Whole brain angiography
Indications
1. Intracranial and extracranial vascular lesions. Such as hemorrhagic or occlusive cerebrovascular lesions.
2. Spontaneous intracerebral hematoma or subarachnoid hemorrhage (SAH) etiology examination.
3. For blood-rich tumors of the head and face, preoperative understanding of the blood supply status.
4. To observe the relationship between blood supply and adjacent blood vessels of intracranial occupying lesions and the characterization of certain tumors.
5. Review after treatment of head, face and intracranial vascular diseases.
Contraindications
1. Allergy to iodine (after desensitization treatment or use of iodine-free contrast media).
2. Those with serious bleeding tendency or bleeding disorders.
3. Severe cardiac, hepatic or renal insufficiency.
4. Late brain herniation and brainstem failure.
Preoperative preparation
1. Routine preoperative examination: including blood and urine routine, bleeding and clotting time, liver and kidney function, electrocardiogram and chest X-ray.
2. 8h preoperative dietary restriction. In special cases, such as emergencies, may be shortened at the discretion of the anesthesiologist.
3. Iodine allergy test: 1ml of the contrast agent to be used for imaging, intravenous push. The test should be negative if there are no signs of allergy such as panic, shortness of breath, urticaria and bulbar conjunctival congestion, and if the blood pressure pulsation is less than 10~20mmHg measured before and after the injection. If the iodine allergy test is positive and contrast must be performed, hormone therapy should be given 3 d before surgery and non-ionic iodine aqueous contrast preparation should be used as much as possible.
4. Bilateral inguinal and perineal area skin preparation: Patients with long operation time should have indwelling catheter.
5. Intramuscular injection of phenobarbital 30 min before surgery.
6. Continuous intravenous administration of calcium antagonist 24h before surgery, if appropriate.
7. Instrument preparation
1 angiography bag, 2 pressure bags, 500ml×4 bags of soft packing isotonic saline, 1 Y-shaped valve, 2 tee connectors, 1 cerebral angiography catheter, 1 catheter sheath (5F, 6F), 1 short 30cm guidewire and 1 long 160cm guidewire. High-pressure syringe and connecting tube, 100~200ml of contrast medium. Puncture needle (16G or 18G for adults, 18G or 20G for children).
Operation method and procedure
1.Transfemoral artery puncture operation steps
(1) Routinely disinfect the inguinal and perineal areas bilaterally by laying sheets and exposing the groin on both sides.
(2) Connect at least 2 sets of intra-arterial continuous drippers (1 of which is connected to the catheter target and the other one is spare or connected to the Y-valve guidewire). Connect a high-pressure syringe and aspirate the contrast medium. All connections should be free of air bubbles. Rinse the contrast tube with heparin saline.
(3) The puncture site is chosen 1.5~2 cm below the inguinal ligament where the femoral artery pulsation is most obvious, with local infiltration anesthesia, and the angle of needle entry is 30 degrees~45 degrees to the skin.
(4) After successful puncture, the vascular sheath is placed with the assistance of a short guidewire. Continuous titration is regulated with a drop count of 15-30 drops/min.
(5) Systemic heparinization with control of activated partial thromboplastin time (APTT) > 120s or activated clotting time (ACT) > 250s. The method of heparinization can be referred to the following: the first dose of 2/3mg per kg of body weight is given intravenously, followed by half amount after 1h, and then 1/4 amount after 2h, followed by additional half amount of the previous dose every 1h, and if it is reduced to 10mg, every 1h Give 10mg
.
(6) Under fluoroscopy, perform whole brain angiography, including bilateral internal and external carotid arteries and bilateral vertebral arteries. If necessary, bilateral thyrocervical trunk and cribriocervical trunk angiograms can be performed. In the case of tortuous vessels, a guide wire can be used to assist when the catheter is not in place.
(8) Neutralize sodium heparin with fisetin (1~1.5mg can counteract 1mg of sodium heparin) after the end of the angiography.
2.Postoperative treatment
(1) Compress and pressure bandage the puncture site, lie in bed for 24h and keep the lower limb on the punctured side straight.
(2) Monitor the dorsalis pedis artery pulsation of the punctured limb for 1 time/0.5h.
【Complications】.
Complication causes prevention and treatment
Bleeding at the puncture site patient coagulation mechanism disorder; there may be patient agitation, premature excessive movement of the lower limb, etc. Postoperative heparin neutralization after 10-20 minutes to pull out the sheath, three fingers compression of the puncture site for 15-20 minutes, release and observe for five minutes, no bleeding after compression bandage.
Small hematoma (diameter <10 cm = 24 hours after local hot compress or physiotherapy. Those causing local compression may be removed by incision.
Vasospasm may be due to the catheter or cause stimulation of the endothelial cells of the vessel by the guidewire after vasospasm can be given with a slow intra-arterial push of poppy booster (15 mg plus 10 ml isotonic saline) subintimal passage (vascular entrapment) may be due to the catheter or guidewire entering the subintima or excessive pressure of the injected contrast agent under fluoroscopy, monitor the direction and position of the catheter and guidewire, and should not be forcibly inserted at the femoral artery when resistance is encountered mostly Cis-clamping, can be self-healing. In severe cases, stenting or anticoagulation is required, and controlled pressure reduction and thoracic cardiovascular surgery are required.
Thrombosis or embolism may be related to the hypercoagulable state of blood and platelet dislodgement. After thrombosis, sedation should be maintained and comprehensive imaging should be performed to find out the location of the embolus.
Thrombolytic therapy for vessel perforation or vessel wall tear may be related to abnormal vessel structure. Path diagrams must be used for vessels with complex structures. Use a multilaterally perforated catheter for aortograms. The end of the catheter should not be held against the vessel during angiography to neutralize heparin in time to stop bleeding and lower pressure. Endovascular occlusion is performed for vessels that can be occluded; compression or surgical repair is performed for vessels that cannot be occluded.
Pseudoaneurysm or arteriovenous fistula at the puncture site may be due to the patient’s clotting mechanism disorder, or the use of anticoagulation, thrombolytic, or antiplatelet aggregation drugs. Patient irritability, premature excessive exercise of the lower extremity with local compression, balloon embolization, stenting with membrane, or surgical repair.
Thrombophlebitis may be related to endothelial cell damage due to contrast agents and venous blood stasis strict anticoagulation elevation of the affected limb to reduce pain.