HTI48104Vascular and Interventional Radiology

Week 8
Thoracic Angiography

Edward Wong
Associate Professor of Practice https://carolinaradiology.com/procedures/interventional-vascular/
Pulmonary Hypertension (PH)

 Pulmonary hypertension (PH) is a debilitating progressive disease

characterized by increased pulmonary arterial pressures, leading to
right ventricular (RV) failure, heart failure and, eventually, death
 PH patients can be subdivided into the following five groups:
 pulmonary arterial hypertension (PAH)
 PH due to left heart disease
 PH due to lung disease
 Chronic thromboembolic PH (CTEPH), and
 PH with unclear and/or multifactorial mechanisms
Chronic thromboembolic pulmonary
hypertension (CTEPH)
• Chronic occlusion/ stenosis of pulmonary vessels
• Persistent symptomatic pulmonary hypertension with
pulmonary emboli
• Prevalence: 8 - 40 cases per million population
• Mortality (untreated): 90%
• Current treatments: Pulmonary endarterectomy (PEA)
and medical therapy (pulmonary vasodilators,
warfarin,et.)
• 40% CTEPH patients are inoperable

2
Diagnosis of CTEPH

3
 Treatment of CTEPH

60%

35% 5%
 Treatment of CTEPH

 CTEPH team is Multidisciplinary

 Operable CTEPH
 Diagnostic Angiography
 Inoperable CTEPH
 Balloon Angiography
 Treatment of CTEPH
Pulmonary endarterectomy (PEA)
• Surgery is the best treatment for
patients with CTEPH
• Improves haemodynamics
• Morbidity and mortality
• Invasive +++

Medical Treatment
• Improves symptoms
• No impact on mortality
• Expensive +++
 Balloon Pulmonary Angioplasty (BPA)

It may be a treatment option for patient with the

following conditions:
• The clots or scar tissue that are blocking the
blood vessels in lungs are deep and distally
• Patient with other medical conditions that are
contraindicative for PEA surgery
• Patients already received PEA surgery and
now have pulmonary hypertension
 Right Heart Catherization (RHC)

• RHC using a pulmonary artery catheter remains

the gold standard in the diagnosis of pulmonary
arterial hypertension (PAH)

• Either percutaneous femoral vein approach or an

internal jugular vein approach will be used
Progressive increase in
Pulmonary Vascular Resistance

When the mean PA pressure (mPAP) is elevated >25 mm Hg and the PA

occlusion pressure (PAOP) is <15 mm Hg, PAH is for diagnosis
 Procedures of BPA
❖ Recent CXR before pulmonary angiogram

❖ Contrast medium will be administered to show the

blood circulation of the lungs. People with CTEPH
have blood vessels in the lungs with webs of scar
tissue.

❖ An angiogram helps the interventional radiologist to

identify which vessel(s) is affected and where is/ are
the thrombus.
Pathology
 Patient preparation for BPA
❖ No eating or drinking from midnight (12:00
am) the night before the BPA procedure.

❖ Pre-medication: anticoagulation drugs in the

morning before the examination.

❖ Hospitalization is necessary.
 The BPA Procedures
1. Interventional radiologist locates the femoral vein at the
groin area using an ultrasound machine. Can it be located
by palpation?

2. Groin area was sterilized

and cleaned using
antiseptic techniques
 The BPA Procedures
3. Under LA, the femoral vein was punctured for
guidewire insertion

4. Once the guidewire reached the right location, a

catheter of appropriate type and size will be advanced
through the femoral vein to the target vessel

The direction of advancement of the catheter as below:

inferior vena cava → to right atrium → to

right ventricle → to main pulmonary artery
→ to smaller pulmonary artery
Pathway of the catheter in BPA Procedures
 The BPA Procedures
5. When the catheter will be guided under fluoroscopic
screening with contrast injection until it is in place

6. Pulmonary arteriography will be performed to visualize

the blood flow within the lung and the locations of scar
tissue

7. Besides, information related to the morphology & anatomy

of the thrombi/ pulmonary artery, quantitative data such as
pulmonary artery pressure will also be assessed
 The BPA Procedures

8. Stenosed vessel will be embolized by balloon of

suitable size to widen the lumen of the affected blood
vessel by crushing the emboli/ scar into the inner
vessel wall

9. By the end of the procedure, all instruments

including the catheter will be removed and pressure
application at the punctured site of the groin area for
15-30 minutes to stop any bleeding.
Procedures of BPA
Procedures of BPA
BPA is lengthy procedure when multiple
vessels are affected
Pulmonary Angiogram showing multiple
affected vessels
Balloon Pulmonary Angioplasty
Pulmonary Endarterectomy (PEA)
 Surgical removal of the organized thromboembolic material from the proximal
pulmonary arteries

