Angiography: Principles,

Techniques (Including
CTA and MRA) and
CHAPTER

6
Complications

James E. Jackson, David J. Allison

and James Meaney

Multidetector CT angiography Contraindications

Clinical applications Anaesthesia
Magnetic resonance angiography Arterial puncture
Background Digital subtraction angiography
Contrast mechanisms Intravenous digital subtraction angiography (IVDSA)
Post-processing Aftercare
MRA in clinical practice Complications
Supplemental imaging: when is imaging of the lumen not Catheter venography
enough? Techniques
Future directions Complications
Catheter arteriography Embolization techniques
Technique Embolic materials and techniques
Preparation of the patient Indications for therapeutic arterial embolization

The imaging of blood vessels has changed considerably since
the first edition of this textbook and, indeed, there have
been significant new developments in cross-sectional imag-
ing techniques even since the 4th edition. These have made
many of the diagnostic catheter angiographic techniques
described in previous editions almost obsolete. On the whole
this is clearly a welcome advance; the newer multidetector
CT angiographic techniques are obviously less invasive and,
therefore, safer. Furthermore, in many instances these tech-
niques will give more diagnostic information than could be
obtained by conventional catheter arteriography because of
the concurrent visualization of surrounding tissues and the
ability to reconstruct the data in any plane. One of the disad-
vantages of the decline in the number of diagnostic catheter
angiograms performed, however, is that it has become more
difficult for radiologists to acquire suitable expertise in the
catheter techniques that are still required for more complex
therapeutic interventional procedures. As a good under-
standing of the basic principles and techniques of catheter
angiography remains essential for those intending to become
interventional radiologists (and it becomes less likely that
they will be able to obtain sufficient practical experience
during their training for the reasons given earlier) it perhaps
becomes more important that this information is available
in this textbook. The newer cross-sectional techniques for
imaging blood vessels will, however, be discussed first as these
will, quite rightly, be requested before (and often instead of )
conventional catheter angiography.
110 SECTION 1 IMAGING TECHNIQUES AND GENERAL ISSUES

MULTIDETECTOR CT ANGIOGRAPHY (MDCTA)

The development of CT machines combining a fan-shaped only one slice of information and multiple separate images are
x-ray source and multiple detector rows has led to the ability required to see the vessel in its entirety (Fig. 6.1).
to acquire image data from a large tissue volume in a single 2 MIP techniques produce a planar image from a volume of data
breath hold. With IV contrast medium and appropriate tim- within which the pixel values are determined by the highest
ing, exquisite images can be obtained of blood vessels during voxel value in a ray projected along the data set in a specified
any particular vascular phase. Optimal imaging of the vessels direction.The images obtained are those most similar to a con-
requires the relatively rapid IV injection of iodinated con- ventional arteriogram but one of the clear disadvantages of this
trast medium (usually 35 mls-1) and the acquisition of data technique is that any tissue of high density (such as bone or
at the appropriate time of vascular enhancement. The lat- vascular calcification) lying within the ray through a vessel will
ter can be estimated based upon the normal time of arrival determine the pixel intensity instead of the contrast medium
of the contrast medium within the organ being imaged or, itself within the blood vessel (Fig. 6.2).This is a common cause
more commonly nowadays, by the more accurate use of con- of overestimation of vascular stenoses.
trast bolus detection technology. Tight boluses of contrast 3 Volume-rendering techniques assess the entire volume of data
medium using a chaser of normal saline may be useful not with an attenuation threshold for display and produce a
only to improve vascular opacification but also to reduce the three-dimensional image. Typically, tissues are assigned a
total volume of contrast medium required.
Depending upon the region and volume of the body
being imaged hundreds, if not thousands, of axial images will
be acquired; whilst all the diagnostic information is available
in this data-set, evaluation of the axial images alone can be
extremely time-consuming and is helped considerably by
reconstruction of the data in axial, coronal, and oblique planes
without loss of resolution, so-called multiplanar reconstruc-
tion (MPR). Tortuous vessels can be straightened by curved
MPR to aid in the assessment of luminal narrowing due to,
for example, atheromatous disease or encasement by tumour.
Maximum intensity projection (MIP) and volume rendering
(VR) techniques are additional tools that help greatly in the
assessment of blood vessels. Each of these reconstruction tech-
niques has its advantages and disadvantages:

1 MPR is very useful for the rapid review of blood vessels in any
plane including the surrounding bone and soft tissues, and will
allow the assessment of vessel walls that might be obscured in
MIP and VR techniques by the presence of, for example, cal- Figure 6.2 An MIP image from an MDCT of a renal transplant artery
cification or an endoluminal stent. Each image, however, gives clearly demonstrating the vascular anatomy.

A B C
Figure 6.1 MDCT images of a gastroduodenal artery pseudoaneurysm. (A) An axial image demonstrates an enhancing pseudoaneurysm cavity
surrounded by a large haematoma in the region of the pancreatic head. (B) A sagittal MPR image demonstrates a pseudoaneurysm arising from the
gastroduodenal artery. (C) A further sagittal MPR image demonstrates that the right hepatic artery, from which the gastroduodenal artery arises,
originates from the superior mesenteric artery.
 CHAPTER 6 ANGIOGRAPHY: PRINCIPLES, TECHNIQUES (INCLUDING CTA AND MRA) AND COMPLICATIONS 111

colour that is dependent upon their attenuation values, facil-
itating the differentiation of structures of differing density
(Figs 6.3, 6.5). The final images can be rotated in real time
to find the best projection to display anatomy and pathol-
ogy and this is the most important feature of this technique.
Vascular stenoses can be overestimated, however, and small
vessels may not be clearly visualized.
It should be remembered that, whilst these post-processing
techniques are very helpful for diagnostic assessment and for
display in multidisciplinary team meetings, the axial source
images are essential and often allow the operator to distin-
guish between artefact and disease when an abnormality is
suggested on reformatted views.
CLINICAL APPLICATIONS
MDCT angiography (MDCTA) is replacing conventional
angiography in many, if not all, body areas and is indicated,
therefore, in any disease process that requires the visualization
of blood vessels to improve diagnosis and outcome. Within
the thorax, for example, this would include the assessment of:
pulmonary embolic disease1,2 (Fig. 6.4); thoracic aortic disease35;
coronary artery graft patency610; and bronchial artery anatomy
and pathology in massive haemoptysis11. In the abdomen com-
mon indications include the pre-operative planning and post-
treatment assessment of abdominal aortic aneurysmal disease12,13
(Fig. 6.5); the assessment of native and transplant renal arteries1416;
the staging of hepato-pancreaticobiliary neoplasms1720; and the
assessment of vascular complications in patients suffering severe
trauma21. It is also used increasingly in the assessment of periph-
eral arterial disease in the lower (and upper) limbs where it is less
invasive, less expensive and exposes the individual to less radiation
than conventional catheter angiography2226.
The scanning technique (positioning of the patient, rate of
contrast medium administration, time of image acquisition), and
the post-processing techniques most suited to the different indi-
cations listed earlier will clearly vary and lie outside the scope
of this chapter; interested readers are referred to other chapters
within this book and to other texts cited in the reference list.

A B C D
Figure 6.3 The value of MDCT MPR and VR images in the assessment of pulmonary sequestration. (A) The CXR demonstrates a mass projected
through the left side of the cardiac silhouette. (B) An axial image from an MDCT examination demonstrates a left paraspinal soft-tissue mass. A feeding
vessel arising from the thoracic aorta is visible. (C) MPR and (D) VR images show the full length of the oblique course of feeding artery.

