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V Evaluation of the vascular system

" 9 scan
~ •eadily available Ȃ 24/7
~ Patient comfort
~ Fast scan time
~ Open gantry Ȃclaustrophobia is less of an issue
Ionizing radiation
" on-ionic iodinated intravenous contrast material
3llergic/contrast induced reactions
3cute renal failure
V Evaluation of the vascular system
" inimally invasive
~ Jarge bore venous access
~ Ga 20 or bigger
~ 3ntecubital vein
¦ •ight Ȃ for pulmonary arteriogram
•isk of contrast extravasation
~ High flow rate of contrast administration
" 3rterial and venous systems
V Evaluation of the vascular system
" 3natomic body scan
~ Other etiologies can be assessed for patientǯs symptoms
~ DzIncidentalomasdz
~ Other pertinent structures can be evaluated
~ Deeper structures are addressed
~ ot readily seen in duplex studies
~ Ideal imaging modality in evaluating post operative
interventions
V ›ersus 9onventional 9atheter 3ngiography
~ 3natomic body scan
~ Other etiologies can be assessed for patientǯs symptoms
~ DzIncidentalomasdz
~ Other pertinent structures can be evaluated
~ Deeper structures are addressed
~ Ideal imaging modality in evaluating of post operative
interventions
~ Jess radiation exposure
~ Jess risk of bleeding and catheter-related iatrogenic
injuries
~ Diagnostic
V ›ersus 9onventional 9atheter 3ngiography
~ 9omparable sensitivity and specificity
~ 4-vessel angiogram
~ 9arotid and verterbal arteriogram
~ 3ortogram
~ •enal artery angiogram
~ Pulmonary arteriogram
V ›ersus 9onventional 9atheter 3ngiography
~ 9oronary arteries
~ High negative predictive value
~ Better evaluation of fistulas and sinuses
~ Better pick up of myocardial bridging
~ Soft and vulnerable plaques
3rrhythmias
Heart rate > 80 or 90 beats per minute
9alcium score of > 400
¦ Proximal •93 and J3D
¦ J
V PO for at least 4 hours
V Serum creatinine (7-10 days)
" If elevated, clear with 3P and/or attending
nephrologist
" Determine creatinine clearance
" Better if patient will undergo scheduled or S 3
dialysis on the day or immediately after the
procedure
" 9lear with 3P's and informed consent if S 3
procedure
V 9reatinine clearance
" 9ockcroft-Gault Formula
~ 140-3ge x ass (kg.) x 0.85 (if female)
----------------------------------------------
72 x serum creatinine (mg./dJ)
" ormal values
~ ale: 55-146 mJ./min.
~ Female: 52-134 mJ./min.
V Jarge bore M M  
M

M 
 
V If < Ga. 20, decrease flow rate (not < 3 mJ/sec)
and increase HU threshold (at least 120 HU)
" Possibility of acquiring suboptimal images
precluding adequate evaluation
V •etrieve and review all previous pertinent
imaging studies done on the patient
V Special considerations
" 9ontemplated •3IU studies
~ Iodinated I› contrast will interfere with future •3IU for the
next three months
~ It decreases thyroid uptake of the I-138
" •enal impairment
~ •enal failure
" 3llergic/asthmatic patients
~ Exacerbations
" Post chemotherapy patients
~ Fragile peripheral venous structures
~ Difficulty of line insertion
V For coronary 9 3, heart rate should not be > 70
bpm and no arrhythmia
" Prepare Isordil (nitrate) 5 mg SJ to be given to patient
while inside the 9 scan unit Ȃ for dilatation of the
coronary arteries hence better visualization and
evaluability
~ ×      M    M M
 M    

   M   
V •etrieve/review all previous 9 or conventional
coronary angiography studies, E9G results, 2D
echo, stress test (conventional and nuclear)
V Jarge bore access (antecubital vein) is a must,
take note of 3› fistula site of dialysis
patients- I› access should be on the
contralateral extremity
V If admitted
" Inform Dr. •ichard o or Dr. 3lmajar for 9o-
reading
" Inform 9ardiology Fellow-on-duty
" •efer to Service of 9ardiology for H• control and
BP monitoring
V If out patient
" •efer back to attending cardiologist and inform
Drs. o and 3lmajar for 9o-reading
" If no in-house attending cardiologist, we still
inform Drs. o and 3lmajar
~ If no contraindications to beta blockers (9OPD, 3sthma)
~ Give etoprolol 50 mg. PO night before and 3 to 4 hours before
the procedure
~ If with contraindications
~ Give ›erapamil 80 mg 3 to 4 hours before the procedure (Watch
out for hypotension, determine baseline BP)
V Heart rate versus rhythm
" Prospective E9G gating
~ Step and shoot acquisition
~ Specific delay in the •-• interval
" •etrospective E9G gating
~ 9ontinuous/spiral scanning
~ Best diastolic phase (0-90%)
~ anual reformation is possible
Prospective E9G gating

