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Angiography
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{{Short description|Medical imaging technique}} {{redirect|Angio|subjects associated with the prefix "angio-"|Blood vessel|and|Lymph vessel}} {{Medref|date=November 2021}} {{Infobox medical intervention | Name = Angiography | Image = Cerebral angiography, arteria vertebralis sinister injection.JPG | Caption = Angiogram of the brain showing a [[Transverse plane|transverse projection]] of the [[vertebral artery|vertebro]] [[basilar artery|basilar]] and [[posterior cerebral]] circulation. | ICD10 = | ICD9 = {{ICD9proc|88.40}}-{{ICD9proc|88.68}} | OPS301 = {{OPS301|3–60}} | MeshID = D000792 | OtherCodes = }} '''Angiography''' or '''arteriography''' is a [[medical imaging]] technique used to visualize the inside, or [[lumen (anatomy)|lumen]], of blood vessels and organs of the body, with particular interest in the [[artery|arteries]], [[vein]]s, and the [[Heart#Chambers|heart chambers]]. Modern angiography is performed by injecting a radio-opaque [[radiocontrast|contrast agent]] into the blood vessel and imaging using [[X-ray]] based techniques such as [[fluoroscopy]]. With time-of-flight (TOF) magnetic resonance it is no longer necessary to use a contrast. The word itself comes from the [[Ancient Greek|Greek]] words ἀνγεῖον ''angeion'' 'vessel' and γράφειν ''graphein'' 'to write, record'. The film or image of the [[blood vessel]]s is called an ''angiograph'', or more commonly an ''angiogram''. Though the word can describe both an '''arteriogram''' and a '''venogram''', in everyday usage the terms angiogram and arteriogram are often used synonymously, whereas the term venogram is used more precisely.<ref>{{cite news|title=Arteriograms, Venograms Are Angiogram Territory|url=https://www.chicagotribune.com/1986/01/23/arteriograms-venograms-are-angiogram-territory/|access-date=12 September 2011|author =G. Timothy Johnson, M.D.|work=Chicago Tribune|date=1986-01-23}}</ref> The term angiography has been applied to [[radionuclide angiography]] and newer vascular imaging techniques such as [[Carbon Dioxide Angiography|CO<sub>2</sub> angiography]], [[Computed tomography angiography|CT angiography]] and [[Magnetic resonance angiography|MR angiography]].<ref>{{cite book|last1=Martin|first1=Elizabeth|title=Concise Medical Dictionary|publisher=Oxford University Press|location=Oxford|isbn=9780199687817|edition=9th|chapter-url=http://www.oxfordreference.com/view/10.1093/acref/9780199687817.001.0001/acref-9780199687817-e-457|chapter=Angiography|doi=10.1093/acref/9780199687817.001.0001|year=2015}}</ref> The term ''isotope angiography'' has also been used, although this more correctly is referred to as [[isotope perfusion scanning]]. ==History== [[File:Renal artery angiography.ogg|thumb|right|Renal artery angiography video]] The technique was first developed in 1927 by the [[Portugal|Portuguese]] physician and neurologist [[Egas Moniz]] at the [[University of Lisbon]] to provide contrasted X-ray [[cerebral angiography]] in order to diagnose several kinds of nervous diseases, such as tumors, artery disease and [[arteriovenous malformations]]. Moniz is recognized as the pioneer in this field.<ref name="pmid11619209">{{cite journal | vauthors = Berrios GE | title = The origins of psychosurgery: Shaw, Burckhardt and Moniz | journal = History of Psychiatry | volume = 8 | issue = 29 pt 1 | pages = 61–81 | date = March 1997 | pmid = 11619209 | doi = 10.1177/0957154X9700802905 | s2cid = 22225524 }}</ref> He performed the first cerebral angiogram in Lisbon in 1927, and [[Reynaldo dos Santos]] performed the first aortogram in the same city in 1929. In fact, many current angiography techniques were developed by the Portuguese at the University of Lisbon. For example, in 1932, [[Fausto Lopo de Carvalho|Lopo de Carvalho]] performed the first pulmonary angiogram via venous puncture of the superior member. In 1948 the first cavogram was performed by [[Sousa Pereira]]. With the introduction of the [[Seldinger technique]] in 1953, the procedure became markedly safer as no sharp introductory devices needed to remain inside the vascular lumen. Radial access technique for angiography can be traced back to 1989, when [[Lucien Campeau]] first cannulated the radial artery to perform a coronary angiogram.