So, we'll get started. Good morning. And first, we'll get comfortable and relax and we'll go through this basics of angiography. Interestingly, I haven't, even though I've been doing this for so long, I haven't given an intro course to angio ever. So, I had to borrow a lot of the slides from one of my partners, Tibor Besky, in case you don't know Tibor. He's a fabulous guy. And one of my residents, Omar Tanwir, who's in the audience. We were all putting this together yesterday. So, if you have any questions, feel free. Remember, with angio, just like surgery, there are subtle nuances that may be particular to an institution or an individual and how they like to do things. I have one little quirk and I'll tell you about that. It's something that I started doing, I thought, because I was trained in my fellowship. And then, my old mentor told me that he never told me to do that. But, we'll start. That's my disclosure slide. Prior to doing any angiography, the basic, just like any operation, consists of a patient evaluation. Obviously, a glance through at the laboratories, the patient's laboratories. Patient education. Maybe you do this in your office, but in patients that are transferred in, either the family or the patient themselves really need to understand why you're doing this. This is an invasive procedure. Even though it may take you only 15 minutes to do, it's important that the patient understand why it's being done and that you obtain informed consent. I can't tell you, I mean, all of us in this room will be involved in some legal thing at some point where this subject comes up, informed consent. And luckily, I was told long ago to put a note in the chart, and usually there's two or three notes documenting the consenting process. So, patients need to understand why things are being done, but you also need to make sure that their questions are answered. So, why is the clinical and laboratory information important? Well, you need that history of what's going on because the history can have an important effect on why you're leading towards angiography. Certain medications, as you know, can interact with the dyes that we are using and can cause potential problems or even anaphylaxis in the situation of allergies, and obviously, the regular routine labs. The one that comes up a lot is the shellfish allergy. You may or may not know that the American College of Radiology no longer considers a shellfish allergy a contraindication to contrast, and as you know, many of the contrasts that we use are not iodine-based anymore. One of the most important things, and this should go back to the earliest days of your residency and medical school, it seems it should be easier now with everything being digital in the digital medical record, but, you know, when I was training, we had to search for cut films. Lou Kim, who was the junior resident in Phoenix when I was a fellow, Lou would disappear for hours looking for the cut films for the cases for the next day, and that was so that we all could review the imaging before the case. Understand what you're going to do and what your goal of the angiography is going to be. You need to know when you're going to use general anesthesia. At our place, at our institution, all children get general anesthesia, for the most part, unless it's a particularly mature 16 or 17-year-old, and I always use general anesthesia when I'm doing an EMBO procedure. One, I think I get better images, and we can do apnea and hold the breath and get clear images and clear rotational images, but also I don't like the patient moving. This isn't the case at a lot of places, but that is one of the things that I learned back in 96 when I was doing my fellowship. Conscious sedation, at both institutions now, you have to be certified in conscious sedation, and you can do this as residents. Our residents are certified. Isn't that correct, Omar? Our residents are certified in conscious sedation. Whether or not you want to use a sheath, again, we don't use a sheath in children, but I use a sheath pretty much for everything else. That is not the standard radiology way of doing an angiogram, so a lot of people will have a groin puncture, and then over a wire, a catheter will be introduced, and then with a two-way stopcock, with repeat flushing, do their angio that way, and you'll see as we go on into the talk that that's not actually what I do. I actually came up, and I think other people use it also, a continuous flush setup, which is very simple and allows you to open and close and not have to worry about flushing the catheters and to do your angiogram. Again, a lot of people will do an arch study. Particularly, you'll hear at the cardiology meetings, there isn't an interventional cardiologist I know that doesn't start his procedure at least once in the care of a particular patient with a study of the arch. I almost never do that. A lot of our MRAs and CTAs will have good images of the arch, and unless I'm forewarned that it's some particularly difficult or elderly patient, I usually don't go looking at the arch beforehand. I standard start with a five or a four French if it's a small individual or child, catheters or sheaths. Some people like to start with a diseased vessel first for the angiogram, and what's the extent of the evaluation? It depends on what you're looking for. If someone has a subarachnoid hemorrhage, you're