of degree of stenosis was based on the perfused area in the axial slices. Plaque morphology (soft and hard) and ulceration were evaluated. Results: CTA detected nine cases of significant stenosis, which had been underestimated by DSA. CTA failed in two cases of a membraneous stenosis, which were underestimated, and in two cases with teeth artifacts. Calcifications were more readily appreciated by CTA than in CFD. In this respect, both methods were superior to DSA. CFD, DSA and CTA had a sensitivity of 100% for occlusions, respectively. Conclusion: CT angiography is useful in case of inconclusive CFD in the pre- and postoperative phase, and as a third modality in case of disagreement between DSA and CFD.

Carotid calcifications on panoramic radiography identify an asymptomatic male patient at risk for stroke: A case report

Although stroke may be preventable, a major challenge is to find effective methods of detection of stroke-prone patients. Most noncardiogenic strokes occur as a result of atherosclerosis involving the proximal internal carotid artery, calcifications of which can be detected on dental panoramic radiography. This report describes the case of an asymptomatic patient whose dental radiographic findings led to carotid endarterectomy. Calcifications were viewed bilaterally in the soft tissues of the neck in the area of the carotid bifurcation on a screening panoramic radiograph of an asymptomatic 75-year-old man. Subsequent duplex Doppler ultrasound revealed extensive atherosclerotic changes bilaterally with critical stenosis (90%+) in the right internal carotid artery. Carotid digital subtraction angiography revealed a 95%+ stenosis at the origin of the right internal carotid artery. The patient underwent right carotid endarterectomy involving the internal, external, and common carotid arteries. Twelve months later the patient was alive and well. Dental panoramic radiography represents a useful imaging modality for detection of some asymptomatic stroke-prone patients. Identification of calcifications in the area of a patient's carotid vasculature should prompt expeditious referral to a physician for a cerebrovascular and cardiovascular work-up as part of an active stroke prevention strategy.

Double-blind comparison of safety and efficacy of iomeprol and iopamidol in carotid digital subtraction angiography

Iomeprol is a nonionic monomer which provides injectable formulations with the lowest osmolalities and the lowest viscosities among the currently available low-osmolar radiographic contrast agents of the same category. These favourable physico-chemical characteristics, together with high water solubility and low molecular toxicity, make this agent particularly suitable for carotid angiography, a procedure in which contrast-induced blood-brain barrier damage is maximal. This single-centre, randomised, double-blind, parallel-group study aimed at comparing the safety, tolerance and efficacy of 200 mgI/ml solutions of iomeprol and iopamidol in 100 consenting adult inpatients undergoing carotid intra-arterial digital subtraction angiography (IA-DSA). Both agents appeared to be safe and well tolerated. Only minor and transient adverse events occurred throughout the study. Electroencephalographic and neurological examinations performed pre- and post-contrast showed no abnormality induced by the test compounds. Vessel opacification was good or excellent in the vast majority of technically adequate examinations. Information provided by the angiographic examination was useful for subsequent patient management in almost all cases. It is concluded that iomeprol-200 and iopamidol-200 are safe and effective contrast media when used for carotid IA-DSA, an examination which proves useful not only for the diagnosis of vascular lesions, but also to best direct the management of patients scheduled for surgery of intracranial tumors.

Organ doses from cardiac and carotid digital subtraction angiography.

Estimates of mean organ doses from cardiac and carotid digital subtraction angiography (DSA) are obtained from measurements done using a Rando-Alderson tissue-equivalent phantom. Thermoluminescent dosemeter chips and discs were calibrated and used for all measurements in the primary and scattered radiation fields. Skin doses as well as mean doses received by the thyroid, lung, lens of the eye, breast, uterus and the ovaries were measured. A 30 degree right anterior oblique (RAO) cardiac DSA study produces a beam entrance dose of about 121 mGy at a rate of 0.48 mGy/frame. The highest mean organ dose from cardiac DSA was to the lung with a value of 14.4 mGy. The rest of the organs received doses below 1 mGy. In carotid DSA, the mean entrance doses resulted from the RAO, left anterior oblique, and the Towne's view projections give an average of 168 mGy at a rate of 8.4 mGy/frame. The highest mean organ dose from the three projections, 21 mGy, was received by the thyroid. The uterus and ovaries received the lowest doses from both procedures with values below 0.04 mGy. Patient and phantom surface exposures were compared using an exposure area product system. Hence, exposure conditions used for measuring organ doses on the phantom were adjusted to resemble those used for patients.

