P ERCUTANEOUS axillar artery cathetenization

Transcription

1 NOVEMBER, 1973 ABDOMINAL AORTOGRAPHY FROM THE AXILLARY APPROACH* By MICHAEL C. BEACHLEY, M.D., and KLAUS R.ANNIGER, MI). RICHMOND, P ERCUTANEOUS axillar artery cathetenization for angiographs of the vertebral and carotid arteries and the aorta is a relatively easy maneuver.1 4 However, in the older age group it is frequently difficult to pass the catheter into the descending thoracic aorta for abdominal aortographv.7 Some methods described to overcome this problem include reflection of a guidewire off the aortic valves, deflector catheters,2 double catheter techniques, 5 and use of curved catheters and guidewires.4 6 This communication describes a simple method of accomplishing catheterization of the descending thoracic aorta using regular catheters and guidewires, as well as a method of obtaining technically good aortographic studies in the occasional patient in whom the guidewire and catheter cannot be advanced distal to the aortic arch. INDICATIONS Angiographers use femoral, translumbar, and axillary approaches depending on the status of the pulses and objectives of the procedure, as well as their experience and personal preference. Puncture of the femoral artery is most commonly used and any arteriographic study can be performed with this technique. When the femoral pulses are weak or absent, the translumbar or axillary approaches must be utilized. Translumbar aortographv can be used for abdominal aortographv, whereas the axillary artery catheterization is necessary for thoracic aorta and brachiocephalic arteriography. M any angiographers, however, prefer not to use the translumbar approach for abdominal aortograph, and this communique is most applicable to their practice. virg1ni M EIHOI) \Ve usuall utilize a Green Kifa French) or Yellow Squibb (7 French) catheter. Two catheters are prepared. One is straight and has side holes (Fig. ia), and the other has a 360#{176}or more rather tight distal curve (approximately I cm. radius) and also contains 4 side holes (Fig. ib). A 145 cm. J-tipped removable core teflon coated guidewire is used, with the core adjusted so that approximately the distal 6 inches of the guidewire is flexible (Fig. ic). The percutaneous left axillarv artery catheterization is performed b the Seldinger technique. 4 If the guidewire mitiallv enters the descending aorta, the straight catheter (Fig. ia) is introduced and aortographv is performed. In tortuous aortas, however, the guidewire often enters the ascending aorta, and cannot be advanced into the descending aorta. In such an instance, the curved catheter is inserted. Because of the acute angle between the subclavian artery and the aortic arcil, an extreme distal curvature of the catheter is necessar to assure that it can be aimed posterosupeniorl over the aortic arch. The catheter curve can be altered in situ by withdrawing it into the left subclavian artery (Fig. 2, A and B), until the position of the catheter will result in its being aimed over the aortic arch. The guidewire within the catheter is then advanced over the arch and well into the descending thoracic aorta (Fig. 2C). Its long flexible portion allows it to pass over the arch without straightening the catheter. While observing the tip of the guidewire in the distal aorta fluoroscopically, the catheter is removed, simultaneously advancing the guidewire further into the aorta so that it is not * From the Department of Radiology, Virginia Commonwealth University, Medical College of Virginia, Richmond, Virginia. o8

2 Abdominal.Aortograph from the Axillar Approach \oi. 119, No. 509 f;, S -. FIG. 1. (A) Straight French catheter with 4 side holes; (B) same catheter with 6o#{176} end (C). rnm. radius j-tipped adjustable core guidewire; (D) pigtail catheter. withdrawn to tile point wilere it slips into the ascending aorta. Tile straight catheter is then inserted and will follow tile guidewire into tile descending thoracic and abdominal aorta (Fig. 2D). Selective injections can subsequently be performed with the same or selective catheters. In young and middle aged patients, with only moderate elongation of tile aorta, a pigtail type catheter (Fig. id Cook or Cordis) may be used to aim tile guidewire over the distal aortic arch. In this case, tile pigtail catheter can then be advanced over tile guidewire illto the distal aorta, and aortograph\ can be performed without having to cilange catheters (Fig. 2, F and F). The use of a single catheter is a significant advantage if the predicted elongation of the aorta is not great. The curve on the pigtail catheter, however, is not as great as the catheter demonstrated in Figure i B, -- curve; and may not negotiate tile more tortuous aortic arches of older patients. In this case, the curved catheter (Fig. IB) as described, should be used for this maneuver. The pigtail catheter with tile side holes proximal to the curve has the same disadvantage of other ascending aortic injections for abdominal and femoral arteniographv (Fig. 3B), in that contrast medium is unnecessanil injected into the brachiocephalic circulation, and detracts from the quality of the abdominal aortogram. Rarel, because of advanced atherosclerotic plaques or extreme tortuosity of the arch, it may not be possible to pass the guidewire into the descending thoracic aorta. In this case, the curved catheter with 4 side holes (Fig. ib) is simpl left in place and the aortographv is performed with this catheter. Because of its curve, most of the contrast material bolus enters

