https://doi.org/10.3329/bjns.v12i2.

71941

Original Article

Digital Subtraction Angiogram: Beginners Perspective

Sikder MSR1, Hasan MM2, Rana MS3, Rahman MA4, Alam MJU5, Islam MS6, Hossain M7

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Abstract
Digital Subtraction Angiography (DSA) is a modern technique which integrates
Conflict of interest: There is no Conflict digital data collection and computer processing to produce a medical image. X-ray
of interest relevant to this paper to signals are detected electronically rather than on film and then converted to

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disclose. digital form to be processed by a computer before being displayed. DSA is an
Funding Agency: Was not funded by
integral investigation in the management of patients with neurovascular diseases. It
any institute or any group. is basically used for diagnosis, but in many instances, it may be therapeutic in the
same sitting. Indications for diagnostic DSA include both extracranial and intracranial
Contribution of Authors: Principal
vascular diseases. A sound understanding of the principles of appropriate
Investigator- Prof. Md. Shafiqul Islam
periprocedural care and anatomy, catheter technique and basic disease pathology are
Manuscript preparation- Dr. Md
vital to use DSA as a diagnostic as well as therapeutic purposes.
Motasimul Hasan Dr. Major Monowar

Vol. 12,
Morshed, Dr. Md. Sumon Rana Keywords: Digital Subtraction Angiography, neurovascular diseases
Data collection- Dr. Md Shahidur Bang. J Neurosurgery 2023; 12(2): 102-113
Rahman Sikder
Editorial formatting - Prof.

No. 2,
Mohammad Hossain
Copyright: @2022bang. BJNS
published by BSNS. This article is

january 2023
published under the creative commons
CC-BY-NC license. This license permits
use distribution (https://creativecommons.
orgf/licences/by-nc/4-0/) reproduction in
any medium, provided the original work
is properly cited and is not used for
commercial purposes.
Received: 20 July, 2022
Accepted: 23 August, 2022

Introduction is very important to know the relevant anatomy, basics

Digital Subtraction Angiography (DSA) is an integral of the procedure, periprocedural preparations as well
procedure in the management of patients with as pathology to avoid complications, interpret the
neurovascular diseases. It is used for both diagnosis
findings and plan treatment.2
as well as interventional treatment in the same sitting.1
A sound understanding of the principles of appropriate Relevant Anatomy
periprocedural care and anatomy, angiography Embryologic development explains the many anatomic
technique, and angiographic appearance of pathology variants of cerebrovascular circulation. However, details
are vital for the test to be diagnostic. For a beginner it about embryology are beyond the scope of this article.

1. Dr. Md Shahidur Rahman Sikder, Assistant Registrar, Department of Endovascular & Stroke Surgery, Dhaka Medical College, Dhaka.
2. Dr. Md Motasimul Hasan, Associate Professor, Department of Endovascular & Stroke Surgery, Dhaka Medical College, Dhaka
3. Dr. Md. Sumon Rana, Assistant Professor, Department of Neurosurgery, Dhaka Medical College, Dhaka.
4. Md Atikur Rahman, Associate Professor, Neurosurgery Department, Bangabandhu Sheikh Mujib Medical University, Shahbag Dhaka.
5. Dr. Mohammad Jahangir Ul Alam, Assistant Professor, Department of Medicine, Sir Salimullah Medical College & Mitford Hospital, Dhaka.
6. Prof. Md. Shafiqul Islam, Professor, Department of Neurosurgery, Dhaka Medical College, Dhaka.
7. Prof. Mohammad Hossain, Professor, Department of Neurosurgery, Bangabandhu Sheikh Mujib Medical University, Shahbag, Dhaka.
Address of Correspondence: Dr. Md Shahidur Rahman Sikder, Assistant Registrar, Department of Endovascular & Stroke
Surgery, Dhaka Medical College, Dhaka. Mobile: 01710201018
Digital Subtraction Angiogram: Beginners Perspective Sikder MSR et al.