Relative safety of intravenous digital subtraction angiography over other methods of carotid angiography and impact on clinical management of cerebrovascular disease.

Data from a multicentre survey based on three London teaching hospitals on the relative safety and clinical utility of intravenous carotid digital subtraction angiography (DSA) over intra-arterial DSA and conventional carotid angiography are presented. The incidence of stroke during intra-arterial DSA was 0.7% (n = 538) and during conventional angiography was 0.8% (n = 780). The incidence of stroke during intravenous DSA was zero (n = 3710). When it constituted the initial investigation, intravenous DSA achieved a 93.8% replacement value over intra-arterial studies as a whole (n = 474) and 89% replacement value for patients having carotid endarterectomy (n = 99). It was also noted that the installation of DSA equipment at one unit coincided with a sixfold increase in the number of carotid angiographic examinations and an almost threefold increase in carotid endarterectomies.

Cerebrovascular disease: outpatient evaluation with selective carotid DSA performed via a transbrachial approach.

A total of 355 outpatients and 73 inpatients were studied for cerebrovascular disease with intraarterial digital subtraction angiography (DSA). The studies were performed by means of selective carotid and vertebral artery catheterization from a transbrachial approach. Selective catheterization of the carotid artery was possible in 95% of patients, with definitive examinations of both extra- and intracranial circulation obtained in 95%-100% of all patients. Vessel opacification was very good to excellent, and the technique was inherently free from artifact caused by vessel overlap or involuntary motion. There were 25 complications, of which 20 were local in nature. Iodine load per case was extremely low, averaging 4.2-7.0 g. Selective carotid and vertebral catheterizations by the brachial route proved to be as safe as intravenous DSA and aortic arch intraarterial DSA with less contrast material load and superior images.

Radiation exposure of personnel during digital subtraction angiography

Radiation exposure to the lens of physicians performing intravenous and hand-injected intraarterial digital subtraction angiography (DSA) were monitored with and without a combined face and body shield. Shielding provided nearly a three-fold reduction in dose for both intravenous and intraarterial exams, with the highest doses recorded for intraarterial exams due to longer fluoroscopy and exposure during imaging. When compared with the NCRP guidelines of maximum exposure to the lens, an angiographer could theoretically perform up to two intraarterial and 14 intravenous studies per day with protection or one intraarterial and two intravenous studies per day without protection. The exposure values in this study reflect our equipment and personal technique in carotid DSA and may not apply to other departments, but should encourage other angiographers to monitor exposure in their own angiography suites.

Limitations in the interpretation of intravenous carotid digital subtraction angiography.

To evaluate the limitations of intravenous carotid digital subtraction angiography (DSA) in the diagnosis of carotid disease, studies of 130 patients were reviewed. Factors that resulted in a nondiagnostic study included: (1) misregistration larynx artifact overlying the carotid bifurcation; (2) external carotid or vertebral artery overlying the internal carotid artery; and (3) poor arterial contrast density secondary to poor cardiac function. As a result of these limitations, the ideal of adequate demonstration of both carotid bifurcations in two opposite oblique projections or an oblique and anteroposterior projection was achieved in only 34 patients (26%). Of 126 carotid bifurcations that were seen adequately in two or more different projections, 19 (15%) showed an abnormality in one projection but appeared normal in another. These abnormalities would not have been detected had the vessel been visualized only in the spuriously normal-appearing projection. These and other limitations of intravenous DSA, such as contrast load and morbidity, are discussed.