Diagnostic Angiogram (Maham Rahimi, MD, Yusuf Chauhan, MD)

Summary

This video demonstrates a diagnostic arteriogram on an elderly female with a history of left lower extremity vascular issues. The procedure, performed under monitored sedation, involves accessing the right common femoral artery using a mini stick and 0.018 guide wire under ultrasound guidance. After confirming wire placement in the abdominal aorta, a sheath is inserted and flushed. Angiography is conducted to visualize the aorta, iliac system, and distal vessels. The patient is found to have occlusions in the SFA, popliteal, peroneal, and anterior tibial arteries, with the posterior tibial artery reconstituting distally via collaterals from the profunda femoral artery.

Takeaways

• 👩‍⚕️ The video demonstrates a left lower extremity diagnostic arteriogram on an elderly female with a history of multiple left lower extremity endovascular interventions.
• 🦵 The patient presented with a three-day history of rest pain and discoloration of her left fourth and fifth toes.
• 🩺 Ultrasound arterial duplex of the left leg showed an occluded left SFA (superficial femoral artery) and TA (tibial artery) with reduced Doppler signals in remaining vessels.
• 📋 The decision was made to perform an arteriogram of the left leg, with contralateral access planned and the left groin prepped in case access is needed.
• 💉 The procedure is typically performed under monitored sedation, with local infiltration of lidocaine and epinephrine for analgesia at the access site.
• 🔍 Initial access to the vessel is obtained using a mini stick coaxial micro introducer kit under ultrasound guidance, allowing minimal complications due to reduced needle diameter and increased tip echogenicity.
• 📏 Fluoroscopy is used to confirm wire placement into the abdominal aorta, followed by the advancement of a five French dilator and sheath over the wire.
• 🔄 An exchange is made for a 0.035 Benson wire for access into the contralateral lower extremity, confirmed again with fluoroscopy.
• 📸 Digital subtraction angiography (DSA) is performed to ensure no access complications, and a Contra catheter is used for abdominal aorta and contralateral limb access.
• 🖥️ The patient was found to have long segment occlusions in the SFA and popliteal arteries, an occluded peroneal artery, and an occluded anterior tibial artery, with the posterior tibial artery reconstituting distally via collaterals from the profunda femoral artery.

Q & A

What is the main procedure demonstrated in the video?

The main procedure demonstrated in the video is a left lower extremity diagnostic arteriogram.

What was the patient's medical history leading to the need for an arteriogram?

The patient is an elderly female with a history of multiple left lower extremity endovascular interventions, presenting with a three-day history of rest pain and discoloration of her left fourth and fifth toes.

What did the ultrasound arterial duplex of the left leg reveal?

The ultrasound arterial duplex of the left leg revealed an occluded left superficial femoral artery (SFA) and a tibial artery (TA) with reduced Doppler signals in the remaining vessels.

What precautions are taken during the preparation for the arteriogram?

The patient is prepped and draped in standard sterile fashion, and care is taken to prep the left groin in case contralateral access becomes necessary during the procedure.

How is initial access to the vessel obtained?

Initial access to the vessel is obtained using a mini stick coaxial micro introducer kit under ultrasound guidance with a 21-gauge needle and a 0.018-inch guide wire.

What is the purpose of using lidocaine and epinephrine during the procedure?

Lidocaine and epinephrine are used for local infiltration at the access site to provide analgesia and minimize bleeding.

How is wire placement into the abdominal aorta confirmed?

Wire placement into the abdominal aorta is confirmed using fluoroscopy.

What is the purpose of injecting contrast during digital subtraction angiography (DSA)?

The contrast is injected during DSA to visualize the access vessel and ensure there are no access complications, and to visualize the aortoiliac system.

What findings were observed regarding the patient's vascular condition?

The patient was found to have long-segment occlusion of the SFA and popliteal arteries, an occluded peroneal artery, and an occluded anterior tibial artery. The posterior tibial artery was found to reconstitute distally through collaterals from the profunda femoral artery.

What is the significance of using a Bentson wire during the procedure?

The Bentson wire is used to facilitate access into the contralateral lower extremity and aid in the advancement of the catheter into the left common iliac artery.