Figure 6.4 MDCT demonstration of bilateral pulmonary emboli. (A) Axial and (B) coronal MPR images demonstrating extensive bilateral pulmonary
emboli in central pulmonary arteries.
112 SECTION 1 IMAGING TECHNIQUES AND GENERAL ISSUES

Figure 6.5 MDCT images of abdominal aortic aneurysmal disease before and after stent insertion. A large infrarenal abdominal aortic aneurysm is
seen on axial (A and D), coronal MPR (B and E) and VR (C and F) images before and after the insertion of an endoluminal bifurcated stent

MAGNETIC RESONANCE ANGIOGRAPHY

BACKGROUND ing a source of artefacts on MR images, flow phenomena

Magnetic resonance angiography (MRA) is a method for
generating images of blood vessels with magnetic resonance
imaging (MRI)27,28. With improved understanding of the
nature of the signals emanating from blood vessels on MR
images, it became evident that rather than simply contribut-
could be harnessed to generate diagnostic angiograms2729.
MRA has undergone a revolution over the last decade, replac-
ing catheter angiography as the primary diagnostic tool for
the evaluation of most vascular territories (apart from the
coronary arteries); this change is due mainly to the success of
contrast-enhanced techniques30.
 CHAPTER 6 ANGIOGRAPHY: PRINCIPLES, TECHNIQUES (INCLUDING CTA AND MRA) AND COMPLICATIONS
CONTRAST MECHANISMS
Unenhanced (time-of-ight [TOF] and phase
contrast [PC]) MRA
With these techniques, the intravascular signal depends on inher-
ent properties of flow, and the MR parameters must be carefully
tailored to ensure a high intravascular signal27,28. In the case of
TOF MRA, for example, data must be acquired perpendicular
(and ideally orthogonal) to the direction of flow, and the time
between successive radio frequency (RF) pulses (the repeti-
tion time [TR]), must be sufficiently long to allow an adequate
inflow of fully relaxed protons into the imaging slice27.The TR,
therefore, is dictated by expected flow rates within the region-
of-interest and, typically, should be 35 ms or greater. As the data
acquisition time is directly proportional to the TR (acquisition
time = TR number of phase-encoding steps number of
slices number of excitations), a TR substantially greater than
the shortest possible for gradient-echo imaging (35 ms) must
be used, with resultant prolongation of scan time. Additionally,
owing the predominant headfoot orientation of the major
arteries (e.g. the aorta, ilio-femoral and infra-popliteal vessels),
the axial plane must be used, which also prolongs the data acqui-
sition owing to the large number of slices required. Despite
faster techniques, therefore, acquisition times for TOF MRA are
artificially prolonged, firstly as a result of physiological bloodflow
rates that mandate the use of a relatively long TR and secondly
by the requirement for axial imaging, which affords poor spatial
coverage in comparison with sagittal or coronal imaging30.
Selective arteriograms or venograms can be acquired by
employing a (travelling) saturation pulse placed downstream of
the imaging slice for MRA (to eliminate venous return from
the opposite direction) or upstream of the imaging slice to gen-
erate MRVs (venograms). If no saturation pulses are employed,
both arteries and veins are identified on the same image.
Time-of-ight MRA methodology and limitations
TOF angiography relies on the fact that the blood enters the
volume under consideration with relatively high velocity and
traverses it quickly, so that it receives very few RF pulses27,28.
In order to maintain a highest possible inflow effect, all protons
within the imaging volume must be replenished between suc-
cessive TRs, though maximal inflow may not be necessary in
clinical practice and some trade-offs can be accepted.An oblique
course of the blood vessel being imaged in relation to the slice
orientation and short TRs both adversely affect signal-to-noise
ratios (SNR) as a result of protons under these circumstances
experiencing more RF pulses whilst in the imaging slice. The
severity and length of stenoses also tend to be overestimated on
TOF MRA images because of intra-voxel dephasing secondary
to turbulent, slow or pulsatile flow.
As a result of these limitations,TOF MRA has failed to offer a
viable non-invasive screening alternative to conventional arteri-
ography, and has not had a major impact on clinical practice.
Phase-contrast MRA
Phase-contrast angiography (PCA) is now seldom used in
clinical MRA. The methodology underpinning the technique
113
is somewhat complex and, like TOF MRA, images are prone
to artefacts and data acquisition is lengthy29.
The term phase refers to the angle that the transverse mag-
netization makes relative to a reference axis. When protons
are moving, for example, in flowing blood, a change in phase
proportional to the distance the proton moves (and, there-
fore to blood velocity) is induced by the imaging gradients,
in particular the slice-selection gradient and the frequency-
encoding gradient. As these gradients actually consist of a pair
of gradient pulses applied in opposite directions (so-called
bipolar gradients), the effect of each gradient on the phase of
protons for stationary (i.e. background, motionless) tissues
is equal and opposite, and the effect cancels out. For mov-
ing (flowing blood) protons, the position of each proton will
change between consecutive pulses resulting in a phase change
relative to stationary protons that is proportional to velocity.
This observation of gradient-induced phase change provides
the basis for phase-contrast angiography in which the gradient
pulses are designed to produce phase changes for a given veloc-
ity range. In this way, the signals do not cancel, phase information
is preserved during the image reconstruction. Pixel brightness
is directly proportional to the phase-shift acquired by a moving
proton in the magnetic field and, therefore, to velocity. In prac-
tice, as the method is only sensitive for the velocity compo-
nent applied along the flow-encoding gradient, the acquisition
must be repeated a total of four times in order to generate an
angiogram: an initial flow-compensated sequence is followed
by three flow-encoded acquisitions one for each direction of
flow (headfoot, leftright, anteroposterior), followed by a com-
plex subtraction to generate the final angiographic image. As
the phase is unchanged for static protons, the subtraction com-
pletely suppresses the signal from the background tissue thus
facilitating the generation of high-quality images29.
One of the major challenges of PCA relates to the require-
ment of the operator to appropriately select the velocity-encoding
gradient.As the signal intensity is proportional to velocity, the range
of velocities present within the vessels of interest must be inferred
or measured to allow the operator to set the velocity-encoding
gradient (Venc) correctly.This assumes an a priori knowledge of the
blood flow velocities within the relevant artery and, though this
can be rapidly measured directly by acquiring a series of 2D PC
images with different phase-encoding values, it is time-consuming
and the presence of different flow velocities within the arteries
enclosed within a single field of view may introduce artefacts29.
Limitations of unenhanced MRA and requirement
for contrast agents
At each stage of the evolution of MRA, high accuracy was
reported for almost all techniques when compared with cath-
eter angiography2729 but TOF and PC MRA did not gain
widespread acceptance in clinical practice because of long
examination times, suboptimal resolution and frequent arte-
facts. TOF MRA was used to evaluate disease involving the
carotid bulb and the femoro-popliteal and pedal arteries as
these vascular territories were ideally suited to this technique
due to the relatively straight course of their vessels, which
114 SECTION 1 IMAGING TECHNIQUES AND GENERAL ISSUES
meant that adequate inflow could be ensured. MRA was
also established as an accurate modality for portrayal of the
proximal intra-cranial arteries (despite the fact that the arteries
demonstrate marked tortuosity) because of the relatively small
volume of tissue that needed to be covered, coupled with the
fact that constant blood flow within the cerebral arteries over
the cardiac cycle optimizes intravascular signal29,30.
Contrast-enhanced MRA (CEMRA)
Because of their unmatched high contrast-to-noise ratios, high
spatial resolution, rapid speed of acquisition and relative free-
dom from artefacts, contrast-enhanced techniques have almost
universally replaced non-contrast techniques in clinical prac-
tice30. Unlike TOF and PCA techniques, where the intravas-
cular signal is dependent on inherent properties of flow and is,
therefore, at the mercy of alterations in flow rate secondary to
vascular disease, intravascular signal for contrast-enhanced MRA
(CEMRA) depends on a T1 shortening effect induced by the
injection of a paramagnetic contrast agent (usually gadolinium
based). Images can, therefore, be acquired in any plane including
coronal, which affords the best anatomical coverage for virtu-
ally all vascular territories outside the brain (Fig. 6.6). In addi-
tion, the ability to exploit ultrafast 3D acquisitions (by using the
shortest TRs possible), allows rapid image acquisition that can
easily be accommodated within a single breath-hold, an impor-
tant factor when imaging in the chest and abdomen. In order to
generate selective arteriograms, images are acquired during the
first arterial passage of the contrast agent before its arrival within
the veins.The synchronization of data acquisition with the peak
arterial bolus is one of the major challenges of CEMRA as
the rate of transit of contrast medium from the peripheral vein
injection site to the vessel of interest is affected by a number of
factors including heart rate, stroke volume and the presence or
Figure 6.6 A surgically created dialysis (arteriovenous) fistula in the left
arm of patient with chronic renal failure.
absence of proximal steno-occlusive lesions. Although the cir-
culation time can be measured using a test bolus, or can be
inferred by making some assumptions about the patients car-
diovascular status, the process is now automated by employing
an MR fluoroscopic approach a technique that demonstrates
contrast medium arrival in real time on the display monitor,
thus signalling the appropriate time for data acquisition31.
The unique nature of k-space (the array of data from
which the final image is generated) whereby the central lines
determine image contrast and the peripheral lines deter-
mine image resolution, can be uniquely exploited to generate
CEMRA images with unrivalled signal-to-noise ratios32. In
situations where breath-holding is not required (e.g. peripheral
MRA and carotid artery imaging) as long as collection of the
contrast-defining central lines of k-space is completed during
the arterial peak before contrast medium reaches the veins, the
continued collection of resolution-defining peripheral lines of
k-space during venous enhancement does not result in venous
contamination of the images32.
CEMRA is now the standard of reference for MRA against
which all new techniques must be measured.
POST-PROCESSING
Regardless of which method is employed to generate MR
angiograms, the aim of all techniques is to make the arter-
ies the brightest structures on the images, and to extract the
vascular data by means of a maximum intensity projection
(MIP) computer algorithm28 (Figs 6.7, 6.8). Other methods
of post-processing include multi-planar reformatting, volume
rendering and surface-shaded displays. For phase-contrast
MRA, there is inherent complete background suppression
because of the absence of bulk motion in background tissues.
Figure 6.7 Normal MRA. Note clear depiction of the abdominal aorta,
iliac arteries and renal arteries on the frontal MIP.
 CHAPTER 6 ANGIOGRAPHY: PRINCIPLES, TECHNIQUES (INCLUDING CTA AND MRA) AND COMPLICATIONS
Figure 6.8 Severe left renal artery stenosis and right common iliac
artery occlusion.
For TOF MRA, the background is suppressed by virtue of
the short TR in relation to the longish T1s of background
tissues. Although fat remains bright, it can be eliminated by
use of fat-saturation techniques, albeit with an additional
time penalty. For CEMRA, there is the additional benefit
that the background tissues can be completely eliminated by
the subtraction of a mask acquired before the injection of
contrast material.
MRA IN CLINICAL PRACTICE
MRA is an excellent technique for imaging most vascular territo-
ries but is generally avoided in unstable and/or ventilated patients
and those with severe trauma because of the hazards of the MR
environment and the difficulties in monitoring patients within
the MR room. Standard contra-indications to MRI (pacemakers,
intracranial uneurysm clips) also preclude use of MRA.
Thoracic aorta and great arteries
Because of the relatively large size of these vessels, they can be
demonstrated with a wide variety of techniques but CEMRA
is favoured in most instances owing to its rapid speed of
acquisition and the quality of the images generated33,34.
Pulmonary arteries
Although several studies have established high accuracy for
MRA compared with pulmonary angiography for the evalu-
ation of suspected pulmonary embolism, it is not widely used
clinically35,36. Reasons for this include a reluctance to refer
potentially unstable patients to MRI; the availability of CT pul-
115
monary angiography; and the fact that catheter pulmonary angi-
ography, the reference standard against which new and improved
MRA techniques should be compared, has largely disappeared
from clinical practice due to the success of CTA, thus depriving
MRA of a valid arbiter for comparative studies.
Improvements in spatial resolution bring the subsegmental
arteries within the realm of MRA (Fig. 6.9) and further refine-
ments including MR perfusion and ventilation (mirroring the
ventilation and perfusion components of nuclear medicine stud-
ies albeit at much higher resolution) offer additional functional-
ity to determine the location and distribution of small emboli36.
Abdominal aorta, renal and mesenteric arteries
CEMRA is the MR technique of choice for imaging the aorta
in its entirety and for evaluating its large and medium-sized
branches including the renal (Fig. 6.8) and proximal mesen-
teric arteries30,3740. Because of the need for breath-holding
the techniques spatial resolution remains inferior to that of
catheter angiography because of the inability to collect a high-
resolution data-set that matches that of DSA during a breath-
hold. Nonetheless, numerous studies and meta-analyses attest
to the accuracy of MRA in clinical practice38. An additional
benefit of MRA lies in its ability directly to measure the flow
rate to each kidney using a two-dimensional (2D) cardiac-
triggered, phase-contrast approach, which facilitates both the
assessment of both end-organ damage and the likelihood of
success of transluminal angioplasty37.
MRA is also highly accurate for depicting the mesenteric arter-
ies in patients with suspected chronic mesenteric ischaemia39.
In patients with abdominal aortic aneurysms, the external
dimensions of the aneurysm can easily be delineated, should
this be necessary, with targeted pre-contrast or post-contrast
Figure 6.9 Normal pulmonary MRA.
116 SECTION 1 IMAGING TECHNIQUES AND GENERAL ISSUES
images as only the lumen is demonstrated with CEMRA40.
Calcium within the wall is not demonstrated, however, and
aneurysm assessment for planning endovascular stenting is
usually performed with CTA.
Carotid arteries
Because of the requirement accurately to differentiate steno-
sis at a 70 per cent cut-off within a relatively small (internal
carotid) artery, there are stringent spatial resolution require-
ments for carotid MRA41. As the carotid bifurcation does not
move with respiration a relatively long data acquisition that
generates images with sufficiently high (isotropic) spatial reso-
lution is recommended. Despite the fact that the resultant data
acquisition is substantially longer than the arterio-venous transit
A B
D E
G H
time of 812 s (the bloodbrain barrier prevents the paren-
chymal extraction of gadolinium and therefore facilitates rapid
transit from artery to vein), this does not lead to unacceptable
venous contamination of the images as there is sufficient time
within this arterio-venous window for acquisition of the con-
trast-defining central lines of k-space. Clearly, acquisition of
these central lines must be synchronized with the peak arterial
bolus by combining some form of bolus detection as described
previously with a centric order of k-space filling.
In comparison with cathether angiography CEMRA has
demonstrated high accuracy in evaluating the carotid artery,
e.g. for differentiating between significant and insignificant ste-
noses, differentiating between critical stenoses and occlusions,
and for depicting carotid and vertebral dissections (Fig. 6.10).
C
F
Figure 6.10 T2, FLAIR and diffusion-weighted images in a patient
with right-sided weakness and aphasia. All the images were acquired
in the axial plane at the same level. (AD) Note the high signal on T2
(A), FLAIR (B), and Diffusion-weighted images (C) (arrowed) with a
corresponding low-signal intensity on ADC map (D), ringed indicating
an acute cerebral infarct. (E, F) Whole-volume MIP images from a TOF
MRA in coronal (E) and axial (F) orientation demonstrate reduced signal
intensity within the left internal carotid (short arrows) and left middle
cerebral arteries. Targeted MIP images of the left-sided carotid and
vertebral arteries demonstrate a severe stenosis of the internal carotid
artery just beyond the bulb (not shown). Axial T1 (G) and T2w (H)
images with fat-saturation reveal crescentic high-signal intensity within
the left ICA (long arrows) at the site of the stenosis demonstrated on
CEMRA, diagnostic of acute dissection.
 CHAPTER 6 ANGIOGRAPHY: PRINCIPLES, TECHNIQUES (INCLUDING CTA AND MRA) AND COMPLICATIONS 117

