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A simple angiographic method for assessing aorto-femoral bypass grafts
ClinicalRadiology (1981) 32, 117-119
0009-9260/81/01650117502.00
© 1981 Royal Collegeof Radiologists
A Simple Angiographic Method for Assessing Aorto-femoral Bypass Grafts N. C. GOURTSOYIANNIS and E. W. L. FLETCHER §
Department of Radiology, University o f Oxford, John Radcliffe Hospital, Headington, Oxford Direct puncture of femoral bypass grafts in the groin with retrograde injection of contrast was employed to assess the lower abdominal aorta, iliac and lower limb arteries. The technique was effective, simple, quick and safe.
The frequent use of dacron as a material for replacing diseased blood vessels has resulted in the angiographer being asked to perform investigations involving such grafts. The most frequent area of investigation is in the lower limbs and many such patients have had both femoral arteries grafted. Some of these patients may be investigated by the axillary route or by high translumbar puncture. The percutaneous catheterisation of the dacron grafts has also been employed (Eisenberg et al., 1976; Marks et al., 1977). We have used a very simple technique employing a Sheldon cannula to demonstrate both the lower abdominal aorta and the vessels to the lower limbs in patients with aorto-femoral grafts. MATERIAL AND METHOD
During 1978-79 five patients with severe arteriopathy who had bilateral dacron trouser grafts extending from the aorta to the superficial femoral arteries were referred for lower limb angiography. A Sheldon* cannula was inserted into the dacron graft in the groin, above the suture line but below the inguinal ligament. If possible an anterior wall puncture only was performed, although the dacron was so tough that the sudden movement of the cannula through the anterior wall resulted in the cannula puncturing the posterior wall in two patients. The cannula was threaded into the lumen of the dacron graft, using the short Sheldon guide wire. Fiftyfive millilitres of Urografin 76 was injected at a rate of 18ml/s using a Medradt injector with the maximum pressure set at 450 lb/in 2. A series of tNms was taken of the lower abdomen, pelvis and lower limbs, using a Puck serial changer and an automatic moving table top. Films were taken *V. J. MiUard,36, Highgate Hill, London N19 5NL. t Medrad mark IV Angiographic Injector, Wolverson X-ray and Electro-medical Ltd, Walsall Street, Willenhall, West MidlandsWV1 32DY. § Reprints from E.W.L. Fletcher.
1.5 s (aorta), 4 and 5 s (pelvis), .7s (thigh)~ 9, 10.5, 12 and 13.5 s (knee and lower leg) after the injection of contrast medium. Two patients required a second injection of contrast with a slower series of films. RESULTS The technique produced good visualisation of the lower abdominal aorta, iliac and lower limb vessels of both sides in all five patients (Figs 1, 2). No complications of the procedure were encountered. DISCUSSION
Bron (1971) advised the use of the left axillary approach to the abdominal aorta in patients with aorto-femoral bypass grafts despite the presence of strong femoral pulses. Lower limb aortography is often difficult in these patients as the axillary arteries are affected by generalised arteriopathy. High translumbar puncture is more difficult and possibly more hazardous than the standard technique (Gammill and Graighead, 1975) and usually requires general anaesthesia in patients in whom general anaesthesia carries an increased risk. Furthermore our experience with over 100 high translumbar aortograms leads us to believe that the details of lower limb vessels is inferior to that obtained by retrograde femoral aortography through a cannula. Patients may be investigated by inserting a catheter directly into the dacron graft in the groin with good results (Eisenberg et al., 1976). However, the procedure may be complicated by a part of the catheter becoming detached in the graft when the catheter is being removed at the end of the examination (Mani and Costin, 1977; Feigenbaum and Grollman, 1980; Weinshelbaum and Carson, 1980). Mani and Costin (1977) suggested that reinsertion of the guide wire before removing the catheter would prevent this complication, but Feigenbaum and
118
CLINICAL RADIOLOGY
Fig. 1 - The abdominal aorta is shown by injection of contrast through a Sheldon cannula inserted into the dacron graft in the right groin. The left external iliac part of the dacron trouser graft is occluded.
Fig. 2 - Same patient as shown in Fig. 1. The left femoral and popliteal arteries are weU filled through collateral vessels. Two runs were performed as the flow of contrast down the left leg was much slower than on the right. The lower limb arteries were well shown from the level of L3 vertebra to the ankles.
Grollman (1980) encountered problems in two patients despite the reinsertion of the guide wire; one patient requiring surgical removal of 5 cm of broken catheter from the graft. Weinshelbaum and Carson (1980) lost 10cm of catheter in a graft because the catheter could not stand the torque stresses placed upon it during manipulation through the tough fibrous tissue round the graft, and the high friction between the catheter and the graft. Retrograde aortography has been used extensively to investigate lesions of the heart and thoracic aorta by inserting a needle into the exposed brachial artery (Catellanos and Pereiras, 1950; Abrams, 1971). There are fewer reports of perfemoral retrograde aortography but Castellanos and Pereiras (1939, 1950) and Farinas (1946) produced excellent radiographs of the abdominal aorta and its branches by this technique.
We have found that percutaneous direct puncture of the aorto-femoral graft is the quickest and easiest method o f performing lower limb aortography in patients with aorto-femoral bypass grafts. The dacron graft is usually straight so that the Sheldon cannula directed retrogradely will result in contrast easily reaching the lower abdominal aorta and showing all the arteries in both lower limbs. The technique is extremely easy and safe to perform, avoiding the complications sometimes encountered when manipulating a catheter through a dacron graft.
