Percutaneous Carotid Angiography Research Articles

Birth and Growth of Neuroimaging and Vascular Intervention at Sree Chitra Tirunal Institute for Medical Sciences & Technology, Thiruvananthapuram—Part I

AbstractThis article is a historical narrative that traces the growth of neuroradiology and interventional radiology at the Sree Chitra Tirunal Institute of Medical Sciences and Technology, Thiruvananthapuram. From its humble origins in the pre-CT scan era of the mid and late 1970s, when invasive diagnostic procedures such as percutaneous carotid angiography, myelography, pneumoencephalography (PEG) and ventriculography were the mainstay of neuroimaging, the authors take the reader through their gradual foray into catheter four-vessel angiography and later free-flow embolization of arteriovenous malformations (AVMs), and finally to the use of microcatheters for selective embolization procedures. The equipment used in those early years—fluoroscopic tilting table, roll-film cameras, serial changers, PEG tables—provide an insight to an era with all its challenges before the advent of digital imaging. The authors’ efforts to indigenize some of the hardware such as metallic stents and embolization material such as hydrogel spheres and lyophilized dura are also highlighted. The development of peripheral vascular intervention alongside neuroradiology is also highlighted. The authors pay tribute to an early pioneer of neuroradiology in India, Prof. Mahadevan Pillai, who was a guiding light to them during those nascent years.

Spontaneous Occlusion of Traumatic Carotid Cavernous Fistula with Pseudoaneurysm Formation-management with Neuroform Stent and Coiling: A Case Report

W e experienced a case of traumatic carotid cavernous fistula (CCF) which was occluded spontaneously within 7 days after transfemoral carotid angiography with complete disapperance of symtoms. Traumatic CCF is almost always type A and known to rarely resolves spontaneously. The suggested mechanism of spontaneous occlusion were manual compression of carotid artery, hypotension during percutaneous or open direct carotid angiography under general anesthesia in the past as well as thrombo- genicity of iodinated contrast media and catheterization procedure itself are more related with recent transfemoral carotid angio- graphy. The pseudoaneurysm managed with coil or balloon should be frequently followed up due to compaction by the surrounding thrombus.

Dose-Area Product Measurements During Angiographic X Ray Procedures

Radiation exposure during angiography is relatively high compared with other types of radiological procedures. In order to estimate the integral radiation dose absorbed by the patient, the applied dose-area product (DAP) is the most appropriate measurement. The purpose of this study was a systematic recording of measured fluoroscopic DAP, spot DAP, and total DAP as well as detailed examination data acquired at our Department of Diagnostic Radiology to obtain a profile of the radiation exposure in everyday angiographic routine. The data of 86 angiographic X ray procedures were acquired during four weeks. Of these, 74 were among the five most frequent examination types: femoral angiography, iliacofemoral angiography, percutaneous transluminal angioplasty (PTA), carotid angiography and renal angiography. The measured DAP varied considerably, depending on the type of procedure and even among procedures of the same type. Angiography of the lower extremities produced the lowest values (16 Gy.cm2); 177 Gy.cm2 during renal angiography was the highest recorded median DAP.

The thorny road to minimally invasive techniques in neurosurgery.

This article is a brief personal account of a neurosurgeon who started his career in 1950. In spite of the subjective nature, this paper also attempts to provide some objective evidence to the history of our specialty. The terrible pain-causing pneumoencephalography and percutaneous carotid angiography, indispensable of the neurosurgery yesterday, seem to be a nightmare even for a physician today. The psychological stress of a patient at a brain operation in local anaesthesia was enormous, not to speak about the vegetative instability inherent with this anaesthesiological modality. The technical and scientific progress in the last decades, the modern diagnostic methods, the introduction of microsurgical technique and the modern anaesthetical methods and intensive care brought about an important change in the strategy and tactical considerations of neurosurgical interventions. Today the aim of our operations is not only to save life, but to improve the quality of life of the patient. Our surgical policy is directed by the knowledge of microscopical anatomy, the knowledge of arachnoidal membranes and cisterns and the introduction of microneurosurgical techniques.

