1.Indications
①Spinal cord vascular lesions.
②Partial cerebral subarachnoid hemorrhage with negative cerebral angiogram.
③To understand the relationship between spinal cord tumor and blood vessels.
④Preoperative embolization of spinal cord vascular rich tumor.
⑤ Review of spinal cord vascular lesions.
2. Contraindications
①Allergic to iodine.
②People with serious bleeding tendency or bleeding disorders.
③Persons with severe cardiac, hepatic or renal insufficiency.
④Patients with severe hypertension or atherosclerosis.
3.Pre-operative preparation
①Routine preoperative examination: including blood and urine routine, bleeding and clotting time, liver and kidney function, electrocardiogram and chest X-ray.
②8h preoperative fasting, special cases, such as emergencies can be shortened at the discretion of the anesthesiologist.
③Iodine allergy test: 1 ml of the contrast agent to be used for imaging, intravenous push. No allergic signs such as panic, shortness of breath, urticaria and bulbar conjunctival congestion, and blood pressure pulsations below 10-20 mm Hg measured before and after injection are considered negative. 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 agent should be used as much as possible.
④Bilateral inguinal and perineal area skin preparation:A catheter should be left in place for patients with long operation time.
⑤ Intramuscular injection of phenobarbital 30 min before surgery.
⑥If appropriate, calcium antagonists should be given intravenously and continuously 24 h before surgery.
(7) Equipment preparation: 1 angiography bag, 2 pressure bags, 500ml x 4 bags of soft packing isotonic saline, 1 Y-shaped valve, 2 tee connectors, 1 contrast catheter (5F or 4F, different shape of contrast catheter if appropriate), 1 catheter sheath (5F, 6F), 1 short 30cm guidewire and 1 long 160cm guidewire. High-pressure syringe and connecting tube, 100-200 ml of contrast medium. Puncture needle (16G or 18G for adults, 18G or 20G for children).
4. Operation methods and procedures
4.1 Operation steps of transfemoral artery puncture:
① Routinely disinfect the inguinal and perineal areas bilaterally to spread the sheet and expose both sides of the groin.
② Connect at least 2 sets of intra-arterial continuous drippers (1 of which is connected to the catheter sheath 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. The contrast tube is flushed with heparin saline.
The puncture site is chosen 1.5-2 cm below the inguinal ligament where the femoral artery pulsation is most evident, and is anesthetized by local infiltration.
④After successful puncture, a vascular sheath was placed with the aid of a short guidewire. Continuous titration is regulated with a drop count of 15 to 30 drops/min.
⑤ Systemic heparinization, control activated partial thromboplastin time (APTT) > 120 s, or activated clotting time (ACT) > 250 s. The method of heparinization can be referred to the following: the first dose of 2/3 mg per kg of body weight is given intravenously, followed by half a dose after 1 h, and then 1/4 amount after 2 h. Additional half of the previous dose is given every 1 h thereafter, and if reduced to 10 mg, every 1 h Give 10mg.
(6) Bilateral vertebral arteries, bilateral thyroglossal and cribriform trunks, bilateral intercostal arteries, and bilateral lumbar arteries were performed sequentially under fluoroscopy. In case of tortuous vessels, a guide wire can be used to assist when the catheter cannot be placed.
(7) In elderly patients, each trunk artery should be contrasted from the bottom up, and if necessary, the aortic arch should be contrasted with a pigtail catheter.
(8) Neutralize sodium heparin with fisetin (1-1.5 mg can counteract 1 mg of sodium heparin) after the end of the angiogram.
4.2 Postoperative management:
① Compression and pressure bandaging of the puncture site, bed rest for 24h, keeping the lower limb on the puncture side straight. If a vascular closure device is used, brake for 6 hours.
②Monitor the dorsalis pedis artery pulsation of the punctured limb once/4h.
③Give antibiotics and hormones appropriately.
5.Caution
①Before imaging, lead numbers or other markers must be affixed under fluoroscopy to clarify the location of the corresponding vertebrae.
②The angiography must include all spinal arteries, such as bilateral vertebral arteries, thyrocervical trunk, cribriform trunk, each intercostal artery, lumbar artery, and internal skeletal artery.
③The routine injection dose of intercostal artery and lumbar artery is 1 ml/s for a total of 2 to 5 ml. If there are lesions with high blood flow, the dose can be increased appropriately.
6.Complications
Individual patients may suffer from increased symptoms such as paralysis and sensory impairment, which may be related to the catheter stimulation causing arterial spasm and blocked blood flow, thus aggravating spinal cord ischemia. Before imaging, dexamethasone and calcium antagonists should be used. The catheter should not be too thick, and 4F, 5F Cobra, Yashiro, and MIK catheters are more commonly used.