Peripheral arteries Figure 6.11 Peripheral MRA

performed using a three-
In the peripheral arteries, as in most other areas, TOF MRA station, moving-table approach.
has been superseded by CEMRA. Although the spatial cov- The study demonstrates excellent
erage offered by single-field-of-view imaging is insufficient visualization of the entire run-off
to address all of the relevant anatomy, the introduction of arteries from the mid-abdominal
moving-table MRA has opened the way for routine non- aorta to the level of the pedal
arch. Note extensive vascular
invasive MRA of the entire run-off arteries in a short time- stenoses and occlusions and
frame (<20-minute examination)42,43 (Fig. 6.11). The major a bypass graft from the right
limitation of moving-table MRA is venous contamination popliteal artery to the right
in the third location. Methods to eliminate this include the anterior tibial artery.
use of tourniquets inflated to sub-systolic pressures to delay
onset of venous enhancement, careful attention to detail in
setting up the examination (to avoid any redundancy in ana-
tomical coverage), the use of high parallel-imaging factors
and the exploitation of ultra-short TR imaging42,43.

SUPPLEMENTAL IMAGING: WHEN IS IMAGING

OF THE LUMEN NOT ENOUGH?
Currently, virtually all clinical decision making is based on the
appearance of the lumen, though clearly the relevant pathology
(atheroma) lies within the wall. Efforts to delineate the various
components of plaque, in particular the unstable plaque, have
met with mixed results. A particular situation exists in the imag-
ing of carotid and vertebral artery dissections, where imaging of
the lumen alone simply demonstrates narrowing indistinguish-
able from other causes, but where cross-sectional imaging of the
lumen with spin-echo imaging is essential to demonstrate the
typically bright appearance of the usually crescent-shaped intra-
mural haematoma. Therefore, in all cases of suspected carotid or
vertebral dissection pre-contrast T1 and T2w fat images saturated
should be performed. Failure to do so results in the identification
of a focal stenosis only, and robs the clinician of the opportunity
to prescribe anticoagulation therapy, the treatment of choice for
Improved coil efficiency and new parallel imaging methods
dissection.
that increase acquisition speed and/or spatial resolution by a
Other instances in which imaging additional to that pro-
factor of 216 are becoming routine in clinical practice44,45 and
vided by the luminogram is helpful include arteritides (e.g
3T imaging opens new horizons due to its improved signal-
Takayasus and Behets disease), aneurysms and the assessment
to-noise capability44,46. New contrast agents (1.0 M and blood-
of vessels narrowed or invaded by tumour.
pool agents) and the potential for routine functional imaging of
end-organ function offer exciting prospects for future improve-
FUTURE DIRECTIONS ments. Currently, new applications are being added constantly,
and isotropic submillimetre resolution studies for all regions
Improvements in MRA are aimed at increasing both spatial and of interest combined in a single examination with functional
temporal resolution whilst minimizing contrast-to-noise loss. evaluation are anticipated within the near future.