going to do a complete angiogram if you're looking and you don't know where you're going, but in most patients, they have a full angiogram. We already talked about informed consent and, in some cases, premedication of people that have true documented contrast allergies. Whenever possible, obviously, you want to baseline neurological examination. You want to know if the patient's going to tolerate the procedure. If you're not doing it under general anesthesia and it's going to be a conscious sedation case, we've all been in the situation. I know that when I give conscious sedation, I leave my patients a little light. I can talk to them. I can communicate with them. They can hold still. When I ask them to hold still, sometimes when I've asked the anesthesiologist to do conscious sedation for me, their idea of conscious sedation is a little bit deeper for the patient, but the patient is still moving and I don't get the images that I like. I like really crisp and clean images. A lot of effort is taken, at least in our setup, to really get the best images that we can so we can make decisions off of that. Like I said, is the patient going to cooperate? Key to successful angiography is all the stuff that happens in the room before you actually put on your lead and go in there. It could be your residents and your fellows and the techs and the nurses getting everything together, but the first thing that happens is the tech comes in and turns on the machine. How many times have they come in and turned on the machine? The machines won't boot up and you have to get Siemens or Philips or whoever your vendor is to figure out what's going on with the machine. The machine has to be turned on. You have to have all the emergency medications. We have anesthesia ventilators and all their drugs in our INR suites, but also the crash units available. Monitors have to be booted up. Clear labeling. This is all now required at most institutions, but you have to label things. Injecting a syringe full of lidocaine obviously would be really bad, so you have to label things so you know what you're using. Bubble-free fresh lines. Bubbles are bad. Air is bad, and you all know the consequences of that. Have enough syringes so that you have everything that you need at your fingertips. You want to flush all your catheters and sheaths and soak them in the heparinized saline, wires in the bath, and again, confirm that the adequate amount of heparin has been put into your flush lines and bags. Just a quick illustration that we have a reference that lists this that Omer got these from, but really creating the bubble and passing it through the line, you all have seen this before. We all use pressurized bags, most of us, and then you have to get the air out of the line, and the easiest way is to create a large bubble and let it pass through the system and pick up all the bubbles on the way. At the beginning of every year, just like when the turnover of residents and nurses come through for training, you have to be a little bit more vigilant looking for the air in the line, because air is not your friend in this situation. Vascular access, obviously if you're doing conscious sedation, you're going to use lidocaine. I don't use local if the patients are under general anesthesia. The way I was taught was that you could use the lidocaine not only for numbing the skin, but you can inject on either side of the artery and fix the artery. I still do that, so I will always come in, feel the pulse, and actually inject lidocaine on either side of the vessel when I do it to try to keep the artery from rolling. Some people like to use a puncture needle that has a stylet in it. I use an open puncture needle. That's my preference, so there are little subtleties in that. Then you just have to use the landmarks, common femoral artery, medial aspect of the femoral head, as you know, under x-ray. If you're sticking and you can't see, particularly in a patient that might be a little heavier, x-ray. You've got all these great tools. Turn on the machine and look for the medial aspect of the femoral head. The ideal puncture site is two to three centimeters below the inguinal ligament. Well, where's that? Well, that's between the symphysis pumice and the iliac crest. It's so that you don't get into the intraperitoneal, so you don't get into the peritoneum. Obviously, the artery is lateral to the vein. We all remember that from medical school. Just some dynamics. At this point, I try. I'm getting old and I've been exposed to a lot of radiation, so I usually have to stay in the control room at the beginning of the case while the residents and the fellows are trying to get their access. You'll see wires going into different places. Obviously, either you're too low, too high, or you're in a small branch vessel, and you can see by the direction that it is. Often, you can just reposition the wire and get where you need to be. Just some images. Obviously, you want to get the wire up. The wire is your friend. Even though wires can do bad things and they can go through the vessel wall, if you don't push very hard, usually, and the wire goes easily, then you know that you're in a good place and you can slide your catheters over that. We talked about groin sheath. I use usually six French sheaths when I'm getting ready to do an EMBO, or the long sheaths. We do a lot of pipeline at NYU, for