Aortic Arch . Right aortic arch (Fig 1-m and n) may be an incidental
The challenges posed by complex aortic anatomy finding or may be associated with known congenital
demand specific considerations in choice of introducer heart disease or a vascular ring.This variant is one of
catheters. It must be emphasized that catheter the greatest challenges for cerebral angiography when
manipulation in atherosclerotic arches is likely a it is encountered in late adulthood. The carotid vessels
significant source of embolic complications. So it is can be very proximal in their origin on the aorta and

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very important to know about the anatomy of the arch very difficult to catheterize.
for a successful procedure.
Extracranial Carotid System (Figure-2)
• Common carotid artery (CCA): Left CCA from the

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aortic arch and right CCA from the brachiocephalic
trunk.
• External carotid artery (ECA): From the upper
border of the thyroid cartilage (C4 vertebral level)
to terminal branches. Branches include the
following:

Vol. 12,
1) Superior thyroid artery
2) Ascending pharyngeal artery
3) Lingual artery

No. 2,
4) Facial artery
5) Occipital artery
6) Posterior auricular artery

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7) Terminal branches ’! superficial temporal and
internal maxillary arteries.

Anterior Circulation
• Internal carotid artery (ICA) (1,2,4): Bouthillier
classification,from below upward
• C1—Cervical segment. From the common carotid
bifurcation to entry into the carotid canal.
• C2—Petrous segment. Completely within the bony
carotid canal. Small branches not appreciable on
digital subtraction angiography (DSA).
• C3—Laceral segment. Up to the petrolingual
Figure 1: (A–P) Aortic arch variations and anomalies. ligament. First 1 cm of the ICA after exit from the
Schematic illustration of the major groups of aortic carotid canal.
anomalies.3 1-d is bi-innominate artery.This is a rare • C4—Cavernous segment. Up to the proximal dural
entity. The aortic arch has a symmetric appearance rim, just inferior to the clinoid process. Branches
with each innominate artery giving a common carotid are meningohypophyseal trunk and inferolateral
and subclavian artery.aBerrant right SuBclavian artery trunk.
(1-k) is a common anomaly and has an association
• C5—Clinoid segment. Smallest segment, by the
with trisomy 21. The term usually refers to the origin
side of the anterior clinoid segment. Ophthalmic
of the right subclavian artery from a point distal to the
artery can arise from it, else no significant
left subclavian artery. Bicarotid trunk where both
branches.
carotids originate from the same trunk making
catheterisation very difficult(1-c,1-e). Double aortic • C6—Ophthalmic segment from distal dural ring up
arch where usually, each arch will give off a common to the posterior communicating artery (PCOM).
carotid artery and a subclavian artery (Fig. 1-o and p) • C7—Communicating from PCOM to ICA bifurcation.

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Bangladesh Journal of Neurosurgery Vol. 12, No. 2, January 2023

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Fig.-2: Common carotid artery injection showing its primary and secondary branches (2).

Fig.-3: Anterior Circulation

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Digital Subtraction Angiogram: Beginners Perspective Sikder MSR et al.

Middle cerebral artery (MCA) • A2—ACOM to origin of the pericallosal and

callosomarginal artery.
• M1—Up to insula, not the bifurcation. The
bifurcation can be of the early or lateral type. • A3—Precallosal segment.
• M2—Curved course over the surface of the insula. • A4—Supracallosal segment.
• M3—Descends along the circular sulcus of the • A5—Postcallosal segment.

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insula/ operculum up to the cortical surface.
Figure 4:(5)Lateral views, showing the five ACA
• M4—Along the convex cortical surface. segments and 12 arteries that can enter the surgical
field around an anterior communicating artery (ACoA)
Figure 4(5) :Superior and Lateral views showing the
aneurysm. The five ACA segments are as follows: A1,

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MCA segments: M1, sphenoidal segment; M2, insular
precommunicating or horizontal segment; A2,
segment; M3, opercular segment; and M4, cortical
postcommunicating or infracallosal segment; A3,
seg- ments. AChA, anterior choroidal artery; ICA,
precallosal segment; A4, supracallosal segment; and
internal carotid artery; IT, inferior trunk; LSA,
A5, postcallosal segment. CmaA, callosomarginal
lenticulostriate artery; OphA, ophthalmic artery; PCoA,
artery; FpA, frontopolar artery; ICA, internal carotid
posterior communicating artery; ST, superior trunk.
artery; LSA, lenticulostriate artery; MCA, middle