Before PEA: A-right pulmonary artery

(marked oligaemia in the right upper lobe-
asterisk), B-left pulmonary artery. After PEA:
C-contrast material filling in the right upper
lobe pulmonary artery is affirmative of
successful recanalization (postoperative
sternal wires are visible), C and D images
show decreased pulmonary arterial
tortuosity, reduction in diameters of the
right and left pulmonary arteries
 Cardiac Catherization
• Minor cardiac surgical procedure for diagnostic
evaluation or interventional (therapeutic)
purposes

• Diagnostic
– Collects data to evaluate patient’s condition

• Therapeutic
– To intervene by mechanical means to treat disorders
of the vascular and conduction systems within the
heart
 Catheterization
• Prepare catheter introduction
site with aseptic technique
– Shaved and cleaned

• Can be at femoral (most

common), brachial, radial,
axillary, jugular and
subclavian areas

• Employs Seldinger technique

 Clinical Indications
• Suspected or known coronary
• heart disease

• Myodcardial infarction

• Sudden cardiovascular death

• Valvular heart disease

• Congenital heart disease

• Aortic dissection

• Pericardial constriction

• Cardiomyopathy
• Initial and follow up assessment for heart transplant
 Contraindications
• Active GI bleed • Patient refusal
• Renal failure • Uncontrolled
• Recent stroke hypertension
• Fever from infection • Bleeding disorders
• Electrolyte imbalance • Pulmonary edema
• Anemia • Uncontrolled ventricular
• Short life expectancy arrhythmias
• Digitalis intoxication • Aortic valve endocarditiis
• Allergic to contrast
 Complications and Risks
• Death
• Myocardial infarction
• CVA
• Arrhythmia
• Hemorrhage
• Contrast
• Hemodynamic
• Perforation
 Cardiac Catheters
• For Left cardiac
catheterization,
similar to those for
angiography
 Cardiac Catheters

For Right cardiac

catheterization, it
requires specialized
catheters

• Typically flow
directed catheters

• With manifolds
 Contrast Media
• High Osmolar Ionic
– Sometimes causes ECG
changes

• Widely used
– Non-ionic
– Ionic low osmolar

• Restricted costs causes limited

use of low osmolar contrast
agents

• Pressure injector
 Pressure measurement: Zero Calibration

• Before starting a cardiac procedure, a zero

calibration is done for each patient

• According to an international agreement, the

reference level for the pressure measurement
system is the pressure on the surface of the right
atrium

• It can be assumed that the pressure there is

identical to atmospheric pressure at the end of
expiration
Pressure measurement: Zero Calibration
 Cardiac Output
• The cardiac output is mainly influenced by
changes in the stroke volume and the heart rate

• The cardiac output in healthy adults is between

5 and 8 litres per minute

• During a cardiac procedure, the Cardiac Output

(CO) is measured using different techniques:
1. Thermodilution
2. Fick
Thermodilution
Fick method
 Coronar y arteries
• There are two main coronary arteries - the left and right.
– The Left Coronary artery (LCA)
• begins as a main stem called the Left Main Coronary
Artery (LMCA) which varies between 1 and 15 mm in
length
• This artery divides in two major branches,
– the Left Anterior Descending artery (LAD)
– the Circumflex artery (CX)
– The LAD and CX each supply large areas of heart
muscle with blood

– The Right Coronary Artery (RCA)

• a single long vessel with smaller side branches
 Procedure : Access
• Common Femoral Arterial access is the most
common arterial access for performing left heart
catheterization
• Anatomic landmarks are used to identify the
correct site of arterial puncture
• For the femoral artery access, the femoral head
provides the best visible landmark
• Arterial puncture at this site remains below the
inguinal ligament
Procedure : Access
 Procedures
• Catheters are pushed up along the aorta, usually via the
femoral or brachial artery and then into the coronary
arteries
– Contrast medium is injected to assess blood flow
through the artery while various exposures are taken
from different angles

• Then another catheter, pigtail shaped, is placed into the

aorta where pressure measurements are made
– This catheter is then advanced across the aortic valve
and pressures within the left ventricle are obtained
 Procedures
• The catheter is then attached to an injector and contrast
medium is injected

– Pressure measurements are again taken after

injection of contrast medium and as the catheter is
withdrawn back across the aortic valve and then
removed
 Projections
• To visualise the coronary arteries adequate
number of projections are necessary

