Fig. 1.1
A sterile angiography table is usually positioned behind the surgeon for easy access to equipment. The setup shown is prior to the patient being prepped and draped. The tubing in the left lower corner of the figure will be used for heparinized flushes of sheath and catheters and will come to lie on the sterile drape of the operating table, rather than the angiography table. A guide wire in its sheath can be seen in the large blue bowl. Heparinized saline will be added to the bowl, and once the hydrophilic coating of the guidewire is activated, it is kept wet at all times. Same is the case for catheters. A micropuncture kit and access sheath lie next to the tubing on the surgical towel. A Guide catheter can be seen lying across the table. The red foam container for sharps with scalpel, syringe with local anesthesia, micropuncture needle, and 2-0 silk suture can be seen
The equipment table should be kept clean and uncluttered. The length of the table should be long enough that catheters and wires may be stretched out over it during preparation. If needed, two tables may be placed end to end for adequate space.
The table and the contents upon it are part of the operating field, and sterile precautions are maintained.
Sterile drapes for the patient and angiography operating table and sterile gowns and gloves for the operators may be opened on this table according to operator preference.
The table bears a round basin with sterile heparinized saline. The basin should be large and deep enough to hold wires and catheters when they are not in use. To ensure that the various catheters and wires don’t get entangled, each one is looped to fit the basin and may be wrapped at one point in a moist Telfa® or gauze piece. It is ensured that the heparinized saline in the bowl is clean and devoid of any clots or other foreign bodies. If a clot is detected, discard the saline for a clean supply.
A moist piece of Telfa or particle-free sponge should be available to wipe the wires when they are retracted from the catheter, and it should be replaced when any clot or debris is noted upon it.
A foam-bedded container for sharps is provided, and the micropuncture needle, scalpel, suture needle, etc., are stuck into it after use. Do not attempt to recap needles.
A manifold with a one-way valve may be used to dispense sterile heparinized saline, contrast, and waste fluids from syringes into a closed system. The manifold may be clipped to the equipment table or the angio table depending upon the preference of the surgeon.
Sterile cotton gauzes (4 × 4) and towels are also provided.
Instruments
The following basic equipment would be required for any procedure, diagnostic or interventional: micropuncture kit: 21G needle with 0.018 guidewire and 4 Fr dilator OR single wall needle: 18G.
Medications (with Typical Doses)
Fentanyl (e.g., 50–100 µgm IV) and Versed (0.5–1 mg) for sedation prior to arterial puncture. Administer additional doses through the procedure to maintain mild to moderate sedation, alleviating any anxiety while the patient is still able to follow instructions. These medications are not necessary if the procedure is done under general anesthesia.
Heparin is present in the flush systems (see below) and is also administered IV to maintain the desired ACT during interventional procedures. For flush systems, 6000 IU of heparin in 1000 ml of normal saline (6 IU/ml) is continuously administered at a rate of 30 ml/hr through each indwelling catheter or sheath used. During interventional procedures, a 5000 IU (or 70 IU/kg) of heparin bolus is usually administered after arterial access or once the Guide catheter has been secured in its position. In case of ruptured aneurysm, the heparin bolus may be deferred until the first coil has been placed. The ACT is measured 20 min after the bolus and then hourly. Additional heparin is administered as needed to maintain desired ACT. For goal ACTs, refer to specific procedure.
Consult a hematologist first, in case of heparin-induced thrombocytopenia.
2% Lidocaine for local anesthesia. Infiltrate skin with lidocaine prior to stab incision. Initially, raise a skin wheel and then advance the needle deeper into soft tissue. Before injecting, aspirate to ensure the needle tip is not in a vessel. Aspirate and inject as the needle is withdrawn.
Guidewires
We typically use 0.035″ or 0.038″ to support 5 Fr and larger catheters, e.g., Glidewire® (Terumo Interventional Systems, Somerset, NJ) for diagnostic catheters and Guide catheters.
Shape
Curved tip (30–60°) is useful for most selective catheterization.
Straight tips are useful when navigating the abdominal aorta to avoid renal or splanchnic vessel selection.
Coating
Hydrophilic coating, e.g., Glidewire®, may minimize friction and clot formation.
Coated wires should NOT be used with arterial access needles as the coating may be stripped if the wire is withdrawn through the needle, resulting in embolic complications. For certain procedures where a sheath is not inserted and repeated angiographies via the same artery are anticipated (e.g., intra-arterial chemotherapy for brain tumors), we use a Bentson wire (Cook Medical, Bloomington, IN). It can be inserted and slid back through the arteriotomy needle without sheering off any coating.
Table 1.1 shows common wires for diagnostic angiography. Refer to Chap. 5 for greater details.
Table 1.1
Common wires for diagnostic angiography
Wire type
Caliber
Length (cm)
Tip shape
Glidewires
(Terumo)
Standard, long taper, stiff shaft, stiff shaft long taper, long taper,
1 cm taper
0.032, 0.035, 0.038
120, 150, 180, 260 cm
Angled,
Shapeable tip,
J-tip,
Bolia curve
Bentson
(Cook medical)
0.025, 0.032, 0.035, 0.038
145, 180, 200, 260 cm
1.5, 3 mm J
Sheaths
Placed to enable exchange of wires, catheters, etc., without losing arterial access or causing repeated trauma to the vessel (Fig. 1.2a, b). The sheath is connected to a continuously running flush of heparinized saline.
Fig. 1.2
a Terumo Pinnacle sheath. Typically, 5 Fr is used for diagnostic purposes, while 6 Fr and larger are used for intervention. The sheaths are frequently color coded for size. In this picture, the dilator (tapered blue end extending beyond the white sheath tip) has been inserted into the sheath and is ready to be inserted over the wire into the vessel. The short tubing enables attachment of the sheath to continuous flush. The additional port on the side can be used to draw blood or for injections. The labeling at the back of the package enables rapid access to information for sheath election b. The size of the sheath (arrow) and its length (double arrows) and the size of compatible wires (curved arrows) are shown. The number in a rectangle (in the first row with double arrows) indicates the number of sheaths in the package. The expiry date (asterisk) can be seen. The package contents can be easily visualized from the front c. The color of the sheath and dilator cap readily indicates that it is 6 Fr. The packaging of a 5-Fr sheath can be discerned from the 6 Fr label shown above by the number as well as the different color (d, arrow). Similarly, the sheath itself and the dilator cap are also colored gray
5 Fr for diagnostic procedures; 6 Fr or larger for interventional procedures, e.g., coiling.
10–11 cm length is used for normal vasculature, 14 cm or longer for tortuous vasculature. May need to use an 80-cm or longer sheath, e.g., shuttle® sheath (Cook Medical, Bloomington, IN) in case intervention is required in tortuous vasculature.
2-0 silk suture or Tegaderm patch to secure the sheath, so that it is not displaced during procedure.Related posts:
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