Emergency percutaneous carotid angiography

Emergency percutaneous carotid angiography

Iliopsoas abscess: an unusual complication of femoral artery catheterization

We report a case of iliopsoas abscess following percutaneous transfemoral carotid angiography. To our knowledge there are no previous reports of this complication. The patient, a woman aged 49, was admitted for investigation of occlusive cerebrovascular disease. She was a smoker and had a history of exopthalmic Graves' disease and thyrotoxicosis, previously treated with Iodine 131. Current medications were thyroxine, Voltarol Retard and Nifedipine Retard. Prior to the procedure, haemoglobin level was 14.2 g/dl, white cell count was 8400 × 103/ml and platelet count was 283 000 × 103/ml. Full clotting studies were normal. Carotid arteriography was performed using a modified Seldinger technique. Full aseptic precautions were taken including groin shave, cleansing with chlorhexidine, povidone iodine skin preparation and sterile drapes and gowns. A 5 F Mani catheter (William Cook Europe ApS) and a 0.035 inch straight guidewire were used during the procedure which was protracted owing to inability to catheterize the left common carotid artery. A subsequent arteriogram using a 5 F pigtail catheter revealed complete occlusion of this vessel at its origin. Compression was applied to the puncture site for 20 min. The patient was well following the procedure and was discharged home shortly thereafter. Minor bruising only was seen at the puncture site. She presented again 22 days post-investigation complaining of increasing pain in the right groin and difficulty with walking. On examination she was pyrexial; and greenish, offensivesmelling fluid was oozing from the puncture site in the right groin.

Objective feature extraction applied to the diagnosis of carotid artery disease using a Doppler ultrasound technique

Using the maximum frequency envelope obtained from the sonogram of the Doppler shifted frequencies a mathematical feature extraction technique has been used to provide an objective identification of the significant waveform features. The technique described is that of principal component factor analysis. The data used were taken from an eighteen month programme in which techniques based on the use of directional Doppler ultrasound were evaluated in comparison with direct percutaneous carotid angiography and arch aortography. A tracing of the vessel outlined based on the anterior-posterior view of the angiogram was used to classify each vessel segment studied. Two groups only are considered in this initial study, a normal group (25 vessel segments) and a stenosis group (18 vessel segments). The principal component analysis technique was shown to provide a superior classification of the vessel segments when compared with the more familiar A/B ratio. Nevertheless the principal diagnostic feature is shown to be the A/B ratio.

Assessment of directional Doppler ultrasound techniques in the diagnosis of carotid artery diseases.

Three diagnostic techniques based on the use of directional doppler ultrasound have been evaluated in comparison with direct percutaneous carotid angiography and arch aortography. The results indicate that the non-invasive techniques provide a safe, atraumatic method of assessing patients with symptoms of extracranial occlusive arterial disease.

Foreign body embolism of retinal arteries as a complication of carotid angiography.

Two cases of foreign body embolism of the retinal arteries after percutaneous carotid angiography were encountered within a period of 7 months. Both patients were non-arteriosclerotic. Loss of visual function in direct relation to carotid angiography and the observation of a dark foreign body in a retinal arteriole indicated exogenous embolism. No or only slight remission occurred. Careful ophthalmoscopy in cases of visual complaints after carotid angiography is advised, and if foreign body embolism is suspected, treatment with vasodilators (e. g. amyl nitrite) should be given a trial.

Changes in carotid flow velocity induced by direct percutaneous carotid angiography in man.

Quantitative percutaneous flow velocity measurements are possible in carotid arteries. The results of the direct percutaneous angiography were measured by means of a Doppler directional flow velocity device and registered on a polygraphy. The results indicate an increase in the flow velocity of the injected as well as the non-injected carotid system. This implies that there are no local constrictions of the carotid artery following intervention and, furthermore, it implies a systematic effect of the puncture and injection itself, or of the contrast medium, on the whole cerebral circulation. A diffuse vasodilatation, at least in the cerebral circulation, is postulated. The possible implications are discussed.

Subdural Empyema.

Subdural empyema is a distinct clinical entity not uncommon in Ceylon. Forty-seven cases have been analysed. The commonest sources of infection are otitis media and frontal sinusitis. These empyemas are often complicated by cortical thrombophlebitis, meningitis and intracerebral abscesses. The symptomatology is difficult to differentiate clinically from that of other forms of intracranial suppuration. Percutaneous carotid angiography is the investigation of choice. The treatment consists of surgical evacuation of pus combined with correct antibiotic therapy and skilled nursing. Our mortality of 25·5% was due to uncontrollable associated infections, usually the result of late referral.

Percutaneous Carotid Angiography under Digital Proximal Compression of Jpsilateral Common Carotid Artery

Percutaneous Carotid Angiography under Digital Proximal Compression of Jpsilateral Common Carotid Artery

Simplified selective femorocerebral angiography.