CATHETER ARTERIOGRAPHY
TECHNIQUE
The risks associated with modern arteriography are extremely
small. Arteriography is still nevertheless an invasive procedure
and it should never be undertaken unless the radiologist is
satisfied that the likely benefits justify the potential risks. An
arteriogram should never be carried out simply because it
has been scheduled or routinely requested by a clinical team;
mistakes inevitably occur and the radiologist responsible for
the procedure should be satisfied in every case that proper
indications exist for the particular study requested. The arteri-
ographer should also be quite clear before starting as to what
information is required from the procedure; this ensures that
the correct studies and projections are obtained and allows
for rational decision making during the procedure if some-
thing unexpected is shown or a problem arises. Most of these
118 SECTION 1 IMAGING TECHNIQUES AND GENERAL ISSUES
comments are clearly applicable to any imaging technique but
are arguably more important and perhaps easier to enforce
than is the case for non-invasive studies.
PREPARATION OF THE PATIENT
Informed consent should be obtained for arteriography. A
doctor, preferably the responsible radiologist or a member of
the radiology department, should see the patient before the
procedure to explain what is to be done, check that no con-
traindications to the study exist, check the appropriate pulses
and ensure that adequate premedication is arranged.The groin
should be shaved if a femoral approach is to be used. It has
been the usual practice for patients to be nil by mouth for
an appropriate period before the procedure to avoid the risk
of aspiration during a possible reaction to contrast medium or
other serious accident. It is now the policy in many depart-
ments, however, only to stop solid foods and to permit free
oral fluids unless general anaesthesia or heavy premedication is
being used. Whatever regimen is adopted, adequate measures
should be taken to avoid dehydration during the procedure
and the recovery period.
CONTRAINDICATIONS
There are very few absolute contraindications to arteriogra-
phy but there are many factors that considerably increase the
hazards of the technique. Always check that a patient is not
pregnant before arteriography, as the radiation dose may be
considerable. If arteriography is essential in a pregnant patient,
the dose to the fetus should be minimized by protection, field
collimation and careful choice of filming sequences. Caution
should be exercised in patients on anticoagulant therapy or
with other bleeding diatheses.Arteriography should be avoided
if possible in such cases; if it is essential then all possible steps
should be taken to correct or improve the coagulation defect
before and during the procedure if this is clinically accept-
able. Other factors that increase the risk of bleeding from an
arterial puncture site include systemic hypertension and disor-
ders predisposing to increased fragility of the vessel wall such
as Cushings syndrome, prolonged steroid treatment and rare
connective tissue disorders such as certain types (especially
type IV) of the EhlersDanlos syndrome.
Arteriography may be necessary in a patient with a suspected
or known previous adverse reaction to contrast medium and this
problem is discussed in Chapter 2. Arteriography can require
larger doses of contrast medium than any other radiological
procedure and particular care must be exercised in infants and
in dehydrated or shocked patients, patients with serious cardiac
or respiratory disease, patients in hepatic or renal failure, and
other patients with serious metabolic abnormalities.
ANAESTHESIA
Most arteriography is performed under local anaesthesia,
though general anaesthesia is necessary for babies and young
children, for confused, difficult or very nervous patients, and in
some complex and interventional procedures. Although gen-
eral anaesthesia can be more pleasant for the patient than local
anaesthesia and reduces motion artefact on the radiographs, it
nevertheless adds to the risks of arteriography. This is not only
because of the (small) risks inherent in general anaesthesia but
also because it masks the patients subjective symptoms and reac-
tions.These may provide the radiologist with immediate warning
of a mishap such as the subintimal injection of contrast medium
or the inadvertent wedging of the catheter tip in a small artery: a
warning that may well prevent more serious injury.
ARTERIAL PUNCTURE
It is often said that the most important part of an angiographic
procedure is the initial vessel puncture and there is no doubt
that a good technique is likely to make the subsequent angio-
gram not only more comfortable for the patient but also easier
for the angiographer. It should go without saying that the
most suitable route of access in order to achieve the aims of
the study should have been chosen before the patient enters
the angiographic suite; this decision will often depend upon a
number of factors including previous imaging studies, opera-
tion notes and clinical examination. For example, when per-
forming a diagnostic arteriogram (or angioplasty) of the main
artery supplying a renal transplant it is worthwhile reviewing
the operative notes to see if the arterial anastomosis was made
end-to-end with the internal iliac artery or end-to-side with
the external iliac artery; the former is often easier to selectively
catheterize from a contralateral femoral arterial approach,
whilst the latter is best studied via an ipsilateral puncture.
The most common vessel punctured for diagnostic and ther-
apeutic angiography is the common femoral artery. Axillary,
brachial or radial approaches can be used but these routes are
usually reserved for those patients in whom a femoral approach
is not possible due to iliac occlusive disease.There has, in recent
years, been a trend towards the greater use of upper extremity
access even in those individuals with patent femoral vessels.This
is partly because DSA enables adequate studies to be obtained
by injection through smaller calibre catheters (presumed to be
associated with a lower morbidity than larger catheters) and
partly because of the move towards the performance of angiog-
raphy as an outpatient or day-case investigation. The latter trend,
motivated by economic and logistic considerations as well as those
related to the patients convenience, favours the upper extrem-
ity approach because of the rapidity with which a patient who
has undergone an axillary, brachial, or radial procedure can be
mobilized in comparison with one who has had a groin puncture
and the greater ease with which the upper extremity puncture
or arteriotomy site can be monitored and controlled during the
hours following the investigation.A popliteal artery puncture may
be useful in certain instances such as angioplasty of the superficial
femoral artery when it is not possible to catheterize this vessel via
an antegrade approach.
The technique of arterial puncture and catheterization of
those vessels most commonly used for arterial access will be
described.
 CHAPTER 6 ANGIOGRAPHY: PRINCIPLES, TECHNIQUES (INCLUDING CTA AND MRA) AND COMPLICATIONS
Retrograde Femoral Artery Puncture (Fig. 6.12)
The artery is palpated to select the site of puncture before
local anaesthetic is injected. Various anatomical descriptions
are given regarding the site at which to puncture but the aim
should be to enter the common femoral artery a short dis-
tance below the inguinal ligament. This is best achieved by
puncturing the vessel where it can be most easily palpated,
irrespective of the relationship of this point to the inguinal
skin crease. Since this is the point where the artery crosses
the pubic bone it is also the easiest point at which to achieve
haemostasis afterwards.
It is important that the arterial puncture site should be
adequately anaesthetized. After cleansing the skin with a
suitable preparation, 510 ml of 0.51 per cent lignocaine is
infiltrated around the artery. It is important to inject the local
anaesthetic agent posterior to the artery as well as anterior to
it, even if a single-wall puncture of the vessel is subsequently
made, as it makes the arterial puncture and subsequent cath-
eter manipulation much more comfortable for the patient.
In addition, if the puncture site is inadequately anaesthetized
arterial spasm is more likely, which may make selective cath-
eterization very difficult because of the lack of free catheter
movement.
After local anaesthesia a small scalpel incision is made
in the skin (large enough to accommodate the anticipated
catheter), the skin being temporarily drawn laterally during
the incision to avert the risk of a scalpel injury to the arterial
wall. A pair of fine artery forceps is inserted into the inci-
sion and used to create a tunnel through the subcutaneous
tissues down to the artery. This manoeuvre is particularly
Figure 6.12 Percutaneous catheterization. One of the commonly
used techniques of percutaneous arterial catheterization. The artery
(1) is transfixed (2). The needle is partially withdrawn and re-angled (3).
A guidewire is passed into the needle during free backflow of blood (3, 4),
the needle removed and a catheter or introducer inserted over the wire
(5, 6). When the catheter is safely within the arterial lumen the wire is
withdrawn (7).
119
important in large or obese patients, for it not only facili-
tates catheterization but it reduces the risk of a postopera-
tive haematoma: any escaping blood emerges through the
incision and is immediately apparent, instead of collecting
subcutaneously.
The technique employed for puncturing the artery is a
matter of personal preference. A reliable way is to feel the
artery with the middle and index fingers of the left hand and
insert the needle (held in the right hand) between the two
palpating fingers. Gentle pressure with the needle will alter
the pulse as detected by the lower (index) finger, giving reas-
surance as to its correct alignment. The needle is held angled
forwards and passed through the anterior wall alone or right
through the artery depending upon the angiographers pref-
erence (see later). A single-wall puncture technique is most
commonly performed with a one-part needle, in which case
free pulsatile blood flow will occur as soon as the needle
enters the vessel lumen. When a double-wall puncture tech-
nique is performed a two-part needle is used; after passing
through the vessel, the central stylet is removed, the needle
angled slightly more towards the horizontal and then with-
drawn at an even rate, assisted by gentle rotatory movements
to avoid any sudden jerking. When the tip of the needle
is safely in the arterial lumen there will be a free, spurting
backflow of blood from the hub. While the needle is held
steady with one hand the soft tip of a guidewire is threaded
through the needle into the artery. When a sufficient length
of wire is inside, the needle is removed and firm manual
pressure maintained on the puncture site until the needle has
been exchanged for a catheter or dilator. The guidewire is
removed when the tip of the catheter is in a satisfactory posi-
tion and the catheter is then flushed free of blood with hepa-
rinized saline. At the end of a correctly conducted insertion
procedure there should be no bleeding around the catheter,
which will move freely and painlessly through the puncture
site when manipulated.
There are arguments in favour of both single- and double-
wall arterial punctures; some radiologists prefer to puncture
only the anterior wall of the artery to minimize the trauma
to the vessel, although puncture to both vessel walls does not
increase the risk of complications as these are usually caused by
the subsequent manipulations with guidewires and catheters.
Proponents of a double-wall puncture technique maintain
that this method is safer, particularly when first learning angi-
ography, with a lesser risk of intimal dissection when introduc-
ing the guidewire through the needle when compared with
a single-wall technique. Whichever method is employed, if a
guidewire does not pass freely into the arterial lumen it should
not be forced; this technique is never successful and usually
causes an intimal dissection. If there is good backflow of blood
the reason for failure of the wire to pass freely may be either
that the needle is angled sharply towards one wall of the blood
vessel or that the wire is passing into a small branch vessel such
as the deep circumflex iliac artery. A number of manoeuvres
may help, including fluoroscopy, cautious repositioning of the
angle of the needle or changing to a J-wire. A gentle injection
of contrast medium is possible to help ascertain the nature
120 SECTION 1 IMAGING TECHNIQUES AND GENERAL ISSUES
of the problem but only if good backflow is present. If there
is poor backflow then the needle may be positioned near an
atheromatous plaque or a stenosis, may be only partially in