<ref>{{cite journal |vauthors =Campeau, L|title=Percutaneous radial artery approach for coronary angiography|journal=Catheterization and Cardiovascular Diagnosis |volume=16 |pages=3–7 |year=1989 |issue=1 |pmid=2912567 |doi = 10.1002/ccd.1810160103|doi-access=free }}</ref> ==Technique== Depending on the type of angiogram, access to the blood vessels is gained most commonly through the [[femoral artery]], to look at the left side of the heart and at the [[artery|arterial system]]; or the [[jugular]] or [[femoral vein]], to look at the right side of the heart and at the venous system. Using a system of [[Seldinger technique|guide wires]] and [[catheters]], a type of [[contrast agent]] (which shows up by absorbing the [[X-ray]]s), is added to the blood to make it visible on the X-ray images. The X-ray images taken may either be still, displayed on an [[image intensifier]] or film, or motion images. For all structures except the heart, the images are usually taken using a technique called [[digital subtraction angiography]] or DSA. Images in this case are usually taken at 2–3 frames per second, which allows the [[interventional radiologist]] to evaluate the flow of the blood through a vessel or vessels. This technique "subtracts" the bones and other organs so only the vessels filled with contrast agent can be seen. The heart images are taken at 15–30 frames per second, not using a subtraction technique. Because DSA requires the patient to remain motionless, it cannot be used on the heart. Both these techniques enable the interventional radiologist or cardiologist to see [[stenosis]] (blockages or narrowings) inside the vessel which may be inhibiting the flow of blood and causing pain. After the procedure has been completed, if the femoral technique is applied, the site of arterial entry is either manually compressed, stapled shut, or sutured in order to prevent access-site complications.<ref name="Masters2012">{{Cite book|last=Masters|first=Barry R.|date=2012-05-25|title=Harrison's Principles of Internal Medicine |edition=18th |editor1-first=Dan L. |editor1-last=Longo |editor2-first=Anthony S. |editor2-last=Fauci |editor3-first=Dennis L. |editor3-last=Kasper |editor4-first=Stephen L. |editor4-last=Hauser |editor5-first=J. Larry |editor5-last=Jameson |editor6-first=Joseph |editor6-last=Loscalzo |isbn=9780071748896 |publisher=McGraw Hill|pages=1407–1408|doi=10.1007/s00417-012-1940-9|issn=0721-832X}}</ref> {{multiple image | align = center | image1 = Herzkatheterlabor modern.jpeg | width1 = 350 | alt1 = | caption1 = Catheterization Lab | image2 = Catheterization selective angiography.JPG | width2 = 350 | alt2 = | caption2 = Catheterization in selective angiography | footer = }} ==Uses== [[File:Angiome annulaire.JPG|thumb|Finger [[angioma]] seen on angiogram]] ===Coronary angiography=== {{main|Coronary catheterization|Coronary CT angiography}} One of the most common angiograms performed is to visualize the [[coronary artery|coronary arteries]]. A long, thin, flexible tube called a [[catheter]] is used to administer the X-ray contrast agent at the desired area to be visualized. The catheter is threaded into an artery in the [[forearm]], and the tip is advanced through the arterial system into the major coronary artery. [[X-ray]] images of the transient [[radiocontrast]] distribution within the blood flowing inside the coronary arteries allows visualization of the size of the artery [[lumen (anatomy)|openings]]. The presence or absence of [[atherosclerosis]] or [[atheroma]] within the walls of the [[artery|arteries]] cannot be clearly determined. Coronary angiography can visualize coronary artery [[stenosis]], or narrowing of the blood vessel. The degree of stenosis can be determined by comparing the width of the lumen of narrowed segments of blood vessel with wider segments of adjacent vessel.