obvious reasons. We use a big sheath that goes all the way up, usually into the system that we're working on. No sheath, as I said, for children. I connect the groin sheath to continuous heparin isalein flush, and most people do that. I also use this setup, which you'll see in a second, of continuous flush through the catheter as I'm doing the diagnostic angiogram. There's multiple shapes and sizes. I would say, I don't know, once a week, we wind up having to use a Simmons for a difficult arch. The contrast that we like to use is UltraVest. Just a picture of some different types of tips. The five French Berenstain is what I did my fellowship on with Dr. Berenstain. Interestingly, I don't think he gets very much royalty from this catheter from way back when. Some sort of hockey stick type tip is usually the easiest to use. Then when I have difficulty with an arch, I usually first go to the Simmons II. There's a picture of them from our case yesterday, taken by Omar. Here the Tempo Vert, five French with the slight sort of hockey stick, and then the Simmons that we needed for the left carotid in our case. Forming the Simmons, once you learn how to do it, it becomes usually very straightforward. The cardiologists actually form it against the valve. They go all the way around the arch, and then will bump up the catheter against the valve, and then flip it and pull back. I was always taught to do it this way, either go into any vessel that I could to form it, and then as you know, you turn it to get access into the left, and then you pull on the Simmons, which is a little bit different than pushing the regular Tempos or Berenstains. That will advance the catheter, and then when you're ready to take it out, you push, and you never pull the Simmons out without having a wire in it, because you can actually get it twisted and get it stuck in your short groin stewth, and then have a real problem in trying to get it out. That's about using the Simmons, and here's our reference since we use these pictures from Pierce-Morris' Practical Neurangiology, second edition. Those are actually quite useful pictures. I'd never seen these before. Omar found them yesterday. So here's the continuous flush system. You can see here's my five-fringe diagnostic catheter, two-way valve here, and just a heparinized saline flush, and then I have my contrast here. So with this, I don't have to do the regular flushing that when you see most radiologists doing diagnostic angio. I just flip this valve, and it's flushing continuously. If I'm trying to clear out this, I'll close this, or so I don't get blood back, I'll close this until I put my wire up, and this is I'll put my micros and everything like this, and most people will use something like this when they do an EMBO, but not necessarily when they do a diagnostic angio. It takes a little bit getting used to, because it's a little bit bulkier in your hand, but like I said, you don't have to flush, and that's a huge time saver. I think it can do an angiogram in a very short period of time. So the next thing is patient positioning. This is a, what do you call it phantom that we use at NYU and Tibor put these pictures together for his intro talk for the fellows and residents. But you can be hyper-flexed and that can be an issue or hyper-extended. You really want a true lateral and you have to make sure everything is off of the patient's wires. You know, the anesthesiologist will have this monitors and things like that. You don't want anything on the patient's head that's going to get in the way of your interpretation. You know, obviously glasses are usually taken off, but safety pins in the hair and things like that. All those things have to be removed. Some people will like to use an arch shot. Some people will like to have an arch shot, but usually what we do is we start usually on the right side to get our bearings and then start looking. If there's any concern, obviously you don't necessarily have to do a run, but certainly a puff with contrast or a roadmap will give you an idea of what's going on at some of the origin of the vessels, particularly if you're looking at patients that are having acute stroke or dissection and things like that. So catheterization, these are some slides put together by Tibor. Always know where you're going, all right? So have an idea of where you're trying to be. And so you can use the roadmap and live subtraction, but give puffs of contrast. See what's ahead of you. And you always want to see the tip of your wire. You know, you put your wire up and you're sliding and you're not looking at that point, but either have your partner or you, you have to be cognizant of where your wire is. And you can see here, Tibor doesn't like to use the continuous flush. I put that in down here. But flush, flush, flush, yes, you don't want the blood sitting in the catheter, but with the continuous flush system, you don't need that. And it's good to get an idea. Obviously the carotid bifurcation, patients will have, most patients will have a mild degree of atherosclerosis, but you can see more pronounced types of things. Is this the one? Next one. So you can see, so some things you may miss if you don't rotate them, and that could cause a problem for you. And you may not even want to go beyond something like that right away, just for the diagnostic portion of your study. And then there are