11.1 Peripheral & Access-Site Angiography

Peripheral & Access-Site Angiography

ARRT Cardiac-Interventional Procedures 1.B Peripheral Angiography is the set of angiograms a cardiac lab actually shoots so the operator can plan access, recognize complications, document concomitant disease, and decide whether a graft or a large-bore sheath belongs in that vessel. It is not a stolen vascular-interventional syllabus. These pictures are how coronary and structural cases are allowed to start and how they are allowed to end.

Quick Answer: Before a closure device, shoot a femoral angiogram and confirm the sheath is in the common femoral artery (CFA) — not the superficial femoral artery (SFA) or profunda, and not a sheath that is huge relative to the lumen. Shoot a radial angiogram for loops and spasm. Treat the internal mammary artery (IMA) as a graft conduit, and image the subclavian before trusting a left internal mammary artery (LIMA). Unique risks to memorize as a set: stroke (carotid/arch), limb ischemia (brachial), pneumothorax (internal jugular).

Why the R.T.(CI) images these vessels

Nine named territories appear on the outline because the cath lab uses them, not because the exam wants a complete peripheral runoff atlas.

Access planning. Is this CFA large, plaque-limited, and free of a low bifurcation stick? Is this radial looped or spastic? Can a transcatheter aortic valve replacement (TAVR) sheath traverse the iliacs and a hostile arch?

Complications. Dissection, perforation, occlusion, and contrast outside the lumen at the access site are angiographic diagnoses. Waiting for hypotension to declare a retroperitoneal bleed is not a substitute for looking at the femoral angiogram you already have.

Concomitant disease. Iliac plaque, subclavian stenosis, renal artery stenosis, and carotid disease change the plan even when the coronaries are the stated reason for the case.

IMA as a graft conduit. A LIMA-to-left anterior descending (LAD) graft is only as good as the subclavian that feeds it.

Subclavian stenosis before LIMA. Image the origin before you declare the graft healthy.

Renal arteries before some structural cases. Abdominal aortic and large-bore work can threaten renal ostia; some structural pathways need to know the kidneys are not being sacrificed for access.

Carotids if the arch is atheromatous. A shaggy arch is a stroke factory. Carotid pictures, and restraint with wires, follow that finding.

Femoral angiography

The CFA, over the femoral head, below the inguinal ligament and above the CFA bifurcation, is the default large-bore and closure-device artery.

A femoral angiogram through the sheath — typically an ipsilateral oblique that opens the bifurcation — is teaching-standard before you deploy a vascular closure device. The device is engineered for the CFA:

• Not the SFA
• Not the profunda femoris
• Not a puncture above the ligament (no bone to compress against; retroperitoneal bleed)
• Not a lumen dwarfed by the sheath (sheath-to-artery mismatch)

Read caliber, plaque, dissection, extravasation, and whether the stick is anterior-wall CFA. A low SFA or profunda entry is why collagen plugs and suture devices fail or occlude a branch. A high stick is a bleed you will not compress on the table. Both are reasons to hold manual pressure or change strategy rather than fire a CFA-sized device into the wrong vessel.

The same femoral–iliac pictures map TAVR, Impella, and other large-bore access. If the question is whether this groin can take a 14–18 Fr sheath, the answer is an iliac/CFA angiogram, not a left coronary injection.

Radial angiography

For transradial coronary work, a small hand injection through the sheath or catheter is how you see loops (including 360° loops), spasm (smooth concentric narrowing that often yields to nitrates, a calcium-channel blocker, and patience), high radial origin, and wire-induced perforation. Do not power-inject the radial artery. A programmed left-ventriculogram recipe in a 5 Fr radial sheath is how you rupture a forearm vessel.

If the wire stops, the angiogram tells you whether a hydrophilic wire, spasmolysis, or conversion is next. Pain plus a standing column of contrast outside the lumen is perforation until proven otherwise — stop advancing, compress, and notify the operator. Persistent spasm that will not accept a catheter is a reason to change access, not a reason to keep pushing.

Brachial and axillary — bailout arterial access

Brachial and axillary arteries are bailout when groins are occluded or hostile and the wrists have failed or are too small for the device.

The brachial artery is easy to palpate in the antecubital fossa but behaves as an end-artery to the forearm. Unique teaching risk: limb ischemia. There is no palmar-arch safety net the way there is at the wrist. A hematoma can also crush the median nerve. Angiography here is for entry site, caliber, and complication (dissection or occlusion), not a complete arm runoff for its own sake.

The axillary artery is a large-bore bailout for some mechanical-support devices. Unique teaching risks: brachial-plexus injury and a hematoma you cannot compress against a convenient bone. Confirm the lumen can accept the planned sheath before you upsize.

Internal jugular

The right internal jugular (IJ) is the usual venous route for right-heart catheterization (RHC), temporary pacing, and endomyocardial biopsy. You are not hunting arterial stenosis. Confirm the wire is venous, heading toward the superior vena cava, not in the carotid, and not a low stick toward the lung apex.

Unique teaching risk: pneumothorax, plus inadvertent carotid puncture. Ultrasound belongs to access assessment (Patient Care). A wire on fluoroscopy and, when needed, a contrast venogram belong to Procedures 1.B.

Internal mammary as a graft conduit

The IMA, especially the LIMA, is the preferred surgical conduit to the LAD. CI angiography documents the native IMA or the LIMA-to-LAD graft: origin from the subclavian, full length, and distal anastomosis.

Subclavian stenosis proximal to the LIMA origin limits or steals graft flow. Teaching rule: image the subclavian before you trust the LIMA. A widely patent anastomosis with a tight left subclavian is still anterior-wall ischemia. Do not call the graft clean from a selective IMA injection that never showed the subclavian origin.

Carotid, renal, and great vessels

Carotid (and arch) angiography enters the CI lab when the aortic arch is atheromatous, when cerebral symptoms follow catheter work, or when concomitant extracranial disease matters for surgical planning. Unique teaching risk: stroke. Wires and injections in a shaggy arch embolize plaque. Limited, gentle injections beat a complete four-vessel cerebral survey that nobody ordered.

Renal arteries appear for concomitant renal artery stenosis and before some structural cases that share the abdominal aorta or that cannot afford a contrast and catheter injury to a solitary or tenuous kidney.

Great vessel / arch angiography is TAVR access anatomy: iliofemoral pathway, horizontal arch, mobile atheroma, and whether transfemoral large-bore access is even possible. It is the highway map, not a substitute for the coronary tree already covered in native coronary angiography.

Site / typical CI use / unique risk

Worked case

Elective percutaneous coronary intervention from the right groin. Before a suture-mediated closer, the sheath angiogram in the ipsilateral oblique shows entry below the CFA bifurcation into the SFA, with the profunda origin just above the stick. Do not deploy a CFA-sized plug or suture device in the SFA. Hold pressure or pick a hemostasis strategy that matches the actual puncture, and document the low stick.

Same service: anterior ischemia in a patient with a LIMA-to-LAD graft. The anastomosis looks widely patent. Pull back and shoot the left subclavian. A tight origin stenosis is the lesion — not a failed LIMA.

Exam traps

• Closure devices are for the CFA, not SFA or profunda, and not when the sheath is huge relative to the artery.
• A LIMA picture without the subclavian is an incomplete conduit study.
• Do not swap unique risks: carotid → stroke, brachial → limb ischemia, IJ → pneumothorax.
• Radial angiography is a gentle hand injection, not a power injection.
• Great-vessel angiography for TAVR is access anatomy, not a coronary substitute.