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Anterior cerebral artery (Fig.4) cerebral artery; OfA, orbitofrontal artery; PcaA,
• A1—From ICA bifurcation to anterior pericallosal artery; RAH, re- current artery of Heubner.
communicating artery (ACOM). Posterior Circulation (Fig. 5 and Fig. 6)

No. 2,
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Fig.-4: Anterior Circulation

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Bangladesh Journal of Neurosurgery Vol. 12, No. 2, January 2023

Vertebral artery Venous Anatomy

Superficial and deep venous system are detailed and
• V1—Origin from the subclavian artery to the
marked0in the images provided (Fig. 5).
foramen transversarium of C6.
• V2—C6 to C2 foramen transversarium (acute bend Figure:Superior group of dural venous sinuses. (1)
in course) Superior sagittal sinus; (2) inferior sagittal sinus; (3)
straight sinus; (4) occipital sinus; (5) transverse sinus;

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• V3—C2 to the dura (focal constriction), where it
has a lateral, superior, and superomedial course. (6) sigmoid sinus.
• V4—Intradural part of vertebral artery, up to the Physiologic Phases(7)
formation of the basilar artery. Circulation time: time taken from contrast reaching

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Basilar artery the cavernous ICA to first cortical vein; Around 3.5
seconds is normal. It represents the physiologic
Branches include the following:
perfusion time. More than 7 second periods are
• Anterior inferior cerebellar artery versus posterior abnormal.Arterial, capillary (parenchymal), and venous
inferior cerebellar artery balance ’! supplement each - circulation times at least in two different planes need
other. to be assessed.

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• Basilar perforators—not seen on DSA.
Indications (2)
• Superior cerebellar artery
Intracranial
Posterior Cerebral Artery
• Nontraumatic subarachnoid hemorrhage (SAH) of

No. 2,
• P1—Basilar bifurcation to the PCOM. unknown etiology.
• P2—Around the ambient cistern up to the posterior • Acute stroke.
margin of midbrain. • Nontraumatic parenchymal cerebral hemorrhage.

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• P3—within the quadrigeminal plate cistern. • Intracranial aneurysm: To study cross flow/
• P4—Enters parieto-occipital and calcarine sulcus. complex aneurysm anatomy.
Branches: Thalamo perforator, posterior medial • Cerebral vasospasm.
choroidal, lateral choroidal, splenial artery, and • Mass lesions: Preoperative tumor embolization,
thalamogeniculate artery. e.g., meningioma, cavernous sinus hemangioma.
• Intracranial arteriovenous malformations to classify
(- Spetzler-Martin score) and plan intervention.
• Dural arteriovenous fistulas.
• Wada test.
• To obtain hemodynamic flow information—cross
flow, circulation time, and collateral flow.

Extracranial
• Extracranial carotid stenosis.
• Carotid blowout.
• Subclavian steal.
• Cervical trauma.
• Epistaxis.
• Preoperative tumour embolization juvenile
nasopharyngeal angiofibroma (JNA).

Contraindications
No absolute contraindications.
Relative Contraindications:

Fig.-5: Vertebral artery segments • Contrast allergy

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Digital Subtraction Angiogram: Beginners Perspective Sikder MSR et al.

Remedy Laboratory parameters(2)

• Standard prophylaxis using methylprednisolone, • Complete blood cell count to assess the
12 and 2 hours before the procedure. haemoglobin status and rule out acute sepsis.
• Low osmolar contrast media (LOCM) and judicious • Serum creatinine or glomerular filtration rate (GFR)
use of iodinated contrast. for baseline record of renal status and to rule out

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renal dysfunction.
• Pre- and postprocedure hydration with normal
saline. • Prothrombin time/international normalised ratio
(PT/INR) to rule out coagulopathy.
• Renal insufficiency: Dialysis pre- and
postprocedure, if dialysis dependent. • Anticoagulants should be withheld when possible.

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• Coagulopathy: Should be corrected when possible. • Nil per oral for at least 6 hours preprocedure.
Patient Preparation(2,4,6,8) • The morning insulin dose should be reduced in
half.
Preprocedural Workup
• Bilateral inguinal regions and/or the left arm (radial/
• Informed consent should be taken from the patient.
brachial access) should be prepared and made

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• A brief neurological exam must be conducted to sterile depending on the case.
establish a baseline, should a neurologic change
• An immediate pre-sedation/anaesthesia
occur during or after the procedure.
neurological status assessment should be

No. 2,
• The patient should be asked if he or she has had a performed and documented.
history of iodinated contrast reactions.
Sedation, Analgesia and position
• The femoral pulse, as well as the dorsalis pedis
• Sedation with intravenous midazolam and analgesia

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and posterior tibialis pulses, should be examined.
with fentanyl is used.
• Blood work, including a serum creatinine level and
• Patients should be positioned supine with a
coagulation parameters, should be reviewed.
headrest, and arms are placed beside the body in
• Review of available imaging to assess arch extension with support.
anatomy or variants that may aid in catheter
• Uncooperative patients may need to have their head
selection in case of vessel tortuosity/
gently taped to reduce motion.
atherosclerotic disease.

Fig.-6: Vertebral artery injection showing posterior circulation arteries. AICA, anterior inferior cerebellar artery;
RT, right; SCA, superior cerebellar artery.

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Fig.-7 : Venogram showing superficial and deep venous drainage of the brain.

• Instructions should indicate patients to stay Contrast Agents Used(3)

motionless,especially during image acquisition, Despite its relative expense, nonionic contrast is now
and also be told about a potential sensation of the standard for cerebral angiography. Nonionic contrast
warmth within the head with each injection and to agents are denominated according to the content of
avoid swallowing when imaging the neck organic iodine per millilitre; for example, Omnipaque
vasculature, both aimed to reduce motion-related 300 contains 647 mg of iohexol per millilitre, equivalent
to 300 mg of organic iodine per millilitre.
artefact.
Table-I
Contrast agents used
Name Osmolality Viscosity
Solution (m0smol/kg water)a (cp at 37°C)b Iodine
(mg/mL) Content (mgl/mL)
Isovue 200 iopamidol 408 413 2.00 200
Isovue 300 iopamidol 612 524 4.70 300
Omnipaque 180 iohexol 388 408 2.00 180
Omnipaque 300 iohexol 647 672 6.30 300
Optiray 240 509 502 3.00 240
Optiray 300 606 651 5.70 300
Optiray 320 ioversol 678 702 5.80 320
Visipaque 270 550 270 6.3 270
Visipaque 320 iodixanol 652 290 11.8 320
Weight kg x 5(adult) 4(child)
= tolerable volume of 300 nonionic contrast
Serum creatinine mg/dL

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Digital Subtraction Angiogram: Beginners Perspective Sikder MSR et al.

Projections and views straight lateral view, the floor of the left and right anterior
Biplane angiography is the standard of care for cerebral fossa directly overlap.
angiography. It allows for orthogonal images to be
Angiographic positions for common anatomical
simultaneously obtained with a single contrast
targets. ICA internal carotid artery, PCA posterior
injection, limiting the time and amount of contrast
cerebral artery, SCA superior cerebellar artery, AICA
needed to adequately visualise the cerebral
anterior inferior cerebellar artery, PICA posterior inferior

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vasculature. Monoplanar cerebral angiography is
cerebellar artery.
acceptable only when biplane equipment is not
available. Arterial Puncture
Figure-8 (6):Standard PA and lateral • Right common femoral artery (CFA) is preferred

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projections.(a)Standard PA.The Petrous Bones Lineup for intraarterial access.
with the upper margin of the orbits. (b) Straight PA. • When CFA access is not optimal, radial/brachial
No cranial, or caudal angulation is done. In this case, artery access may be required.
the petrous bones are at the lower edge of the orbits.
• Micropuncture systems with/without ultrasound
(c) Caldwell. 25° caudal angulation. The petrous bones
guidance versus standard 18G access needles can
are about one third of the way up the orbits. (d) Towne.
be used for arterial puncture, and a J-wire