• When mentioning the various projections, be

reminded that:
– L.A.O. rotation indicates that the Flat Panel receiver
(FP) is rotated to the left side of the patient
– R.A.O. rotation indicates that the FP is rotated to the
right side of the patient
– Cranial angulation, the FP angulates to the patient’s
head
– Caudal angulation, the FP angulates towards the
patient’s feet
 Coronary angiographic view
• Accurate diagnosis of a coronary stenosis is
dependent on acquiring multiple views to enable
accurate visualization of all the coronary
segments without foreshortening or overlap

• This is achieved by maneuvering the flat panel

detector into the right and left anterior oblique
planes and either the cranial or caudal
projections
Coronary Artery Anatomy
Cardiac – Coronary Arteries

 The two coronary arteries originate from the from the left aortic sinus
 The right coronary artery originates from the right aortic sinus.
 No artery arises from the posterior aortic sinus.
Coronary angiographic view
Interventricular and Atrioventricular
Grooves
 Coronary angiographic view

.
Coronary Arteries

 Left main coronary artery

 Left anterior descending (2 o’clock)
 Left circumflex (3 - 4 o’ clock)
 Right coronary arteries (11 o’ clock)

RCA

LMA LAD

LCX
Coronary angiographic view
Coronary angiographic view
Coronary angiographic view
Coronary angiographic view
Coronary angiographic view
Coronary angiographic view
Cardiac Arteries anatomy
Cardiac Arteries anatomy
 Physiologic Equipment

• Equipment to monitor
– ECG
– Hemodynamic
pressures

• Vital signs to record

patient function
 Other Equipment

• Oxygen and suction

• Defibrillator
• Temporary pacemaker
• Pulse oximeter
• Blood pressure cuff
• Equipment to perform cardiac output studies
• Activated clotting time (ACT) equipment
Left Ventriculography

• Provides info on valvular

competence
• Interventricular septal
integrity
• Efficiency of the pumping
action of Left ventricle
• Pressure measurements
are made
Coronary Angiography
 Percutaneous Transluminal Coronary
Angioplasty (PTCA)

 Also known as balloon angioplasty

 Employs balloon to dilate the coronary artery stenosis

 The placement of the catheter is placed much in the same way as standard
coronary angiography
 PTCA
• Special steerable PTCA
guidewire is used
• Guidewire is advanced
to stenotic area through
the balloon catheter
• Balloon is pushed
through to the stenotic
area
• Balloon is inflated and
compresses fatty
deposits
 PTCA
• Followed by localized
arteriography

• This may be done repeated times

to assure maximum dilatation

• Restenosis occurs in 30-50% of

patients
PTCA
 PTCA with stent placement

• Similar to PTCA
alone except a stent
is placed
• Restenosis is lower
for patient's who do
this rather than
conventional
angioplasty alone
PTCA with Stent Placement
 Atherectomy
• Atherectomy devices remove
the fatty deposit or thrombus
material within artery

• Directional coronary
atherectomy devices having a
specialized cutting device to
shave out the plaque

• There is a special nose cone

that collect the free floating
particles 55
 Percutaneous transluminal coronary
rotational atherectomy
• The tip is a football shape
and is embedded with
diamond particles
• Special torque guidewire
between 160,000- 200,000
rpm
• The plaque is pulverized
into particles the size of
RBC’s and removed by the
reticuloendothial system
 Interventional Procedures of the Vascular
System: Children
• Balloon Septostomy to enlarge a patent foramen
ovale or preexisting atrial septal defect

• This allows mixing of Right and Left blood

• Balloon is passed through atrial septal opening into

the Left atrium, inflated with contrast and pulled
back through the orifice
Interventional Procedures of the Vascular
System: Children
 Balloon Septostomy with Transeptal
System Approach
• When there is not a preexisting
hole in the atrial septum
• Transeptal approach is used
• Catheter with knife is employed
into Left atrium blade is opened
and pulled back through Right
atrium
• Then balloon septostomy may be
performed to open the hole more
widely
 Interventional Procedures of the
Conduction System: Adults & Children

Antiarrhythmic devices
• Pacemakers
• Implantable cardioverter
defibrillators
R
Leads placement
 Post Catheterization Care
• Firm pressure is applied to puncture site for 15-
30 minutes
• Wound sites are cleaned and dressed
• The patient will be observed in recovery for 4-8
hours
• The insertion site will be checked frequently for
signs of bleeding
• Medications and discharge instructions are
given
• Lots of fluid should be taken in
• Vital signs should be monitored for 24 hours
The End