Angiographic Procedures:

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GETTING COMMON FEMORAL ARTERIAL ACCESS:

 

GREAT YOUTUBE VIDEO ON GETTING R CFA ACCESS STEP BY STEP

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Femoral artery puncture steps

 

1. Localize femoral pulse

2. Confirm anatomic location with fluoroscopy/US

3. Anesthetize skin and deeper tissues with lidocaine

4. Skin entry point should be 1-2 cm below (retrograde access) or above (antegrade access) intended needle entry point into artery

5. Use #11 blade to make 5 mm skin nick

6. Spread skin/subcutaneous tissue with hemostat

7. Hold hub of puncture needle in 1 hand

8. Place tips of index and middle fingers of other hand above and below skin nick, palpate pulse

9. Advance needle slowly through nick at 45° angle

10. When needle tip contacts artery, should feel transmitted pulsations

11. Thrust needle until underlying bone encountered

12. If needle has stylet, remove

13. May anesthetize periosteum through needle

14. Depress needle hub a few degrees toward skin

15. Slowly withdraw needle until pulsatile blood return; stop withdrawing at this point

16. Stabilize needle position

17. Introduce guidewire through needle hub

18. Use atraumatic guidewire, such as J-tip

19. Avoid hydrophilic wire (needle may strip wire)

20. If resistance to guidewire passage

21. Stop advancing wire immediately

22. Using fluoroscopy, gently redirect needle tip to align with vessel long axis; try wire again

23. If resistance still met, remove needle, repuncture

24. After successfully introducing guidewire, remove needle over wire, introduce sheath or catheter

 

JF METHOD CFA ACCESS:

 

• pt supine on fluoro table

• getting access to Right common femoral artery

• prep R groin, drape right groin with blue towels

• start palpating the pulse, the artery curves kinda 45 degrees medial to lateral

• want to enter artery over femoral head, can use FLUORO to demarcate inferior aspect of femoral head

• JF likes to enter skin at level of inguinal crease

• numb skin with wheal, also deep numbing lateral and medial to artery aspirate before inject

• make nick (approx 2 cm caudal to entry site) and open up with kelly clamp

• place the needle in the nick before your go forward trying to access

• the goal is to palpate the pulse, basically put the needle right in the path of your fingers, where the pulse is the strongest and try to hit the femoral head bone.  you should hit the bone

• rember to hold the needle corect way, with thumb over hub underhanded, should have total control of that needel at all times

• once hit bone, give more lidocaine 

• then you will sorta tilt the needle [19 gauge access needle], basically make it more shallow angle and hold the needle in such a way as to have control, very slowly remove needle and look for blood return.  you will sometimes see venous first but then the artery is somtimes above it and you will see pulsatile blood flow coming out stop there.  

• then use the green wire TEFCOR J wire . Be careful with the silver end of the end aspect of this first wire

• get wire up to the aortic bifuraction with wire.

• remove the needle, put the sheath on 10 cm 4F sheath

 

how to set up the sheath:

1. make sure sheath is flushed before hand, no bubbles

2. dilator through sheath

3. the side flush thing is to keep the thing free of clots.  this is hooked up tot he IV pressure bag with tubing.  it should be on KAO, keep artery open.  fast enough to keep the thing clear of clots.  you can adjust the tubing using a small adjustor thing

 

How to set up contrast tubing

1. the contrast tubing will come down to the table.  

2. untangle it

3. the small thin end goes to the contrast injector

4. the other end is what gets hooked up to the angiographic catheters

5. there is a small plastic ompenent that IS sterile.  you twist that tight to tighten up the injector.  rember if thats loose, the contrast will blow off when it fires.  not good

6. Tech will drip contrast till you see it coming out the other end.  then its primed.  can fill up the contrast cup a little bit here

 

Contrast Tubes:

• contrast in the 10s and flush in the 20's

• remember to fil up contrast and flush very delibraretly.  NO BUBBLES.  Get rid of all bubbles and then fill up slowly with tip in the fluid.  Contrast tubes should be filled and ready to go at all times

 

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Doing a flush Pelvic Angiogram:

 

Basically have the tefcor wire in.  put in an omni FLUSH catheter.  youll know its a flush because it will have multiple end holes**** and the curve is characteristic OMNI

 

*Remember when you get the catheter, you leave the plastic thing on there to make it easier to place on the wire*

Use Pinch and Pull technique to advance catheter over wire or to remove the catheter over the wire

Use a soaked telfa pad to wet the wire and catheter

remember think about getting a torque modulator if need be

 

Get the flush catheter into the abdominal aorta above bifurcation and shoot a flush angiogram of the pelvic arteries.  

To do a run:

 

CC / SEC FOR TOTAL CC

Aortogram (aortic arch): 20 for 30.

Mesenteric artery: 5 for 25.

 

Pelvic Artery Anatomy: