Chapter 7 - Cerebral angiography: Techniques and practice
Introduction
In this chapter, I will include my thoughts on how to perform a diagnostic cerebral angiogram. Learning to perform cerebral angiography by reading a textbook is a little bit like learning to drive a car or to play the piano by reading on the subjects. Good teaching, supervised practice, and experience are the most important elements in becoming an accomplished angiographer. Experience over many years of teaching fellows how to perform efficient and safe cerebral angiography has allowed me to compile my thoughts on the topic. I would like to share them here, which I hope will allow the fledgling angiographer to have a good starting point and some baseline knowledge on which to build. The skills of angiography must be learned bit by bit. But there are essentials that must be applied in each case, and learning to perform the same steps in every case diminishes the possibility of a complication.
I am fond of telling my new fellows that performing cerebral angiography is not like the rest of medicine. Indeed, it is somewhat anti-intellectual, in that an ordered pattern of thought, a mental checklist, should be applied in every case. In this way, performing angiography is much more like flying a jet than writing a book chapter. In this chapter, I will include my thoughts about how to perform safe and effective angiography. The best teacher, however, is an experienced angiographer in a fellowship setting that provides solid teaching and many case opportunities.
Section snippets
Preangiography
Requests for angiography can come from many services for many reasons, only some of them valid. I prefer to term them “requests” rather than “orders,” as one would not order an angiogram any more than one would order a surgery. Both require the same degree of vetting, preparation, and evaluation. At the outset, the angiographer should determine whether or not a requested study or procedure is indicated (Sawiris et al., 2014). A brief conversation with the referring physician may be helpful for
Medications and Allergies
The patient consultation also allows the angiographer the opportunity to review the patient's medications and allergies. Pertinent medications, such as antiplatelet, anticoagulants, and insulin, may need to be altered for a procedure.
Documented contrast allergies are far less common than decades ago, owing to the use of nonionic agents. The angiographer should assume the role of the expert in such a case, not ceding the responsibility of determining contrast allergy presence or severity to
Documentation of Physical Examination and Consent
In medicolegal terms, “It didn’t happen if it's not documented.” Once the consent and physical examination have been performed, it must be documented properly in the record, and the more detailed, the better. Documentation of the neurological examination and pulses represents a bare minimum. One should document the discussion of the procedure with the patient, along with its indication, alternatives (which might include surgery, observation, or no therapy), risks of the procedure (including
Team Communication
A great team is nothing without great communication. This is nowhere more true than in the angiography suite. It is critical to have clear, easy, and calm communication among team members, including the doctors, nurses, technologists, and anesthesiologists. Success also requires the affirmation of one's requests or information passage, so-called “closed-loop” communication, such as is done in the military. Good communication also employs the concept of “constructive intervention” in which it is
Radiation and Shielding
If one intends on spending a career in interventional neuroradiology, one must take care to properly protect oneself (Britton and Wholey, 1988). This includes personal protection, room shielding, and radiation “common sense.” Personal gear includes leaded glasses (which can now be tailored to the physician's prescription), fitted body lead, and thyroid, and near-shoulder shielding. Room shielding includes both waist-to-floor and ceiling-mounted protection. The angiographer should be vigilant in
Femoral Access
I instruct trainees to palpate and to mark out the anterior superior iliac spine superolaterally and the symphysis pubis inferomedially, as these two structures define the position of the inguinal ligament. One must stay caudal to this in performing femoral arterial puncture to avoid the possibility of retroperitoneal hemorrhage. I then palpate the femoral artery along its superomedial-to-inferolateral course. In slender patients, the groin crease is usually a good cephalocaudal landmark. In
Management of Complications
A crucial goal of the angiographer should be to reduce the chance of a complication as much as possible (Dawkins et al., 2007; Fifi et al., 2009; Heiserman et al., 1994; Willinsky et al., 2003). This can best be achieved by planning, preparation, standardization of technique, communication, and experience. However, it is unreasonable to never expect a complication, so one must be prepared to handle any untoward event.
As above, the angiographer has discussed in detail with the patient potential
Postangiography
After reviewing the images and confirming that the patient's neurological and pedal pulse examinations are stable, the angiographer has several administrative responsibilities. He or she must document the procedure both in a brief chart note and, in most institutions, in a more formal operative note, which is often used for billing purposes. Orders for access care, admission, or discharge, are entered. The angiographer engages the patient (when he or she awakens from sedation), and the
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