Diagnostic Medical Sonography Program Lecture 16: Miscellaneous Conditions,
Diagnostic Medical Sonography Program Lecture 16: Miscellaneous Conditions, Tests, and Treatments Holdorf Miscellaneous Conditions, Tests, and Treatments Arteriography Method
Percutaneous puncture of superficial artery; insertion of thin catheter Most common arteries used: CFA (safest approach), axillary, brachial After proper positioning contrast agent injected into catheter, flows with moving blood; provides picture of vessel lumen Rapid film changer technique used to expose the films sequentially as contrast agent moves through vessel
Using Fluoroscopy, digital information obtained/stored for later manipulation and interpretation. Catheter removed, pressure held on puncture site; patient supine for 6-8 hours. Sandbag placed on top of dressing to help avoid bleeding. Interpretation Primarily an anatomic study; NOT a functional
study Hemodynamically significant stenosis usually defined as a 50% diameter reduction. Normal anatomy seen on films as contrast media fills vessel Interpretation based on how much (if any) of artery does not fill with blood containing contrast agent. Extent and location of FILLING DEFECT is
determined Interpretation (Arteriography) continued Atherosclerotic plaque appears as irregular or smooth Vessel occlusion: no filling seen: collaterals often present with long standing occlusion Miscellaneous findings;
Aneurysm appears as dilated artery Vasospasm: severe narrowing, usually without occlusion Fibromuscular dysplasia: multiple arterial stenosis caused by medial hyperplasia, appearing as string of beads (Usually found in the Carotid or Renal Artery) Normal Arteriography
Fibromuscular dysplasia Abnormal Arteriography Renal artery stenosis FYI for Renal Angiograms Interlobar branches to
the arcuate Arcuate branches to the interlobular Limitations May be contraindicated in patients allergic to contrast agent or in kidney failure Inaccurate in its hemodynamic assessment because
of inability to provide many images in multiple planes in real time; Two-dimensional view is standard Complications Puncture site hematoma Pseudoaneurysm Local arterial occlusion
Neurologic complications MR Angiography (MRA) NOTE: Does not use radiation Method Employs radio frequency energy and a strong magnetic field to produce images in multiple planes.
MRI instruments quantitates blood flow and constructs images that look like angiograms (MRA). Flowing blood is well distinguished from soft tissue without using contrast agents. MRA of the Renal Arteries and Aorta Limitations Presence of metallic clips, pacemakers, monitoring
equipment Can overestimate stenosis due to slow flow or turbulence Expensive Claustrophobia may limit some patients Interpretation Useful for AAA, dissections, peripheral artery
evaluation Computerized Tomography (CT) Method Employs ionizing radiation to obtain cross-sectional images of the aorta and other body structures IV contrast allows more discrete evaluation
Limitations Patient motion and presence of metal surgical clips One plane used Limited application in PAD due to smaller vessels Interpretation Identifies size of aorta; extent and sixe of aneurysm Helps define relationship of aorta to renal artery
origins CT of AAA which as ruptured Treatment For a healthy Arterial System Medical
Lifestyle modification: Stop smoking Consistent exercise to enhance collateral development Weight control and low cholesterol diet may enhance normal endothelial cell metabolism Protection to prevent injury and or infection to extremity of interest.
Treatment Medical Pharmacologic: Aspirin: An antiplatelet drug that decreases platelet aggregation resulting in decreased thrombotic activity Medications that help decrease blood viscosity Antihypertensive drugs may serve to decrease
shearing forces against vessel walls. Treatment - Surgical Decision to operate depends on extent of disease and primarily the patients symptoms Endarterectomy is surgical removal of atherosclerotic material, usually includes portion of intimal lining. In presence of significant stenosis or occlusion, bypass
graft provides alternate pathway for blood to travel. Successful bypass grafts include the following components: good inflow, patent conduit, and good outflow Common bypass grafts Aorta to both iliac arteries (Also used for AAA) Aorta to Bi-Femoral (Also used for AAA)
Femoral to popliteal Femoral to PTA, to ATA, to peroneal Fem-pop bypass graft Treatment - Endovascular NOTE: Does not remove plaque: Just moves it.
Angioplasty: Percutaneous Transluminal Angioplasty (PTLA) used to dilate focal plaque formation in vessel. Same technique used for ARTERIOGRPHY, except a balloon tipped catheter is utilized. Under Fluoroscopy: Catheter tip is brought to the region of stenosis Balloon is slowly inflated, pushing plaque against the walls of the vessel, dilating artery lumen.
Balloon deflated, catheter is removed Angioplasty Continued Can not be done on all vessels nor on all types of lesions. Procedure usually performed in vessels with focal stenosis such as: Renal Iliac
Femoral Popliteal artery General consideration for catheter intervention Serious complications occur in less than 5% of cases. 2-3% of Angioplasty patients have complications requiring surgery or alter
hospital stay Minor discomfort with the procedure Intravascular Ultrasound (IVUS) Tiny ultrasound probe at tip of catheter provides image of vessels form the inside-out Indications include: To evaluate plaque formation on arterial wall
Post-procedure to assess need for further treatment Determine correct placement of stent Identify aortic dissection Applications for venous evaluations e.g., Chronic Iliac-Vena Cava obstructions Intravascular ultrasound probe
Stent / Stent Graft To maintain intraluminal structure and patency of artery. Acts as a type of scaffold Insertion an deployment technique varies with stent type Similar techniques, as used in arteriography, are utilized with insertion of stent
Limitations (depending on stent site) Abdominal gas Inability of patient to lie flat Complications similar to those of arteriography Problems include: Restenosis due to intimal hyperplasia, stent migration,
graft limb compression, twisting, dislodgement, Endoleaks Utilized in vessels such as: Aorta, renal , iliac, femoral, repair of AAA with stent grafts Should expect some flow acceleration post-stenting Aortic Stent Graft
Miscellaneous Diagnostic Tests/Treatment Arteriography Renal arteries into segmental arteries, then interlobar arteries Most common arteries used for cardiac catherization is CFA MRA
Key limitation: Can overestimate stenosis due to slow flow or turbulence. Endarterectomy is the complete surgical removal of atherosclerotic material. Not done alone. Usually along with a bypass. Problems with Stents/ Stent grafts Endoleaks
Usually type from II from branch vessels (IMA, Lumbar) The Stent sac and get larger and rupture from leaking. Blood going back into the IMA that has been blocked off by the craft. Homework Text book Chapter 17: Alternative Diagnostic Tests and Therapeutic Interventions
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