<ref name="Masters2012"/> The coronary angiography is performed under local anaesthesia. The patient is awake during the procedure. An incision is made in the groin, wrist, or arm, and a catheter is inserted into the artery through it. An X-ray is used to guide the catheter to the area of blockage. A dye is inserted through the catheter to make the places of blockage visible. When the catheter is in position, a thin wire with a balloon is guided to the place of blockage. The balloon is inflated to widen the artery, allowing the blood to flow freely. Often, a stent is used, and as the balloon is inflated, the stent in place expands and holds open the artery. The balloon is then deflated and removed, leaving the stent in place. After the completion of the procedure, the catheter is removed, and the plug area is sealed using angio-seal. The procedure takes around two hours, and the patient can be discharged after an overnight stay in the hospital, depending on the condition.<ref>[https://www.drmanjindersandhu.com/cardiology-insights/coronary-angioplasty-procedure-in-india Procedure of Coronary Angioplasty Treatment in India] by [https://www.drmanjindersandhu.com/ Dr. Manjinder Sandhu], a leading cardiologist in Gurugram</ref> ===Cerebral angiography=== {{Main|Cerebral angiography}} Cerebral angiography provides images of blood vessels in and around the brain to detect abnormalities, including [[arteriovenous malformation]]s and [[aneurysm]]s.<ref>{{cite book |last1=Colman |first1=Andrew M. |title=A Dictionary of Psychology |date=2015 |publisher=Oxford University Press |location=Oxford |isbn=9780191744358 |edition=Fourth |url=https://www.oxfordreference.com/view/10.1093/acref/9780199657681.001.0001/acref-9780199657681 |access-date=24 August 2022}}</ref> One common cerebral angiographic procedure is neuro-vascular [[digital subtraction angiography]].<ref>{{Cite web|last=Glick|first=Yair|title=Digital subtraction angiography {{!}} Radiology Reference Article {{!}} Radiopaedia.org|url=https://radiopaedia.org/articles/digital-subtraction-angiography|access-date=2021-09-29|website=Radiopaedia|language=en-US}}</ref><ref>{{cite journal |vauthors=Eddy AC, Nance DR, Goldman MA, etal |title=Rapid diagnosis of thoracic aortic transection using intravenous digital subtraction angiography |journal=Am. J. Surg. |volume=159 |issue=5 |pages=500–3 |date=May 1990 |pmid=2334014 |doi=10.1016/S0002-9610(05)81255-3}}</ref> ===Pulmonary angiography=== {{Main|Pulmonary angiography}} Pulmonary angiography is used to visualise the anatomy of pulmonary vessels. Pulmonary angiography may be used during embolization of [[Pulmonary arteriovenous malformation|pulmonary arteriovenous malformations]].<ref>{{Cite journal |last1=Cusumano |first1=Lucas R. |last2=Duckwiler |first2=Gary R. |last3=Roberts |first3=Dustin G. |last4=McWilliams |first4=Justin P. |date=January 2020 |title=Treatment of Recurrent Pulmonary Arteriovenous Malformations: Comparison of Proximal Versus Distal Embolization Technique |url=http://link.springer.com/10.1007/s00270-019-02328-0 |journal=CardioVascular and Interventional Radiology |language=en |volume=43 |issue=1 |pages=29–36 |doi=10.1007/s00270-019-02328-0 |pmid=31471718 |issn=0174-1551|url-access=subscription }}</ref> In addition, pulmonary angiography may be performed during treatment of [[Pulmonary embolism|pulmonary embolisms]].