Vol. 12,
35° cranial angulation. The foramen magnum (arrow)
(atraumatic curved tip) is used, over which the
can be seen through the calvarium,(e) Water. The view
arterial sheath is advanced (Fig. 9).
is from below with 45° caudal angulation; the maxillary
sinuses (arrow) can be seen clearly. (f) Submento- • A 5F arterial sheath is placed in situ with a

No. 2,
vertex. The view is from way below, with as much continuous heparinized saline sheath infusion to
caudal angulation as possible; the vertex of the skull prevent perisheath clotting
should be framed by the mandible. (g) Lateral. On a

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Fig.-8:

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Bangladesh Journal of Neurosurgery Vol. 12, No. 2, January 2023

Table-II
Standar views(6)

Target Optimal views Additional views/comments

Carotid bifurcation Standard PA Ipsilateral oblique
Lateral

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Anterior intracranial circulation Standard PA
Lateral
ICA cavernous segment Caldwell Haughton
Lateral
ICA ophthalmic segment Caldwell Transorbital oblique

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Lateral
Posterior communicat-ing artery aneurysms Haughton Lateral
Transorbital oblique
ICA bifurcation Transorbital oblique
Anterior communicating artery aneurysms Transorbital oblique Sometimes submentovertex
Middle cerebral artery aneurysms Transorbital oblique
Submentovertex
Middle cerebral artery candelabra Lateral with Haughton

Vol. 12,
Waters with oblique
Vertebral artery origin Towne The vertebral artery arises from the
posterior aspect of the subclavian artery
Posterior circulation Water Ipsilateral oblique

No. 2,
Lateral
Basilar artery Water Ipsilateral oblique
Lateral Water will “elongate” the basilar artery trunk
PCA, SCA, AICA, PICA Towne Towne elongates PCA. Ipsilateral oblique

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helps
Lateral Caveat: Paired vessels overlap
Basilar apex aneurysms Water Ipsilateral oblique
Lateral

Femoral Artery Puncture • Exchange the needle for a 5F sheath, and secure
• Prepare and drape both the groin areas. it with a silk stitch.
• Palpate the femoral pulse at the inguinal crease, Figure 9:(A-D) Femoral arterial puncture. A line
and infiltrate local anesthesia (2% lidocaine), first between the anterior superior iliac spine and the pubic
by raising a wheal and then injecting deeply toward tubercle corresponds with the inguinal ligament (a).
the artery. In an adult patient, a puncture site 3 fingers’ breadth
below this line along the pulse of the artery pro- vides
Ï• Advance it at a 45° angle to the skin, pointing
a useful guide (arrow in b). From here, a needle thrust
toward the patient’s opposite shoulder.(Fig. 9)
at 45 degrees toward the umbilicus will usually find a
• Attempt a single-wall puncture especially if heparin lie in a position suit- able for compression against
or antiplatelet agents are used. Do it by looking for bone after the case (X in a). Among the difficulties
blood return from the hollow stylet of the Potts encountered in pass- ing a wire retrogradely into the
needle. Advance the needle 1–2 mm after the first femoral artery is the possibility of selecting the
blood return since the stylet protrudes that far circumflex iliac artery (C). With a J-wire, this problem
beyond the tip of the needle. can be sidestepped counterintuitively by directing the
wire toward the offending artery. The J-curve against
• Make a two-wall puncture by advancing the needle
the arterial wall will bounce the wire medially and up
through-and-through both vessel walls, remove the
toward the external iliac artery (D).(3)
stylet, and slowly withdraw the needle until pulsatile
blood return is obtained. Hydrophilic Wires
• When bright red, pulsatile arterial blood is 0.035 in. angled Glidewire® (Terumo Medical,
encountered, gently advance a J-wire through the Somerset, NJ) is soft, flexible, and steerable.The 0.038
needle for 8–10 cm. in. angled Glidewire® (Terumo Medical, Somerset,

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Digital Subtraction Angiogram: Beginners Perspective Sikder MSR et al.