the lumen, or may have caused an intimal dissection. In these
circumstances discretion is advised and it is wise to start again
with a fresh puncture. In difficult cases remember that there is
usually a femoral artery in the opposite leg! Better two groin
punctures than a dissection or a large haematoma.
The catheter is flushed with a heparinized saline solution
throughout the procedure to prevent clotting.Various concen-
trations of heparin are used in different centres; the authors use
2000 IU heparin L-1 normal saline. During an average proce-
dure it would be unusual for a patient to receive much more
than about 5001000 IU in this way. It is almost always prefer-
able to give a firm hand flush intermittently, rather than main-
tain a continuous slow flush infusion. This technique not only
leaves the proximal end of the catheter free for manipulation
but also is more effective, since a slow infusion may only clear
the proximal holes of a catheter with multiple side-ports; clot
forms in the end-port and the more distal side-ports, and is then
blown out into the vascular system when a pressure contrast
injection is performed.
Antegrade femoral artery puncture
The most common indication for an antegrade puncture of
the femoral artery is when performing ipsilateral superficial
femoral, popliteal or infragenicular artery angioplasty. Once
again, the aim should be to puncture the common femoral
artery just below the inguinal ligament. The most common
problem associated with this procedure is catheterization of
the profunda femoris and many methods have been described
in order to manipulate the catheter out of this vessel into
the superficial femoral artery when this has happened. With
a good technique, however, this complication should rarely
occur.
Preparation of the patient is important; obese patients may
have an abdominal apron that hangs over the groin and this
should be lifted superiorly and strapped out of the way with
heavy-duty tape. It is well worthwhile when performing an
antegrade femoral puncture to screen over the femoral head to
determine the correct site for vessel puncture, as this is often
considerably higher than anticipated when using palpation
alone. The fovea of the femoral head is a useful landmark for
the correct site of arterial access and this can be marked on
the skin before local anaesthetic is infiltrated in the same way
as for a retrograde puncture. A skin incision is made with a
scalpel blade and blunt dissection is again performed of the
soft tissues over the femoral artery. The vessel is then punc-
tured with the needle angled slightly towards the feet. The
best wire to use is a wide-angled J-wire with a curvature of
radius 7.5 mm. This should be introduced through the needle
with the tip of the curve directed anteriorly so that, as it exits
the needle tip within the vessel lumen, it is directed into the
superficial femoral artery rather than the profunda femoris. A
straight guidewire is much more likely to pass directly into
the latter vessel because of the posterolateral orientation of
this artery.
Popliteal artery puncture
The patient is placed prone on the angiography table and US
is used to visualize and puncture the popliteal artery, which
lies deep and lateral to the popliteal vein in the popliteal fossa.
Intra-arterial vasodilator agents are commonly employed rou-
tinely to reduce the risk of spasm.
Axillary artery puncture
When performed correctly this is arguably the safest puncture
to perform in the upper limb4749. The term axillary puncture
is in fact incorrect as the most proximal portion of the brachial
artery is punctured rather than the axillary artery itself and
the description of high brachial is preferred by some. With
the arm abducted (the left arm is preferred) to approximately
135 degrees and the hand placed under the patients head, the
artery is palpated over the superior portion of the humerus,
where it is punctured after local anaesthetic infiltration and
skin puncture as previously described.
Complications of haematoma and pseudoaneurysm for-
mation are seen in less than 1 per cent of patients and the
feared complication of brachial plexus injury is rare but if a
haematoma should develop there should be low threshold for
performing surgical decompression to prevent a neurological
deficit. Arterial spasm is less common than when low brachial
and radial artery punctures are performed and intra-arterial
vasodilator agents are not administered routinely.
Brachial artery puncture
The brachial artery may be punctured anywhere along its course
but the most common site is the antecubital fossa above the
elbow joint, where it lies medial to the biceps tendon50. Arterial
spasm is more common than when an axillary artery puncture
is performed51,52 and intra-arterial vasodilators are administered
routinely by some practitioners once the vessel has been cath-
eterized. If a sheath of greater than 7 Fr in size is likely to be
necessary then a formal surgical cut-down is preferred by some.
Radial artery puncture
This vessel is cannulated using a micropuncture set. A 4 Fr sheath
is then introduced through which a 120 cm diagnostic catheter is
manipulated over a guidewire into the aorta. Intra-arterial vasodi-
lator agents are routinely administered to reduce the risk of arte-
rial spasm. Before employing this route it is important to confirm
that there is a good collateral supply to the hand through the
ulnar artery in case of subsequent radial artery occlusion.
Selective catheterization
By manipulating a catheter under fluoroscopic control it is pos-
sible to insert the catheter selectively into various branches of
the vascular system such as the renal artery, coeliac axis, axillary
artery, etc. Different catheter shapes are available (Fig. 6.13),
each of which is suitable for a particular manoeuvre or for
catheterizing certain arterial branches. Superselective catheter-
ization (also known as subselective embolization) is the term
used for the catheterization of small subsidiary arteries that
themselves arise from named branch arteries and is most fre-
quently performed during embolization procedures. A co-axial
 CHAPTER 6 ANGIOGRAPHY: PRINCIPLES, TECHNIQUES (INCLUDING CTA AND MRA) AND COMPLICATIONS
Figure 6.13 Some examples of catheters in common use. Some of
the many different catheter shapes available are illustrated. From left to
right: straight flush; pigtail; cobra; and sidewinder. Note the side-ports in
some of the catheters.
catheter (one that passes through the lumen of a diagnostic or
guiding catheter) is often used for the catheterization of these
small vessels (Fig. 6.14).
DIGITAL SUBTRACTION ANGIOGRAPHY
With any DSA examination particular attention must be paid
to the elimination of movement artefact. Respiratory motion
needs to be controlled (a nose-clip is often helpful) and in
the case of abdominal and pelvic examinations the effects
of bowel movement can be minimized by the use of para-
lytic agents. Multiple mask acquisition is a simple and much-
neglected technique for counteracting the effect of inevitable
movement such as, say, the artefacts produced in pulmonary
arteriograms by cardiac motion. If several precontrast images
Figure 6.14 Co-axial catheterization. (A) A coeliac axis arteriogram performed through a 7 Fr catheter shows an aneurysm at the splenic hilum.
This needs selective embolization but the long tortuous splenic artery presents a formidable technical obstacle to catheterization with a conventional
catheter. (B) A co-axial (tracker) catheter has been passed to the site of the aneurysm, which was successfully occluded without compromising the
splenic circulation.
121
are taken so as to embrace all the different phases of the car-
diac cycle, then appropriate mask selection will subsequently
permit virtually any contrast-filled image to be presented free
of artefact.The same technique can be used in those individu-
als who are unable to hold their breath for any length of time.
Such patients should be asked to breathe normally throughout
the run and multiple images are obtained before the injection
of contrast medium so that a suitable mask for subtraction is
available for every phase of respiration. This technique is par-
ticularly suited to visceral angiography (Fig. 6.15).
INTRAVENOUS DIGITAL SUBTRACTION
ANGIOGRAPHY (IVDSA)
The introduction of IVDSA was hailed as a major break-
through and enthusiasts initially predicted that it would
eventually replace intra-arterial angiography. Experience,
however, has proved that IVDSA often produces nondiagnos-
tic images because of patient movement, poor cardiac output
and the superimposition of vessels. It may also require the use
of very large volumes of contrast medium, which not only
restricts the number of studies that can be obtained during
any one procedure but also makes the technique unsuitable
for patients in whom a significant load of contrast medium
would be particularly undesirable; the indications for its use
are now limited.
AFTERCARE
When an arteriographic study is completed the catheter is
withdrawn and firm manual pressure applied to the puncture
site for 510 min. The radiologist should be absolutely satis-
fied that bleeding has stopped before the patient leaves the
angiography suite. The wound site is then checked at regular
intervals by the nursing staff, who should also record pulse and
122 SECTION 1 IMAGING TECHNIQUES AND GENERAL ISSUES
Figure 6.15 Example of use of breathing technique during visceral angiography. Arterial (A) and venous (B) images from a superior mesenteric
arteriogram acquired during patient respiration. Intestinal peristalsis has been obliterated with hyoscine butylbromide. The arterial and venous images
were acquired at different phases of respiration but the use of different masks (mask 2 for the arterial image and mask 10 for the venous image),
acquired before the injection of contrast medium, has resulted in excellent quality images.
blood pressure observations for a reasonable period following
the procedure and check that distal pulses remain palpable.
Pressure pads, sand bags and other accoutrements are generally
a waste of time. It is much better to be able to see the punc-
ture site than to cover it up. If bleeding does not stop from a
puncture site, press for longer! Almost all post-catheterization
bleeding can ultimately be controlled by local pressure unless
the artery has been torn or there is a coagulation abnormal-
ity. Several devices are now available that are used to seal the
puncture point in the vessel wall at the time of catheter with-
drawal in order to allow rapid mobilization and discharge of
the patient, often within 12 h5355. These have become popu-
lar in many centres following cardiac catheterization and are
being utilized more commonly in peripheral angiography.
Care should be exercised in their use, however, as a least one
meta-analysis of published data has demonstrated little evi-
dence that they are effective and concluded that they may be
associated with an increased risk of haematoma and pseudoa-
neurysm formation56.
An adequate record of the procedure should be entered in
the patients case notes. This should include:
date
name of the operator
puncture site
catheter size
studies performed
names and doses of anaesthetic agents
volumes and concentrations of contrast medium and other
drugs administered
preliminary findings
any complications during the procedure
integrity or otherwise of the pulses peripheral to the punc-
ture site at the end of the procedure
post-procedural nursing instructions.
These notes are important not only for patient care but also
as a medico-legal record and they should be comprehensive
and accurate.
COMPLICATIONS
The principal complications of arteriography are listed in
Table 6.1.
Contrast medium reactions
The many possible adverse effects of contrast media, together
with details of their prevention and treatment, are discussed in
Chapter 2.
Adverse drug reactions
Apart from contrast medium reactions, local anaesthetic agents
or other drugs given during the procedure may cause adverse
or idiosyncratic effects.
Puncture site complications
Haemorrhage
Haemorrhage may occur from the puncture site and may
cause external blood loss or a subcutaneous haematoma, which
can result in extensive bruising (Fig. 6.16). Retroperitoneal
bleeding is uncommon but may occur if the arterial puncture
is performed above the inguinal ligament. Perhaps the com-
monest reason for this is the introduction of the needle during
retrograde femoral artery catheterization at too acute an angle
so that it passes through the back wall of the external iliac
artery above the inguinal ligament. It is less well recognized,
however, that this complication may also occur when the
femoral artery is correctly punctured; this is probably due to a
downward extension of the pelvic and abdominal wall fascial
layers around the femoral artery and vein, the so-called femo-
 CHAPTER 6 ANGIOGRAPHY: PRINCIPLES, TECHNIQUES (INCLUDING CTA AND MRA) AND COMPLICATIONS 123