patients that have extreme tortuosity and things like that. So again, getting some information, I start with carotid runs in the neck almost always, routinely. We'll do a common neck and a common head before I go further, especially in a patient that's had an angiogram before. So you'll see patients that are either your own patients that you've done procedures on and thought they'd gone well, or patients that have come from other institutions, often well-known and well-respected individuals. And you'll find dissections. You'll find things that the patients have been asymptomatic, or sometimes, in some cases, symptomatic, but no one has gone back and looked at their angio. And so if you're coming back into a place where either yourself or others have been before, take a look, because there may be things that you might find that will impact your decision making. And again, roadmaps are easy to obtain. Always go ahead with the wire and want to see the tip here. You don't see the tip, but on this view, you do. And then slide over wire. So the general rule when you're learning is always slide over the wire. My fellows will see me, and I watch them, and the residents, sometimes, I'll watch them doing what I do, which is, in young people, just puffing and pushing the catheter up. Never force. Let things go. Puffing and pushing at least will keep the tip off of the vessel wall. But the real safest way to do angiography is to go over a wire. In the beginning, you should always do that. And then you slide, and like I said, you can have torture specials. You can be straightening vessels. Advancing the catheter, so that's just what I was saying. Roadmap, move over the wire. Once in your position, you remove the wire, here, in this case, double flush. I let blood come back before I switch the valve and let the continuous flush go forward. Always check the flow in the vessel before you inject. So you may be, yesterday we were doing a guy with a tortuous and tight vert, and the position that we had the catheter in, we had flow arrest, and so we had to keep pulling back until we had good forward flow through that. Injection rates, just a standard chart that you would find in any place. If you're going to use a power injector, I only use a power injector. Either in the OR when I'm doing intraoperative angio, I have a power injector that I can use by hand, and we use the regular power injectors when we're doing rotational angiography. There are some places that will hook up every run. In fact, in my fellowship back in 96, every run was done with a power injector and everyone stepping out of the room. It slows down the procedure, but there's less radiation to the operators. Whenever I'm sitting in vascular conference and I'm often looking at outside angiograms, the first thing that I'm always struck by is the number of times that I see that people don't start their angiogram and their angiographic analysis with standard views. This is something I learned from Dr. Bernstein way back when, and that is always start with AP and lateral images. I can't tell you how simple that is and how important it is and how often you see that it's not done. Start with simple AP and lateral views and then you can get fancy with your complex views, but also understand the traditional views. You have to obviously understand AP and lateral, but your towns, Caldwell waters, and oblique or transorbital pictures. So that's a good straight AP, and that's kind of what you see with an AP image. Here's our oblique or transorbital. The way I like to just remind the residents or fellows how to do this is put the orbit towards the center of the image, and that's what you get with that. Here's your Caldwell view. And again, it helps you open up the pathology a little bit and open up the MCA. The waters view we're all familiar with. And lastly, towns. Here you have an anterior circulation, but usually towns, traditionally we're trying to open up the basilar tip. Obviously, monitoring, when you're doing conscious sedation, this is particularly important. Obviously, when you're doing general anesthesia, I like to hear the cardiac monitor in the background, especially when I'm doing particle embolization. So when I'm doing EMBO for tumors, I do it and I time it to the cardiac cycle. So you hear the cardiac monitor beep and you give a little push, and you can see the contrast go through. And that's how I teach the residents and fellows, and that's how I was taught. So I like to hear the cardiac monitor. But when you're doing conscious sedation, it's particularly important for you to be watching the same things that the nurses are watching. And most angiosuites now have the big screens with all the vitals on it. And talk to the patients. That's why I don't like them too deep. I keep them comfortable. They're not really complaining. They don't remember any of the procedure, but they can either hold their breath for a rotational angio image, or they can at least hold still when you're trying to open up something and get a better image of something that you're interested in. So red flags, what things to look for and be worried about. Sometimes you push the guide wire tip in, and then you take it out, and it looks like it's bent. Throw it out. And it's not your job to worry about the cost of the procedure or the cost of the equipment to the hospital. Just toss it away. Same thing with