<ref>{{Cite journal |last1=Palm |first1=Viktoria |last2=Rengier |first2=Fabian |last3=Rajiah |first3=Prabhakar |last4=Heussel |first4=Claus Peter |last5=Partovi |first5=Sasan |date=January 2020 |title=Acute Pulmonary Embolism: Imaging Techniques, Findings, Endovascular Treatment and Differential Diagnoses |url=http://www.thieme-connect.de/DOI/DOI?10.1055/a-0900-4200 |journal=RöFo - Fortschritte auf dem Gebiet der Röntgenstrahlen und der bildgebenden Verfahren |language=de |volume=192 |issue=1 |pages=38–49 |doi=10.1055/a-0900-4200 |pmid=31137046 |issn=1438-9029}}</ref> ===Peripheral angiography=== Angiography is also commonly performed to identify vessels [[stenosis|narrowing]] in patients with leg claudication or ''cramps'', caused by reduced blood flow down the legs and to the feet; in patients with renal stenosis (which commonly causes high blood pressure) and can be used in the head to find and repair stroke. These are all done routinely through the femoral artery, but can also be performed through the brachial or axillary (arm) artery. Any stenoses found may be treated by the use of balloon angioplasty, stenting, or [[atherectomy]]. === Visceral angiography === A common indication for angiography is to evaluate and guide treatment for internal (e.g. gastrointestinal) bleeding.<ref>{{Cite journal |last1=Seyferth |first1=Elisabeth |last2=Dai |first2=Rui |last3=Ronald |first3=James |last4=Martin |first4=Jonathan G. |last5=Sag |first5=Alan A. |last6=Befera |first6=Nicholas |last7=Pabon-Ramos |first7=Waleska M. |last8=Suhocki |first8=Paul V. |last9=Smith |first9=Tony P. |last10=Kim |first10=Charles Y. |date=March 2022 |title=Safety Profile of Particle Embolization for Treatment of Acute Lower Gastrointestinal Bleeding |url=https://linkinghub.elsevier.com/retrieve/pii/S1051044321014780 |journal=Journal of Vascular and Interventional Radiology |language=en |volume=33 |issue=3 |pages=286–294 |doi=10.1016/j.jvir.2021.11.006|pmid=34798292 |url-access=subscription }}</ref> Angiography may also be used during [[hemorrhoidal artery embolization]] for treatment of symptomatic [[Hemorrhoid|hemorrhoids]].<ref>{{Cite AV media |url=https://www.youtube.com/watch?v=Whje31Jlm10 |title=Hemorrhoidal Artery Embolization Minimally Invasive Treatment for Symptomatic Internal Hemorrhoids |date=2024-06-24 |via=UCLA Health |access-date=2024-07-14 |website=YouTube}}</ref> ===Fluorescein angiography=== [[Fluorescein angiography]] is a medical procedure in which a fluorescent dye is injected into the bloodstream. The dye highlights the blood vessels in the back of the eye so they can be photographed. This test is often used to manage eye disorders.<ref>{{cite web|title=Fluorescein Angiography|url=http://www.empireretina.com/medical-services/|website=Empire Retina Consultants|access-date=22 August 2016}}</ref> ===OCT angiography=== [[Optical coherence tomography]] (OCT) is a technology using [[near-infrared]] light to image the eye, in particular penetrate the retina to view the micro-structure behind the retinal surface. [[Optical coherence tomography#Ophthalmology|Ocular OCT]] angiography (OCTA) is a method leveraging OCT technology to assess the vascular health of the retina.<ref name="pmid28760677">{{cite journal | vauthors = Kashani AH, Chen CL, Gahm JK, Zheng F, Richter GM, Rosenfeld PJ, Shi Y, Wang RK | title = Optical coherence tomography angiography: A comprehensive review of current methods and clinical applications | journal = Progress in Retinal and Eye Research | volume = 60 | pages = 66–100 | date = September 2017 | pmid = 28760677 | pmc = 5600872 | doi = 10.1016/j.preteyeres.2017.07.002 }}</ref> ===Microangiography=== [[Microangiography]] is commonly used to visualize tiny blood vessels. ===Post mortem CT angiography=== Post mortem CT angiography for medicolegal cases is a method initially developed by a [[virtopsy]] group. Originating from that project, both watery<ref name="p18430859">{{cite journal |vauthors =Ross S, Spendlove D, Bolliger S, Christe A, Oesterhelweg L, Grabherr S, Thali MJ, Gygax E|title=Postmortem whole-body CT angiography: evaluation of two contrast media solutions.|journal=AJR Am. J. Roentgenol.