Table 6.1 COMPLICATIONS OF ARTERIOGRAPHY ral sheath. If this sheath is transgressed at the time of vessel
Contrast medium-related complications puncture, and bleeding subsequently occurs from the punc-
Minor adverse reactions ture site after catheter or sheath removal for any reason, then
Major adverse reactions and death
blood may spread along the fascial planes continuous with the
femoral sheath into the retroperitoneum or, indeed, into the
Local vascular changes (effects on blood cells, viscosity, vascular tone;
results of extravasation, etc.) anterior abdominal wall.
Systemic vascular changes (effects on blood volume, osmolality, etc.) Four types of haematoma may occur after femoral artery
Individual organ toxicity (heart, kidney, brain, etc.) puncture: (A) abdominal wall, (B) retroperitoneal, (C) groin
Adverse reactions to local anaesthetic or other drugs
and thigh and (D) intraperitoneal. The first three may all
result from puncture of the common femoral artery (i.e.
Puncture site complications
below the inguinal ligament), with (A) and (B) resulting
Haemorrhage (external bleeding or haematoma)
when there is bleeding into the femoral sheath and (C), the
Intramural or perivascular injection of contrast medium
commonest, when there is spread into the femoral triangle.
Vascular thrombosis (dissection, local trauma) Intraperitoneal haemorrhage is even less frequent than ret-
Peripheral embolization from puncture site roperitoneal bleeding and generally requires transgression of
Vascular stenosis or occlusion the peritoneum itself, which is more likely to occur if vessel
Aneurysm or pseudoaneurysm formation puncture is performed above the level of the inguinal liga-
AV fistula ment. Some intraperitoneal bleeding has also been described,
Local sepsis however, when the arterial puncture is below the inguinal
Damage to nerves ligament; it has been postulated that this may be due to the
Damage to other local structures presence of defects in the parietal peritoneum.
Catheter-related and general complications
Excessive bleeding is usually the result of bad technique.
Particular caution is necessary in patients with a bleeding
Catheter thrombus embolism
diathesis or hypertension and following the use of balloon
Air embolism
catheters in transluminal angioplasty. If inexplicable bleeding
Gauze embolism
continues, check that inadvertent over-heparinization has not
Dissection, perforation or rupture of vessels occurred.This can be corrected if necessary by the administra-
Organ ischaemia or infarction secondary to spasm, dissection or embolism tion of protamine sulphate (10 mg of which counteracts the
Interventional accidents effects of approximately 1000 IU heparin).
Fracture and loss of guidewire or catheter fragments
Knot formation in catheters Intramural and perivascular contrast medium injection
Inadvertent injection of toxic material (e.g. skin-cleansing lotion)
Contrast medium may be inadvertently injected into the wall
of a vessel or outside the vessel (perivascular). In most cases
Inadvertent overheparinization
little harm (apart from pain) results from a perivascular injec-
Vasovagal reaction
tion but it is possible to dissect and occlude an artery with a
subintimal injection of contrast medium. Never inject into a
needle or catheter that does not exhibit free backflow.
Vascular thrombosis can result from severe trauma to the
vessel at the puncture site or from a subintimal contrast injec-
tion. It is also possible that thrombus wiped off the outside of
the arterial catheter during its extraction forms a nidus for
thrombus at the puncture site.Vascular trauma at the puncture
site can be minimized by good technique. Never use force to
introduce a wire into a vessel; if it does not pass easily some-
thing is wrong! It is often better for the inexperienced opera-
tor to start again with a fresh needle puncture than to persist
with one that is causing problems. A 10-minute delay with a
successful outcome is always preferable to a dissection and/or
a groin haematoma.
Peripheral embolization from the puncture site probably
occurs to a minor degree in many cases but clinically obvious
embolization is rare.
Local vascular complications such as false aneurysm
(pseudo-aneurysm) or AV fistula formation and late stenosis or
occlusion can all result from arterial procedures. Good tech-
Figure 6.16 Extensive groin haematomas in a patient following nique is the best preventive measure. Femoral artery pseudo-
bilateral femoral artery catheterization. aneurysms are usually due to a combination of a low puncture
124 SECTION 1 IMAGING TECHNIQUES AND GENERAL ISSUES

