Pre-Procedure Planning
Before the procedure, the interventionalist should review the following patient information in addition to a complete history and physical examination:
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Vital signs and hemodynamic parameters
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Allergies, particularly to intravenous contrast material or other procedural medications such as sedatives
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Medications, including anticoagulants, antiplatelet agents, and metformin
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ECG abnormalities: Look specifically for LBBB [32] ; potentially fatal complete heart block is a risk during manipulation of the catheter through the right heart by induction of a right bundle branch block; if LBBB is present, a transvenous pacemaker or external pacing leads should be in place prior to starting the procedure possibly in consultation with the cardiology service
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Laboratory studies: Blood urea nitrogen/creatinine, coagulation parameters (PT, PTT, INR, platelets), pregnancy test (if appropriate)
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Imaging: CT scanning (to evaluate anatomic abnormalities and to plan approach), ultrasonography (to check for location of deep venous thrombosis, if present), echocardiography (may show right heart dysfunction in a patient with PE; PFO increases the risk of periprocedural stroke in rare circumstances)
Patient Preparation
The patient is placed on nothing by mouth (NPO) status according to the institution’s requirements for patients undergoing monitored moderate conscious sedation.
Anesthetize the skin using appropriate anesthetic agent. Conscious sedation may be used depending on the clinical status of the patient.
Be alert for airway issues when giving respiratory depressants. Avoid excessive sedation, since breath-holding during imaging is crucial in obtaining diagnostic-quality imaging.
The patient is placed in the supine position on the angiographic table.
Periprocedural observation includes puncture site checks to evaluate for hematoma, in addition to frequent vital sign monitoring for the first 4 hours postprocedure.
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Pulmonary angiography catheter. The Grollman catheter has a gentle curve along the distal portion, with a 90 degree bend 3 cm from the pigtail terminus. Permission for use granted by Cook Medical Incorporated, Bloomington, Indiana.
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Right femoral vein approach with the St. Charles catheter tip in the right atrium. Courtesy of Christopher Friend, MD.
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Tip of catheter in the main pulmonary artery.
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Digital subtraction angiography image shows the pigtail catheter in the main left pulmonary artery.
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Tip of catheter in the right pulmonary artery. A guidewire (arrowhead) was used for navigation.
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Selective segmental branch pulmonary arteriogram is facilitated with use of a Berenstein catheter.
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Normal right (A) and left (B) pulmonary angiograms showing gradual tapering of the pulmonary arteries, normal caliber vessels, and no filling defects.
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(A) Anteroposterior angiogram of the right pulmonary artery shows no abnormality. (B) On the oblique view, a filling defect is visible posteriorly (arrow).
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(A) Left pulmonary angiogram shows faint subsegmental filling defect in the lateral basal pulmonary artery that is imaged more clearly (arrow) on the magnified view (B).
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Selective left pulmonary angiogram shows abrupt tapering of the segmental pulmonary arteries (arrow) with heterogeneous opacification of the parenchyma. Mean pulmonary arterial pressure was 40 mmHg. These findings are consistent with chronic pulmonary thromboembolism.
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(A) Selective right pulmonary arteriogram shows large filling defects in the right upper (short arrow) and right lower (long arrow) lobe pulmonary arteries. In another patient, selective right pulmonary arteriogram (B) shows a filling defect in the right upper lobe pulmonary artery (arrow), which correlates with a large segmental filling defect (black arrows) on V/Q scan (C).
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PA chest radiograph shows right subclavian port with a fractured fragment in the right lower lung (arrow). B: Fluoroscopic intraprocedure image with a snare (long arrow) tethering the catheter fragment (short arrow).
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(A) Selective interlobar right pulmonary arteriogram shows large AVM in the lateral right lower lobe (arrow). (B) On late arterial phase imaging, there is early opacification of an inferior right pulmonary vein (arrow heads) draining the AVM. (C) Postembolization arteriogram shows occlusion (arrow) of the supplying artery to the AVM.
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(A) Pulmonary arteriogram shows irregular contour to the main (arrow) pulmonary artery with abrupt cutoff in the expected region of the left pulmonary artery (arrowhead) and attenuation of the proximal right pulmonary artery (white arrow). (B) Perfusion image from a VQ scan shows no activity in the left lung (oval), correlating with complete occlusion of the left pulmonary artery seen on angiography.
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(A) Anteroposterior chest radiograph shows increased lung volumes and marked radiolucency of the right upper lung in a patient with severe emphysema. (B) Right pulmonary arteriogram shows thin, severely tapered segmental arteries in the right upper lobe with increased space between vessel. Contrast this appearance with chronic pulmonary embolism (above), in which the space between arteries is normal.