111
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Vol. 12,
Fig.-9: Common femoral artery puncture technique

NJ) is slightly stiffer than the 0.035 in., making it helpful shape. 4 or 5F Simmons 1, Spinal angiography. 4 or

No. 2,
when added wire support is needed. 5F Simmons 2 or 3, Left common carotid artery; bovine
configuration; tortuous aortic arch; patient’s age > 50.
Catheters
5F CK-1 (aka HN-5), Left common carotid or right
Many catheters are suitable for cerebral angiography

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vertebral artery. 5F H1 (aka Headhunter), Right
(Fig. 10). As a general rule, use 100 cm long catheters subclavian artery; right vertebral artery. 4 or 5F Newton,
that have a curve that allows selection of the vessels Tortuous anatomy, patients >65.(6)
from the arch. Simpler curves (e.g. Berenstein curve)
are adaptable to many anatomic situations and are Injection with Hand
most appropriate for young patients with straighter A 10-mL syringe containing contrast should be
vessels. attached to the catheter, and the syringe should be
snapped with the middle finger several times to release
Figure 10:Recommended diagnostic catheters: 5F
bubbles stuck to the inside surface. The syringe should
Angled Taper, Good all-purpose diagnostic catheter.
be held in a vertical position, with the plunger directed
4 or 5F Vertebral, Good all-purpose diagnostic catheter,
upward, to allow bubbles to rise away from the
slightly stiffer than the Angled Taper but similar in
catheter(Fig. 11)

Fig.-10: Different types of catheter

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Fig.-11: Injection technique

Vol. 12,
Figure 11 : Syringe holding method for hand injections. • After compression, the patient should remain
Correct method (a): the syringe is grasped in the palm supine for 5 h, then be allowed to ambulate but
of the hand when it is attached to the catheter; this remain under nursing observation for one more hour

No. 2,
position places the plunger in an upright position to prior to discharge.(6,10)
allow bubbles to rise away from the attachment to the
• Early mobilization even as early as 1.5 h after
catheter. Incorrect method (b): the syringe is held in a
hemostasis does not significantly increase the
horizontal position, like a weapon. Bubbles can go

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incidence of hematomas but definitely reduces
any which way.(6)
complaints of back pain.(6,11)
Hand Injection Method
Post-angiogram Orders (6)
• Use meticulous technique for flushing and contrast
• Bed rest with the accessed leg extended, head of
injections (see above).
bed £30°, for 5 h, then out of bed for 1 h. (If a
• Whenever possible, flush the catheter in the closure device is used, bed rest, with head of bed
descending aorta to keep bubbles away from the elevated 30°, for 1 h, then out of bed for 1 h.
cerebral circulation.
• Vital signs: Check on arrival in the recovery room,
• After filling a syringe, allowing it to sit for a few then Q 1 h until discharge. Call a physician for
minutes before injection will allow bubbles to come SBP <90 mmHg or decrease 25 mmHg; pulse
out of suspension and become visible.(6,9) >120.
• A slower flush is less likely to cause bubbles than • Check the puncture site and distal pulses upon
a rapid flush.(6,9) arrival in the recovery room, then Q 15 min×4, Q
Femoral Artery Puncture Site Management 30 min×2, then Q 1 h until discharge. Call
The “gold standard” for management of the arteriotomy physician if:
after an angiogram is manual compression. - Bleeding or hematoma develops at the puncture
• Remove the sheath and apply pressure to the groin site.
1–2 cm superior to the skin incision.Apply pressure - Distal pulse is not palpable beyond the puncture
for 15 min: usually 5 min of occlusive pressure, site.
followed by 10 min of lesser pressure.For patients
on aspirin and/or clopidogrel, a longer time is - Extremity is blue or cold.
required, usually 40 min. - Check the puncture site after ambulation.
• At the end of the time period, release pressure on • IVF: 0.9N.S. at a maintenance rate until the patient
the groin slowly and apply a pressure dressing. is ambulatory.

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Digital Subtraction Angiogram: Beginners Perspective Sikder MSR et al.

• Resume pre-angiogram diet. from: https://shop.thieme.com/Seven-Aneurysms/

9781604060546
• Resume routine medications.
6. Harrigan MR, Deveikis JP. Handbook of Cerebrovascular
• PO fluids 400 mL. Disease and Neurointerventional Technique [Internet].
Totowa, NJ: Humana Press; 2013 [cited 2023 Nov 25].
• D/C IV prior to discharge. Available from: https://link.springer.com/10.1007/978-1-
61779-946-4

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