In this country, as a rule, carotid angiography is performed by direct puncture and vertebral angiography by brachial catheterization or retrograde brachial injection. There are many, however, who sponsor other needle and catheter technics for cerebral angiography. Among these, advocates of the femoral catheter are scarce. With the catheters now available, selective femorocerebral angiography is a relatively difficult and time-consuming procedure for the average operator. The authors will describe a catheter which greatly simplifies this procedure. The femoral route is the best for selective cerebral angiography. It is the only one-puncture approach which gives access to all four major cerebral arteries for selective study. It provides maximum flexibility of operation for the angiographer (3). It is relatively easy to modify the approach to a diagnostic problem in mid-procedure if the findings on the early angiographs so dictate. At times it is the only adequate technic available for angiographic examination (6). The frequent use of general anesthesia during percutaneous carotid angiography indicates that, at best, it is a traumatic procedure. Almost all physical discomfort and emotional distress are eliminated by use of the femoral technic. With rare exception, general anesthesia may be omitted. Very little premedication is required. The procedure can be done on an out-patient basis. Other catheter methods do allow selective study of individual arteries, but, except for catheterization of the carotid per se, they do not permit individual study of the internal and external carotid arteries as does the femoral technic. In addition, the femoral approach will usually provide comparable or better vascular contrast. Catheter Description The original Ducor catheter2 designed by Viamonte and Stevens (7), is a polyurethane catheter within the wall of which is incorporated a wire braid. The braid enhances torsion control and strengthens the catheter (2). It is the torsion control in conjunction with preformed curves which makes this catheter useful in selective cerebral angiography. We use a modified 100 cm, 8F Ducor catheter with an inner diameter of 0.056 inches. The “pencil” tip has been somewhat blunted to minimize risk of intimal injury; the side-holes have been eliminated to reduce the chance of clotting in the catheter tip; and the distal 10 cm of the catheter have been constructed without braid to eliminate interference with catheter memory and to give flexibility in this segment (Fig. 1) (5). The catheter is given a “head-hunter” configuration by threading a shaping wire with the desired curves into the tip of the catheter and immersing it in boiling water for three minutes. After gas sterilization the catheter is ready for use. Figure 2 illustrates two basic head-hunting configurations, each with a modification demonstrated directly below.

Laryngeal complications of percutaneous cerebral angiography. Continued observations.

Through a systematic laryngological examination of 54 patients undergoing percutaneous carotid angiography, 5 patients presented laryngeal oedemas of varied size and spread on the same side. In another 5 patients both oedema and suggilations of the larynx were found, extending in the cranial direction to the pharynx and the rhinopharynx. The cause and pathogenesis of the laryngeal oedema are discussed and it is concluded that the oedema is produced by the development and dissection of deep neck haematomas which give rise to localized congestion. Furthermore factors which might influence the formation of haematomas during and after puncture have been studied. Hereby it was found that the number of attempts to puncture might exert an influence, however, this is not the sole explanation of the development of the haematoma.From a study of 20 patients undergoing vertebral or coronary angiography via a catheter inserted from the axillary or the femoral arteries, no laryngeal complications were disclosed.

CEREBRAL ANGIOGRAPHY IN THE EVALUATION OF PATIENTS WITH CEREBROVASCULAR DISEASE

Accurate visualization of all of the extracranial and intracranial vasculature, including serial studies for evaluation of collaterals and circulatory physiology is essential before undertaking any therapeutic measures for patients with evidence of ischemic cerebrovascular disease. The methods now at our command make it possible to identify vascular lesions in 80 per cent of patients with cerebrovascular disease. In order to achieve a complete picture of extra-or intracranial circulation one must obtain excellent contrast filling and technically good films of the entire brachiocephalic arterial tree. Films must be obtained in rapid succession and must be taken during a period of time long enough to make visible not only the anatomy but the physiology of flow and collateral circulation. The techniques of angiography used at New York University Medical Center include right and left percutaneous brachial angiography and left carotid angiography. Biplane films of the origins of the vessels and their course in the neck are taken in the oblique projection during the brachial examination. Biplane head and neck films are obtained during both brachial and carotid angiograms. Extracranial stenoses and occlusions are readily identified. Such lesions are most commonly found at the common carotid bifurcation and at the vertebral artery origin. Intracranial stenoses and occlusions may occur in conjunction with extracranial disease or independently. Collateral channels of every conceivable type have been seen. An understanding of the alteration of flow caused by the formation of collateral beds is basic to an understanding of ischemic phenomena. Acute major vascular occlusions are often associated with edema of the involved hemisphere, and in such instances these findings suggest a grave prognosis. Although the status of surgical and medical therapy is not entirely clear at this point, it is probable that surgical removal of certain stenotic lesions in particular cases of stenotic cerebrovascular disease may offer a more favorable prognosis. It is imperative that the study of the entire intra- and extracranial circulation be completed before a rationale for therapy can be developed.