3 510 Michael C. Beachle and Klaus Ranniger Nosi-;suhi;R, )7i 11G. 2. (A) Catheter from 1 igure ib in situ; (B) withdrawal of catheter will straighten the curve so the tip points in the desired direction; (C) the guidewire is advanced into the distal descending thoracic aorta; (D) a straight (Fig. IA) catheter is then exchanged for the curved catheter and advanced into the descending thoracic or abdominal aorta; (E) a pigtail catheter may be satisfactory in the less elongated arches of middle aged patients; (F) the pigtail catheter can then be advanced distally and aortography safely done avoiding catheter exchange. FIG... (A) A Figure ib catheter in place. If the guidewire cannot be advanced distally, aortograph is done through this same catheter and most of the injected contrast medium enters the distal aorta; (B) a disadvantage of the pigtail catheter is that if the guidewire cannot he passed distally, abdominal aortography will he less satisfactory because some of the contrast medium enters the brachiocephalic vessels (arrows).

4 VoL. 119, No. 3 Abdominal Aortography from the Axillary Approach 5 the distal aorta through the tip hole (Fig. 34). The quality of the angiogram using this technique is considerably better than after injection into the ascending aorta with part of the bolus entering the brachiocephalic vessels. In addition, an injection of excessive amounts of contrast material into the cerebral circulation is avoided. SUMMARY A simple method of performing abdominal aortography from the left axillary approach is described, which is successful in most older patients with elongated, tortuous aortic arches. No additional equipment is necessary. A satisfactory alternative method is available on the occasional patient in whom the guidewire cannot be advanced distally over the aortic arch. Michael C. Beachley, M.D. Medical College of Virginia, Box 728 Richmond, Virginia REFERENCES i. HANAFEE, W. Axiliary artery approach to carotid, vertebral, abdominal aorta, and coronary angiography. Radiology, 1963, 8z, HAWKINS, I. F., JR. Deflector catheter approach to abdominal aorta. AM. J. ROENTGENOL., RAD. THERAPY & NUCLEAR MED., 1972, ii#{243}, MILLER, R. E., and CHUA, G. T. Multiple curve guide wire for aortic catheterization. Radiology, 1969, 92, NEWTON, T. H. Axillary approach to arteriog-. raphy of aorta and its branches. AM. J. ROENT- GENOL., RAD. THERAPY & NUCLEAR MED., 1963, 89, RILEY, J. M., HANAFEE, W., and WEIDNER, W. Left axillary approach to abdominal aorta. Radiology, 1965, 84, Roy, P. Percutaneous catheterization via axillary artery: new approach to some technical road blocks in selective arteriography. AM. J. ROENTGENOL., RAD. THERAPY & NUCLEAR MED., 1965, 94, i-i8. 7. THOMAS, M. L., and FLETCHER, E. W. L. Large volume translumbar aortography in aortic occlusion. AM. J. ROENTGENOL., RAD. THER- APY & NUCLEAR MED., 1970, 109,

5 This article has been cited by: 1. J. Hoevels Single Catheter Technique for Transaxillary Aortofemoral Angiography. Acta Radiologica. Diagnosis 24:5, [Crossref] 2. W. M. Marks, J. R. Akin, R. L. Eisenberg, Gretchen A. W. Gooding Direct puncture and angiographic evaluation of axillary-to-femoral bypass grafts. The British Journal of Radiology 50:592, [Crossref]