•etrospective E9G gating


V Heart rate versus rhythm
" DzHighdz heart rate is technically possible
~ Fast gantry rotation
~ Jess breath hold
" DzJowerdz heart rate
~ We want an evaluable study without artifacts the first
time
~ Jimited volume of contrast to be given
~ Jess radiation exposure
~ 3ssures us of a study with optimal evaluability of the
vessels
V Heart rate versus rhythm
" Irregular rhythm
" 3trial fibrillation
~ Difficult to acquire at a specific point in the •-• interval
phase
~ Poor reconstruction
~ otion artifacts
~ Step-off artifacts
V 9hest 9 3 (make sure of clinical indication)
" horacic aorta
~ 3ortic dissection, aneurysm, rupture, stenosis
~ Include abdominal aorta and iliac arteries
~ J    
~ 100 mJ. contrast/30 mJ. saline chaser @ 5 mJ/sec
" Pulmonary artery g  access should be in the right)
~ Pulmonary embolism
~ 9 venography
~ J  
  
~ 60 mJ. contrast/30 mJ. saline chaser @ 5 mJ/sec
3ortogram
Pulmonary
embolism
V 3bdominal aorta 9 3
" 3nuerysm, dissection, rupture, stenosis
" Include iliac arteries
~ J  
  


~ 100 mJ. contrast/30 mJ. saline chaser @ 5 mJ/sec
~ Similar protocol for renal artery, celiac trunk, S 3, and
I 3-9 3
V Peripheral/extremity artery angiography
" 3nuerysm, rupture, stenosis
" Include aortic arch (upper)
~ J       
" Include abdominal aorta (lower)
~ J    
  
 

" 100 mJ. contrast/30 mJ. saline chaser @ 5 mJ/sec
V Peripheral/extremity artery angiography
" Special consideration for upper extremity
arteriography
~ Please indicate which side is of concern
~ 3dministration of contrast is thru the antecubital vein
~ Place the venous access in the contralateral side or the
Dznormaldz side
V 4 vessel 9 3
" Stenosis and aneurysms
" Fistulas
" 9ollaterals
~ J    
  
 !


~ 60 mJ. contrast/30 mJ. saline chaser @ 5 mJ/sec
V more medially placed
V usually smaller in
caliber
V more round in
configuration
V level of 94 vertebral
carotid 94 body
V pyriform sinus level

jugular
V EU•O 4D
1. 9alcium Score Study
" If 9a Score is more than or equal to 400 or calcific
plaques are at the proximal left main coronary
artery or ostium, refer/defer
2. Place venous access either right or left
3. Give Isordil 5 mg. SJ or spray SJ
4. 9or9 3 study
" 50 mJ. contrast/50 mJ. saline chaser @ 5
mJ./sec.
" maximum safe contrast administration is ÿ 
 M with clearance of !  "  

depending on initial creatinine results (longer if
borderline high creatinine results) and if with pre-
existing renal impairment
Philips 16-slice 9 scan Siemens 128-slice 9 scan
V If dual procedures in one patient
" If chest 9 3
~ Do triple rule out: coronary artery disease, dissection,
pulmonary embolism
~ Widen FO› to include entire aortic knob superiorly, the entire
chest width, and the proximal abdominal aorta (beyond 12
or J1 level)
" If body and head
~ Do head first then body 9 3
" If aortogram with conventional whole abdomen with
I› contrast
~ 9 3 will serve as the arterial phase then delay scan(s)
accordingly
remember total amount of contrast that is
allowable in a 24 hour period: ÿ   M 
 MM    !  "  

 

M  M   


M #
$ M 
%   
   M
M %

 
specificity and sensitivity of 9 angiography is similar
to conventional angiography for pulmonary
arteriogram and aortograms

coronary 9 angiography is ideal for screening and


has a good negative predictive value

high calcium scores decrease the sensitivity and


specificity of coronary 9 angiography

9 angiography is only diagnostic and not


therapeutic
hank you!

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