|volume=190 |issue=5 |pages=1380–9 |year=2008 |pmid=18430859 |doi=10.2214/AJR.07.3082}}</ref> and oily<ref name="p17056884">{{cite journal |vauthors =Grabherr S, Djonov V, Friess A, Thali MJ, Ranner G, Vock P, Dirnhofer R|title=Postmortem angiography after vascular perfusion with diesel oil and a lipophilic contrast agent|journal=AJR Am. J. Roentgenol.|volume=187 |issue=5 |pages=W515–23 |year=2006 |pmid=17056884 |doi=10.2214/AJR.05.1394}}</ref> solutions have been evaluated. While oily solutions<ref name="p17056884"/> require special deposition equipment to collect waste water, watery<ref name="p18430859"/> solutions seem to be regarded as less problematic. Watery solutions also were documented to enhance post mortem CT tissue differentiation whereas oily solutions were not. Conversely, oily solutions seem to only minimally disturb ensuing toxicological analysis, while watery solutions may significantly impede toxicological analysis, thus requiring blood sample preservation before post mortem CT angiography.<ref name="p22704555">{{cite journal |vauthors =Rutty GN, Smith P, Visser T, Barber J, Amorosa J, Morgan B|title=The effect on toxicology, biochemistry and immunology investigations by the use of targeted post-mortem computed tomography angiography|journal=Forensic Sci. Int.|year=2012 |pmid=22704555 |volume=225 |issue=1–3 |pages=42–7 |doi=10.1016/j.forsciint.2012.05.012}}</ref> ==Complications== Angiography is a relatively safe procedure. But it does have some minor and very few major complications. After an angiogram, a sudden shock can cause a little pain at the surgery area, but heart attacks and strokes usually do not occur, as they may in bypass surgery. The risk of complications from angiography can be reduced with a prior CT scan by providing clinicians with more information about number and positioning of the clots in advance.<ref>{{Cite journal |last1=Jones |first1=Daniel A. |last2=Beirne |first2=Anne-Marie |last3=Kelham |first3=Matthew |last4=Rathod |first4=Krishnaraj S. |last5=Andiapen |first5=Mervyn |last6=Wynne |first6=Lucinda |last7=Godec |first7=Thomas |last8=Forooghi |first8=Nasim |last9=Ramaseshan |first9=Rohini |last10=Moon |first10=James C. |last11=Davies |first11=Ceri |last12=Bourantas |first12=Christos V. |last13=Baumbach |first13=Andreas |last14=Manisty |first14=Charlotte |last15=Wragg |first15=Andrew |date=2023-10-31 |title=Computed Tomography Cardiac Angiography Before Invasive Coronary Angiography in Patients With Previous Bypass Surgery: The BYPASS-CTCA Trial |journal=Circulation |language=en |volume=148 |issue=18 |pages=1371–1380 |doi=10.1161/CIRCULATIONAHA.123.064465 |issn=0009-7322 |pmc=11139242 |pmid=37772419}}</ref><ref>{{Cite journal |date=6 August 2024 |title=CT scan reduces the complications of angiography after bypass surgery |url=https://evidence.nihr.ac.uk/alert/ct-scan-reduces-the-complications-of-angiography-after-bypass-surgery/ |journal=NIHR Evidence|doi=10.3310/nihrevidence_63153 |doi-access=free }}</ref> ===Cerebral angiography=== Major complications in cerebral angiography such as in [[digital subtraction angiography]] or contrast MRI are also rare but include [[stroke]], an [[allergic]] reaction to the [[anaesthetic]] other medication or the contrast medium, blockage or damage to one of the access veins in the leg, pseudoaneurysm at the puncture site; or [[thrombosis]] and [[embolism]] formation. [[Bleeding]] or [[bruising]] at the site where the contrast is injected are minor complications, delayed bleeding can also occur but is rare.