a micro wire. How many times you pull the micro wire out, and it looks like a pigtail, and you try to use it again, and you see you just throw it out. Get rid of it. You take a catheter out of the sheath, and it looks like there's a kink in it. Throw it out. Just get rid of all these things. Watch for bubbles. Keep watching for bubbles. Look for irregularity in the vessel wall when you're doing the angio. Sometimes, as you know, it's FMD. But sometimes it could be just local spasm. You can give a little puff of verapamil if you're worried about it, if you're going to be in there for a long time. But be aware of what you're looking at, the general vessels. Watch for a stagnant column of contrast. You're occlusive. And you don't want that because clot will form. Contrast hanging out in a branch vessel. Again, either an embolus, a piece of debris from the inside of the vessel. Or an air bubble. Complaints of neck pain or pain that doesn't resolve within a couple of seconds. That could be an early sign of a dissection and a vessel wall tear. And that's patients that you see in your office that have come in after a chiropractic manipulation or an aggressive facial massage. They've got multiple vessel dissections. That kind of pain. That sharp pain that doesn't necessarily go away. It's a tearing kind of pain. And a change in the patient behavior. The signs of stroke, right? Only when you're seeing it on the table, you have to be aware and to recognize these things. Again, so here, pre-embo, you can see this patient's obviously got some reactive vascularity. And so that when you're putting your guiding catheters up here, you could get occlusion or stagnation of flow. One option is to put your bigger catheter down here in the common and come up with a smaller Navien or whatever type of catheter that you want to use. We have much nicer and slippery catheters and small catheters that can be very flexible and get you closer before you even have to put your micro catheter in that you can use in these kinds of situations. Here you can see a stagnant column of contrast in the vert. I don't think that's from our case. And again, contrast that's not washing out, right? So how do you manage spasm? I would keep gently flushing with your heparinized saline or in my case, the continuous flow. I always pull the catheter back a little bit. Some people say not to pull the catheter back. Think about your collaterals if you've already known them. Recheck flow in a couple of minutes and you just slow down and give the vessel spasm time to relax. And then just do a run, all right, to make sure that you didn't do some damage to the vessel. And obviously you want a whole run over the head to make sure that you didn't send something downstream. Know the phases of an angiogram. I'm always surprised that when I'm watching people learn angiography and they're taking pictures and doing the runs that they either come off the pedal too early and they don't follow everything through. You know, you want to get into the arterial phase and then get all the way out, you know, through the capillary phase into the venous phase. And obviously this isn't showing the venous phase. But you have to, the beauty of angiography is it's dynamic. So take advantage of that whole window of time that you're trying to study, right? So you want to see how things flow, particularly when you start treating ABMs. You want to see how blood moves through these things. You take advantage of the dynamic nature of this study so that you can understand flow. And that's a really, really useful tool, but something that you won't pick up on until you've done angiography for a long period of time. You can find all kinds of nasty things and cause all kinds of nasty problems when you do things in a rushed manner. And you can find, like I said, even you can come back and find things that either you had left behind or, and so always start and look and go cautiously. How do you manage a dissection? Again, always flushing, in case we haven't had flushing up there on enough slides. Flushing either continuously or bimanually is very, very important. So obviously if it's not a hemodynamically significant, you can just treat with anti-platelet aspirin. And that's how I treat dissections in the office when they're referred to me. And that's how I would treat them in the clinical setting. Otherwise, if something has a severe dissection and you've got someone on anti-platelet because you just did a pipeline, theoretically you could put another stent across it. And you can always get MRI and MRI images just to make sure that you didn't cause a little boo-boo downstream that you're not seeing, even though the vessels are all filling. And obviously, you can stent things and make them look really nicely if you've caused problems. Again, just be wary of your images, and obviously, be wary of vessel occlusions. And because your time to act is right away, you're there, go in and open things up. So obviously, the sure ways of getting into trouble, obviously being a fellow or a resident, I would say, since residents now are required to spend a significant amount of time in INR for neurosurgery graduation. Failure to flush or use continuous flush, injecting the wrong thing in the wrong place,

angiography

patient evaluation

informed consent

catheters and sheaths

anesthesia

good images

catheterization tips