A New Needle-Cannula Assembly for Direct Percutaneous Carotid Angiography

It is believed that the following technical note may be of interest to many radiologists. The use of a rigid needle or cannula assembly (such as a Seldinger needle) for performing direct percutaneous carotid angiography can often present frustrating technical difficulties in heavy-chested, short-necked patients. A steep entry angle is frequently dictated by the patient's build, unless the shoulders are raised and the head thereby extended. Once entry is gained to the arterial lumen, it is then usually necessary to lower the shoulders and bring the head into more optimal position for properly angled frontal projections. In the attempt to obtain an adequate position, dislodgment of the needle tip or cannula tip from its intraluminal position may occur. We recently began using a simple, inexpensive, disposable needle-cannula assembly2 which has been so successful in overcoming these difficulties that we now employ it routinely for direct carotid angiography. The assembly consists of a long-beveled, very sharp disposable needle, over which a plastic cannula is closely fitted up to the beginning of the bevel. The arterial lumen is usually entered without the necessity of transfixing the distal wall and then backtracking into the lumen. Once the lumen is entered, the cannula is slid down over the needle and threaded well up into the lumen. The needle is now withdrawn. An extension tube previously filled with normal saline solution is attached to the cannula. A normal saline-filled flushing syringe with a three-way stopcock adapter is placed at the operator's end. The flexibility of the plastic cannula permits it to remain securely within the lumen of the artery during positioning of the head for injection of contrast material. This method is incidentally well suited to peripheral arteriography and venography in those situations where high-pressure connections are not required.

A lateral medullary syndrome following vertebral angiography.

We report here a case in which vertebral angiography was followed by the development of symptoms and signs indicative of damage to the lateral medulla, which have persisted. The patient was an otherwise healthy male aged 26 years who was undergoing investigation following two attacks of subarachnoid haemorrhage. Clinical examination was negative and the blood pressure 140/80 mm Hg. On June 14, 1958, bilateral percutaneous carotid angiography was carried out under general anaesthesia. Satisfactory films were obtained after using an injection of 20 ml. of 60 per cent Urografin on each side and no abnormality was demonstrated. Recovery was uneventful. On June 27, 1958, left-sided vertebral angiography was carried out under a general anaesthetic. The anterior approach was used and 16 ml. of 60 per cent Urografin were injected. Films taken after this showed that the contrast medium had not passed beyond the vertebral artery. The needle was adjusted and a further 16 ml. of medium injected. Satisfactory films of...

Visualization of the basilar, cerebellar, and vertebral arteries during carotid cerebral angiography.

The basilar and cerebellar arteries are seldom visualized during carotid angiography. Their recent demonstration in three such examinations prompted us to review our angiographic records and the literature in a search for other instances. The principle of reflux filling is often employed for complete carotid cerebral angiography. Compression of the right common carotid artery above the point of insertion of the needle, together with occlusion of the brachial artery by means of a blood-pressure cuff, may reroute the contrast medium back along the common carotid into the innominate and subclavian arteries and thence into the vertebral artery. Serial films exposed about three seconds after injection will visualize the vertebral and basilar arteries often enough to make this procedure useful (1). A similar mechanism is operative with thrombosis of the right internal carotid artery. Shapiro and Peyton (7) noted retrograde flow of contrast medium during right percutaneous carotid angiography, resulting in visua...

An unusual case of extra-dural haematoma.

classical clinical picture of extra‐dural terval, deteriorating consciousness, pupillary changes, developing hemiplegia, falling pulse rate and rising blood pressure ‐ has often been described, and is stressed to the student as his criterion for the diagnosis of this dramatic and, in its early stages, remediable sequel of head injury. But this condition may masquerade in various disguises, and the differential diagnosis from cerebral vas‐ cular accident, in particular, is often beset with difficulty. THE haematoma‐of head injury, lucid in‐ Lumbar puncture was performed, lightly blood‐ stained cerebrospinal fluid being obtained under a pressure of 205 millimetres of cerebrospinal fluid. Microscopy showed 1,400 erythrocytes and 4 lympho‐ cytes per cubic millimetre. A provisional diagnosis was made of subarachnoid haemorrhage resulting from leaking of an intra‐ cranial aneurysm ‐ probably situated on the right posterior communicating artery ‐ and on the next day percutaneous right carotid angiography under local anaesthesia was attempted ‐without success, owing to failure to puncture the exceedingly mobile artery. This case is recorded because of its interesting clinical and radiological features.Summary An unusual case of post‐traumatic extra‐dural haematoma is reported. There was no history of injury, and the case clini‐ cally resembled intracranial aneurysm. The angiographic picture of extra‐dural haematoma is presented, with demonstra‐ tion of the bleeding point. The‐necessity for early establishment of diagnosis, and for early operative inter‐vention is stressed.

A complication of percutaneous carotid angiography.

A complication of percutaneous carotid angiography.