the superficial femoral or profunda femoris arteries have

often been cannulated instead of the common femoral artery
when this complication occurs and inadequate compression
of the vessel at the end of the procedure.
Local sepsis may occur following an arterial puncture
(although it is extremely rare) and this factor is particularly
important if early surgery is contemplated. The utmost care
should be taken to observe sterile precautions and when a
study is performed in a patient with local skin contamination
(e.g. open wound, ileostomy, etc.) a protective adhesive sheet
helps to keep the operative field uncontaminated.
Injury to local structures such as nerves, joints and
bones is rarely of clinical significance. Occasionally damage
to branches of the femoral nerve gives rise to areas of cutane-
ous anaesthesia or paraesthesia in the thigh57. These normally
recover completely, although this may take several months in
some instances.

Catheter-related and general complications

1 Thrombi can form in or on a catheter (Fig. 6.17) and be
ejected into the vascular system. This is always undesir-
able and in areas such as the cerebral or coronary circula-
tion is extremely dangerous. Catheters should be flushed
assiduously during all arteriographic procedures to prevent
thrombus formation. Other types of embolism that may
occur are air embolism (sometimes from incorrectly loaded
pressure injectors) and thread embolism from fragments of
gauze swab (Fig. 6.17).
2 Vascular injuries distant from the puncture site may be pro-
duced by the catheter or guidewire, or by the intramural
injection of contrast medium or saline. If there is ever any
doubt about whether a needle or catheter tip is in a satisfac-
tory position, contrast medium should always be injected in
preference to saline. Under fluoroscopic control, it is then
possible to stop the injection immediately if any extravasa-
tion or other mishap is apparent. The most common injury
is dissection of the tunica intima from the tunica media and
this complication is far more likely to occur in previously
diseased vessels than in normal vessels. The intima forms a
raised flap (Fig. 6.18) that may completely occlude the ves-
Figure 6.18 Dissection of the aorta and iliac vessels. A catheter has
been passed subintimally from the right groin and created an extensive
arterial dissection involving the aorta and both iliac systems. Note the
suspiciously straight edge of the aortic opacification and the twisted
tape appearance of the left common iliac artery as the dissection spirals
down the vessel (arrow).
sel. It is also possible to perforate vessels with a guidewire or
to rupture them when a forced injection is made through a
catheter wedged into a vessel of the same calibre.
3 Injuries to organs are normally caused by ischaemia during
arteriographic procedures (other than those related to the
effects of contrast medium. This may occur through wedg-
ing of the catheter so that the normal flow to an organ is
obstructed; dissection of the feeding artery; spasm, thrombo-
sis or rupture of the feeding artery; or embolism. The isch-
aemia resulting from one or more of the earlier mentioned
events may have no observable clinical sequelae, may result