<ref name='nhs-angiography-complications'>{{cite web|url=http://www.nhs.uk/Conditions/Angiography/Pages/Complications.aspx |title=Angiography – Complications |access-date=2010-03-24 |date=2009-06-01 |work=Health A-Z |publisher=NHS Choices }}</ref> ===Additional risks=== The contrast medium that is used usually produces a sensation of warmth lasting only a few seconds, but may be felt in a greater degree in the area of injection. If the patient is allergic to the contrast medium, much more serious side effects are inevitable; however, with new contrast agents the risk of a severe reaction is less than one in 80,000 examinations. Additionally, damage to blood vessels can occur at the site of puncture/injection, and anywhere along the vessel during passage of the catheter. If [[digital subtraction angiography]] is used instead, the risks are considerably reduced because the catheter does not need to be passed as far into the blood vessels; thus lessening the chances of damage or blockage. ===Infection=== [[Antibiotic prophylaxis]] may be given in those procedures that are not clean, or clean procedures that results in generation of [[infarcted]] or [[necrotic]] tissues such as [[embolisation]]. Routine diagnostic angiography is often considered a clean procedure. Prophylaxis is also given to prevent infection from infected space into blood stream.<ref>{{Cite journal|last1=Venkatesan|first1=Aradhana M.|last2=Kundu|first2=Sanjoy|last3=Sacks|first3=David|last4=Wallace|first4=Michael J.|last5=Wojak|first5=Joan C.|last6=Rose|first6=Steven C.|last7=Clark|first7=Timothy W.I.|last8=d'Othee|first8=B. Janne|last9=Itkin|first9=Maxim|last10=Jones|first10=Robert S.|last11=Miller|first11=Donald L.|date=November 2010|title=Practice Guideline for Adult Antibiotic Prophylaxis during Vascular and Interventional Radiology Procedures|journal=Journal of Vascular and Interventional Radiology|language=en|volume=21|issue=11|pages=1611–1630|doi=10.1016/j.jvir.2010.07.018|pmid=21029949|doi-access=free}}</ref> ===Thrombosis=== There are six risk factors causing thrombosis after arterial puncture: low blood pressure, small arterial diameter, multiple puncture tries, long duration of cannulation, administration of vasopressor/inotropic agents,<ref>{{Cite journal |last1=Cousins |first1=Teresa R. |last2=O'Donnell |first2=John M. |date=August 2004 |title=Arterial cannulation: a critical review |url=https://pubmed.ncbi.nlm.nih.gov/15354915 |journal=AANA Journal |volume=72 |issue=4 |pages=267–271 |issn=0094-6354 |pmid=15354915}}</ref> and the usage of catheters with side holes.<ref>{{Cite journal |last1=Owen |first1=David G. |last2=de Oliveira |first2=Diana C. |last3=Qian |first3=Shuang |last4=Green |first4=Naomi C. |last5=Shepherd |first5=Duncan E. T. |last6=Espino |first6=Daniel M. |date=2020-08-07 |editor-last=Tian |editor-first=Fang-Bao |title=Impact of side-hole geometry on the performance of hemodialysis catheter tips: A computational fluid dynamics assessment |journal=PLOS ONE |language=en |volume=15 |issue=8 |pages=e0236946 |doi=10.1371/journal.pone.0236946 |issn=1932-6203 |pmc=7413473 |pmid=32764790|bibcode=2020PLoSO..1536946O |doi-access=free }}</ref> ==See also== {{col div|colwidth=30em}} * [[Acoustic angiography]] * [[Angiosarcoma]] * [[Cardiac catheterization]] * [[Computed tomography angiography]] * [[Contrast medium]] * [[Echocardiogram]] * [[Electrocardiogram]] * [[Fluorescein angiography]] * [[Image intensifier]] * [[Interventional radiology]] * [[Intravascular ultrasound]] * [[Intravenous digital subtraction angiography]] * [[Magnetic resonance angiography]] * [[Peripheral artery occlusive disease]] {{colend}} ==References== {{Reflist|30em}} ==External links== {{Commons category|Angiography}} * [https://web.archive.org/web/20110502165046/http://www.radiologyinfo.org/en/sitemap/modal-alias.cfm?modal=Angio RadiologyInfo] for patients: Angiography procedures * [http://www.ptca.org/imaging/cath.html Cardiac Catheterization] from Angioplasty.Org * [https://web.archive.org/web/20161101103044/https://www.ziehm.com/en/products/productfinder/ C-Arms types] Several types of C-Arms * [http://emedicine.medscape.com/article/1603072-overview Coronary CT angiography by Eugene Lin] {{Angiography}} {{Medical imaging}} {{Vascular procedures}} {{Authority control}} [[Category:Cardiac imaging]] [[Category:Projectional radiography]] [[Category:Vascular procedures]]
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