1. Diagnostic Medical Sonography Program
Lecture 16: Miscellaneous Conditions, Tests, and Treatments
Holdorf

2. Miscellaneous Conditions, Tests, and Treatments
Arteriography
Method
Percutaneous puncture of superficial artery; insertion of thin catheter
Most common arteries used: CFA (safest approach), axillary, brachial
After proper positioning contrast agent injected into catheter, flows with moving blood; provides picture of vessel lumen
Rapid film changer technique used to expose the films sequentially as contrast agent moves through vessel
Using Fluoroscopy, digital information obtained/stored for later manipulation and interpretation.
Catheter removed, pressure held on puncture site; patient supine for 6-8 hours. Sandbag placed on top of dressing to help avoid bleeding.

3. Interpretation Primarily an anatomic study; NOT a functional study
Hemodynamically significant stenosis usually defined as a 50% diameter reduction.
Normal anatomy seen on films as contrast media fills vessel
Interpretation based on how much (if any) of artery does not fill with blood containing contrast agent. Extent and location of FILLING DEFECT is determined

4. Interpretation (Arteriography) continued…
Atherosclerotic plaque appears as irregular or smooth
Vessel occlusion: no filling seen: collaterals often present with long standing occlusion
Miscellaneous findings;
Aneurysm appears as dilated artery
Vasospasm: severe narrowing, usually without occlusion
Fibromuscular dysplasia: multiple arterial stenosis caused by medial hyperplasia, appearing as “string of beads” (Usually found in the Carotid or Renal Artery)

5. Normal Arteriography

6. Fibromuscular dysplasia

7. Abnormal Arteriography Renal artery stenosis

8. FYI for Renal Angiograms
Interlobar branches to the arcuate
Arcuate branches to the interlobular

9. Limitations Complications
May be contraindicated in patients allergic to contrast agent or in kidney failure
Inaccurate in its hemodynamic assessment because of inability to provide many images in multiple planes in “real time”; Two-dimensional view is standard
Complications
Puncture site hematoma
Pseudoaneurysm
Local arterial occlusion
Neurologic complications

10. MR Angiography (MRA) NOTE: Does not use radiation Method
Employs radio frequency energy and a strong magnetic field to produce images in multiple planes.
MRI instruments quantitates blood flow and constructs images that look like angiograms (MRA).
Flowing blood is well distinguished from soft tissue without using contrast agents.

11. MRA of the Renal Arteries and Aorta

12. Limitations Interpretation
Presence of metallic clips, pacemakers, monitoring equipment
Can overestimate stenosis due to slow flow or turbulence
Expensive
Claustrophobia may limit some patients
Interpretation
Useful for AAA, dissections, peripheral artery evaluation

13. Computerized Tomography (CT)
Method
Employs ionizing radiation to obtain cross-sectional images of the aorta and other body structures
IV contrast allows more discrete evaluation
Limitations
Patient motion and presence of metal surgical clips
One plane used
Limited application in PAD due to smaller vessels
Interpretation
Identifies size of aorta; extent and sixe of aneurysm
Helps define relationship of aorta to renal artery origins

14. CT of AAA which as ruptured

15. Treatment For a healthy Arterial System– Medical
Lifestyle modification:
Stop smoking
Consistent exercise to enhance collateral development
Weight control and low cholesterol diet may enhance normal endothelial cell metabolism
Protection to prevent injury and or infection to extremity of interest.

16. Treatment – Medical Pharmacologic:
Aspirin: An antiplatelet drug that decreases platelet aggregation resulting in decreased thrombotic activity
Medications that help decrease blood viscosity
Antihypertensive drugs may serve to decrease shearing forces against vessel walls.

17. Treatment - Surgical
Decision to operate depends on extent of disease and primarily the patient’s symptoms
Endarterectomy is surgical removal of atherosclerotic material, usually includes portion of intimal lining.
In presence of significant stenosis or occlusion, bypass graft provides alternate pathway for blood to travel.
Successful bypass grafts include the following components: good inflow, patent conduit, and good outflow

18. Common bypass grafts Aorta to both iliac arteries (Also used for AAA)
Aorta to Bi-Femoral (Also used for AAA)
Femoral to popliteal
Femoral to PTA, to ATA, to peroneal

19. Fem-pop bypass graft

20. Treatment - Endovascular
NOTE: Does not remove plaque: Just moves it.
Angioplasty:
Percutaneous Transluminal Angioplasty (PTLA) used to dilate focal plaque formation in vessel.
Same technique used for ARTERIOGRPHY, except a balloon tipped catheter is utilized.
Under Fluoroscopy:
Catheter tip is brought to the region of stenosis
Balloon is slowly inflated, pushing plaque against the walls of the vessel, dilating artery lumen.
Balloon deflated, catheter is removed

21. Angioplasty Continued
Can not be done on all vessels nor on all types of lesions. Procedure usually performed in vessels with focal stenosis such as: Renal Iliac Femoral Popliteal artery

22. General consideration for catheter intervention
Serious complications occur in less than 5% of cases. 2-3% of Angioplasty patients have complications requiring surgery or alter hospital stay
Minor discomfort with the procedure

23. Intravascular Ultrasound (IVUS)
Tiny ultrasound probe at tip of catheter provides image of vessels form the inside-out
Indications include:
To evaluate plaque formation on arterial wall
Post-procedure to assess need for further treatment
Determine correct placement of stent
Identify aortic dissection
Applications for venous evaluations e.g., Chronic Iliac-Vena Cava obstructions

24. Intravascular ultrasound probe

25. Stent / Stent Graft
To maintain intraluminal structure and patency of artery.
Acts as a type of “scaffold”
Insertion an deployment technique varies with stent type
Similar techniques, as used in arteriography, are utilized with insertion of stent

26. Limitations (depending on stent site)
Abdominal gas
Inability of patient to lie flat
Complications similar to those of arteriography
Problems include:
Restenosis due to intimal hyperplasia, stent migration, graft limb compression, twisting, dislodgement, Endoleaks
Utilized in vessels such as: Aorta, renal , iliac, femoral, repair of AAA with stent grafts
Should expect some flow acceleration post-stenting

27. Aortic Stent Graft

29. Miscellaneous Diagnostic Tests/Treatment
Arteriography
Renal arteries into segmental arteries, then interlobar arteries
Most common arteries used for cardiac catherization is CFA
MRA
Key limitation: Can overestimate stenosis due to slow flow or turbulence.

30. Endarterectomy is the complete surgical removal of atherosclerotic material.
Not done alone. Usually along with a bypass.
Problems with Stents/ Stent grafts
Endoleaks
Usually type from II from branch vessels (IMA, Lumbar)
The Stent sac and get larger and rupture from leaking.
Blood going back into the IMA that has been blocked off by the craft.

31. Homework Text book Chapter 17: SDMS assignments
Alternative Diagnostic Tests and Therapeutic Interventions
Page
SDMS assignments

32. END Arterial Vasculature