Figure 6.17 Catheter thrombus. During a renal arteriogram (A) a filling defect was noted at the catheter tip (arrow). On cautious withdrawal of the
catheter a thrombus was found protruding from the side ports. (B) Note the fragment of gauze thread on the catheter tip; this was incorporated in the
clot and presumably caused it. Care should always be taken when handling swabs in association with wires or catheters.
 CHAPTER 6 ANGIOGRAPHY: PRINCIPLES, TECHNIQUES (INCLUDING CTA AND MRA) AND COMPLICATIONS
in temporary or permanent functional abnormalities in the
affected organ or system, or may cause infarction of the
organ. The clinical importance of these accidents depends
very much on the vascular territory in which they occur;
complete occlusion of a carotid, coronary or renal artery is
likely to have disastrous consequences whereas occlusion
of, say, a hepatic artery may not necessarily produce any
adverse effects.
4 Guidewire fracture. Occasionally fragments of guidewire or
catheter may become detached within the vascular system.
Catheters may also become knotted during overenthusiastic
manipulation procedures.With good technique they should
not occur in the first place.
5 Injection accidents. Tragedies have occurred when toxic sub-
stances have been inadvertently injected into blood vessels.
CATHETER VENOGRAPHY
TECHNIQUE
Direct venography
This is the most common means of opacifying the venous
system. A needle or catheter is placed directly into the vein to
be imaged and contrast medium injected. This can be done
using an antegrade approach, for example a needle inserted
into an antecubital fossa vein to demonstrate the brachial, axil-
lary, subclavian and brachiocephalic veins and superior vena
cava, or a catheter placed in the iliac veins to demonstrate the
inferior vena cava. Alternatively, a catheter may be directed
retrogradely into the venous system, as in selective hepatic
venography, which is now most commonly performed as part
of a transjugular liver biopsy procedure or when performing a
transjugular intrahepatic portosystemic stent shunt.
Indirect venography
In this approach contrast medium is injected into the arterial
system of the area being studied and delayed films are obtained
to image the venous return. This technique is used to great
advantage for examining the portal venous system, for while it
is possible to gain direct access to the portal venous system, the
latter approach is more invasive and requires greater technical
expertise than the indirect approach. Other areas where indi-
rect venography is used include the cerebral and renal veins.
Intraosseous venography
This technique is now of historical interest only; it involves the
injection of contrast medium into the bone marrow cavity at
a site distal to the venous system that is to be imaged. Contrast
medium is injected rapidly into the marrow cavity from which
it drains via sinusoids and small veins into the deep venous
system of the region. The technique was most widely used
for leg venography with injections made into the malleoli or
calcaneum for the calf, into the tibial tubercle or femoral con-
dyle for the thigh, and into the greater trochanter to show the
pelvic veins and inferior vena cava.
125
Skin-cleansing fluids should always be removed from the
instrument trolley immediately after the puncture site has
been prepared. Drugs should always be double-checked
before injection through a catheter and particular care is
necessary with heparin, which is available in solutions that
differ considerably in their concentration.
6 Vasovagal reactions. Vagally mediated reactions may occur
during arteriography in response either to the injection
of contrast medium or to the discomfort and psycholog-
ical effects of the procedure. Bradycardia is a prominent
feature of such reactions, which must be distinguished
from acute allergic responses to the contrast medium
or local anaesthetic. The incidence of vasovagal reac-
tions is considerably reduced if proper premedication
is employed.
COMPLICATIONS
The complications that may occur following venography can
be divided into three main groups: those occurring locally at
the site of injection, those occurring within the vascular sys-
tem, and systemic complications. Many of the complications
of arteriography (Table 6.1) also apply to venography.
Local complications
Pain may occur at the site of contrast injection. Hyper-
tonic contrast agents in particular may cause local pain due
to irritation of the vessel. Extravasation of contrast medium
will also cause pain due to both the irritant nature and vol-
ume of the medium injected. Extravasation of contrast media
into the skin may cause tissue necrosis and sloughing of skin,
although this is less likely with low-osmolality agents. When
injecting any substance careful attention should be paid to the
patients comments. Severe pain at the injection site should
never be ignored, as it does not occur if the needle is correctly
positioned within the vein.
Vascular complications
Dissection of the vein being cannulated/catheterized may
occur at the puncture site or distally, due to catheter and/or
guidewire manipulation.
Systemic complications
1 Pulmonary embolism. Ultrasound is now most commonly used
to confirm or exclude lower limb deep vein thrombosis and
ascending venography is performed infrequently. If venog-
raphy is considered necessary it should be remembered that
calf and femoral vein clots, if loose, can be dislodged by
manipulation of the leg and the forceful injection of con-
trast medium. This complication is rare but when deep vein
thrombosis is demonstrated, vigorous massage of the calf is
inadvisable. Clots in the iliac vein, renal vein, hepatic vein and
inferior vena cava can all be dislodged by the manipulation
126 SECTION 1 IMAGING TECHNIQUES AND GENERAL ISSUES
of catheters and guidewires, as well as by pressure injections
of contrast medium.
2 Cardiac arrhythmias. The manipulation of catheters in the
right side of the heart for any reason can cause arrhyth-
mias. Injections of large volumes of contrast medium in the
right heart, especially for pulmonary angiography, may also
EMBOLIZATION TECHNIQUES
The deliberate occlusion of arteries, veins or abnormal vascu-
lar spaces by embolic material injected through a selectively
positioned catheter or needle is one of the major therapeutic
applications of interventional radiology. Several of the indica-
tions for embolization are covered in other chapters in this
book and for this reason only the important basic principles
and techniques of the procedure will be discussed here.
EMBOLIC MATERIALS AND TECHNIQUES
Many different materials have been used to embolize blood ves-
sels but those most commonly used are metallic coils, absorb-
able gelatin sponge, polyvinyl alcohol foam, sodium tetradechyl
sulphate, absolute ethanol and N-butyl-2-cyanoacrylate. The
choice of agent in any particular setting will depend upon the
indication for embolization and the angiographic findings.
Detailed descriptions of the radiological techniques
employed in embolization are not included here but a few
important points should be noted:
Embolization should always be preceded by high-quality
angiography to define precisely the vascular territory under
consideration and its anastomotic communications.
Embolizing catheters should be sited as selectively as pos-
sible to avoid the unintentional embolization of adjacent
vascular territories. Coaxial catheters may be necessary to
achieve the necessary degree of selectivity and failure to
obtain a satisfactory catheter position will require the pro-
cedure to be abandoned.
The likely route of any overspill of emboli should be
noted during preliminary angiography. Reflux of emboli
into other vessels occurs very easily as flow progressively
diminishes in the embolized bed and this hazard is best
avoided by injecting emboli in small quantities at a time,
under constant fluoroscopic control, or by the use of a bal-
loon catheter (see later). It is important to remember that a
selective preliminary arteriogram may not reveal all routes
of collateral flow, even if they communicate directly with
the vessel into which contrast medium is being injected.
This is because the blood flow in collateral vessels may be
towards the lesion under investigation (especially if it is
very vascular or is shunting into a vein) and therefore they
may not necessarily be opacified when contrast medium
is injected into a principal vessel feeding the lesion. When
the flow haemodynamics are changed during the emboli-
zation procedure, flow may reverse along such collaterals
cause dysrhythmias and continuous electrocardiographic
monitoring is essential.
3 Air embolism. Because of the danger of air embolism in the
venous system, care should be taken neither to inadvertently
inject air into a vein, nor to leave the lumen of any large-bore
cannula or catheter open to the atmosphere.
and carry embolic material to an adjacent bed that was not
visualized on the preliminary arteriograms and, therefore,
fallaciously regarded as being unconnected with the lesion
being embolized.
Non-opaque emboli should always be injected as a suspen-
sion in contrast medium so that they are visible as filling
defects during the injection sequence.
Particular care is necessary in certain areas (e.g. CNS, lower
GI tract, peripheral limb vessels); where there has been
previous surgery (which may have reduced any potential
collateral circulation to a region); and where there is pre-
existing vascular insufficiency (e.g. atheroma).
It may be useful to employ a balloon catheter in some situa-
tions, either to reduce flow through the bed to be embolized
or as a temporary obstruction to flow in nearby branches
supplying normal structures when there seems a potential
danger of emboli entering such vessels.
It is prudent to cover some embolization procedures with
antibiotic prophylaxis.
INDICATIONS FOR THERAPEUTIC ARTERIAL
EMBOLIZATION
There are numerous indications for arterial embolization but
the most common are:
the control of severe bleeding (e.g. gastrointestinal or post-
traumatic haemorrhage from the liver, kidney, or spleen)
the reduction of blood flow to certain tumours as a defini-
tive treatment (e.g. uterine fibroids, certain aneurysmal
bone cysts)
as a preoperative measure (e.g. juvenile nasal angiofibroma,
meningioma)
as a palliative measure (e.g. hepatocellular carcinoma, neu-
roendocrine hepatic metastases)
in the management of vascular malformations.
The most common indication for venous embolization is the
treatment of male varicoceles. Interested readers are referred
to other chapters in this book for more details of some of these
techniques.
The incidence of serious complications following emboli-
zation is low provided that the procedure is conducted with
patience and scrupulous care and that only suitable patients are
selected for treatment by the technique.
 CHAPTER 6 ANGIOGRAPHY: PRINCIPLES, TECHNIQUES (INCLUDING CTA AND MRA) AND COMPLICATIONS
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