Acknowledgements. We would like to thank Miss Y. Williams for typing the manuscript and the Meidcal Illustration Department of the John Radcliffe Hospital for the photographs.
ASSESSING A O R T O - F E M O R A L BYPASS G R A F T S REFERENCES Abrams, H. L. (1974). Angiography, Vol. 1, p. 288. Little, Brown & Company. Bron, K. M. (1971). Femoral arteriography. In Ang~ography, ed. H. Abrams, pp. 1223-1225. Little, Brown & Company. CasteUanos, A. & Pereiras, R. (1939-40). Revista de la sociedad cubana de cardiologiea. Quoted by Castellanos and Pereiras (1950). American Journal of R oentgenology, 134, 559. Castellanos, A. & Pereiras, R. (1950). Retrograde or countercurrent aortography. American Journal of Roentgenology, 68, 559-565. Eisenberg, R. L., Mani, R. L. & McDonald, J. C. E. S. (1976). The complication rate of catheter angiography by direct puncture through aorto-femoral bypass grafts. American Journal of Roentgenology, 126, 814-816. Farinas, P. L. (1946). Retrograde abdominal aortography. American Journal of Roentgenology. 5 5 , 4 4 8 - 4 5 1 .
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Feigenbaum, L. & GroUman, J. H. (1980). Catheter separation in aorto-fernoral grafts despite wire protecttion. American Journal of Roentgenology, 134, 5 8 1 582. Gammill, S. & Graighead, C. (1975). Translumbar aortography updated. Surgery, Gynaecology and Obstetrics, 140, 59-64. Mani, R. L. & Costin, B. S. (1977). Catheter angiography through aorto-femoral grafts: prevention of catheter separation during withdrawal. American Journal of Roentgenology, 128, 328-329. Marks, W. M., Akin, S. R., Eisenberg, R. L. & Gooding, G. A. W. (1977). Direct puncture and angiographic evaluation of axillary-to-femoral bypass grafts. British Journal of Radiology, 50, 256-260. Weinshelbaum, A. & Carson, S. N. (1980). Separation of angiographic catheter during arteriography through vascular graft. American Journal of Roentgenology, 134, 583-584.
0009-9260/81/01650117502.00
© 1981 Royal Collegeof Radiologists
A Simple Angiographic Method for Assessing Aorto-femoral Bypass Grafts N. C. GOURTSOYIANNIS and E. W. L. FLETCHER §
Department of Radiology, University o f Oxford, John Radcliffe Hospital, Headington, Oxford Direct puncture of femoral bypass grafts in the groin with retrograde injection of contrast was employed to assess the lower abdominal aorta, iliac and lower limb arteries. The technique was effective, simple, quick and safe.
The frequent use of dacron as a material for replacing diseased blood vessels has resulted in the angiographer being asked to perform investigations involving such grafts. The most frequent area of investigation is in the lower limbs and many such patients have had both femoral arteries grafted. Some of these patients may be investigated by the axillary route or by high translumbar puncture. The percutaneous catheterisation of the dacron grafts has also been employed (Eisenberg et al., 1976; Marks et al., 1977). We have used a very simple technique employing a Sheldon cannula to demonstrate both the lower abdominal aorta and the vessels to the lower limbs in patients with aorto-femoral grafts. MATERIAL AND METHOD
During 1978-79 five patients with severe arteriopathy who had bilateral dacron trouser grafts extending from the aorta to the superficial femoral arteries were referred for lower limb angiography. A Sheldon* cannula was inserted into the dacron graft in the groin, above the suture line but below the inguinal ligament. If possible an anterior wall puncture only was performed, although the dacron was so tough that the sudden movement of the cannula through the anterior wall resulted in the cannula puncturing the posterior wall in two patients. The cannula was threaded into the lumen of the dacron graft, using the short Sheldon guide wire. Fiftyfive millilitres of Urografin 76 was injected at a rate of 18ml/s using a Medradt injector with the maximum pressure set at 450 lb/in 2. A series of tNms was taken of the lower abdomen, pelvis and lower limbs, using a Puck serial changer and an automatic moving table top. Films were taken *V. J. MiUard,36, Highgate Hill, London N19 5NL. t Medrad mark IV Angiographic Injector, Wolverson X-ray and Electro-medical Ltd, Walsall Street, Willenhall, West MidlandsWV1 32DY. § Reprints from E.W.L. Fletcher.
1.5 s (aorta), 4 and 5 s (pelvis), .7s (thigh)~ 9, 10.5, 12 and 13.5 s (knee and lower leg) after the injection of contrast medium. Two patients required a second injection of contrast with a slower series of films. RESULTS The technique produced good visualisation of the lower abdominal aorta, iliac and lower limb vessels of both sides in all five patients (Figs 1, 2). No complications of the procedure were encountered. DISCUSSION
Bron (1971) advised the use of the left axillary approach to the abdominal aorta in patients with aorto-femoral bypass grafts despite the presence of strong femoral pulses. Lower limb aortography is often difficult in these patients as the axillary arteries are affected by generalised arteriopathy. High translumbar puncture is more difficult and possibly more hazardous than the standard technique (Gammill and Graighead, 1975) and usually requires general anaesthesia in patients in whom general anaesthesia carries an increased risk. Furthermore our experience with over 100 high translumbar aortograms leads us to believe that the details of lower limb vessels is inferior to that obtained by retrograde femoral aortography through a cannula. Patients may be investigated by inserting a catheter directly into the dacron graft in the groin with good results (Eisenberg et al., 1976). However, the procedure may be complicated by a part of the catheter becoming detached in the graft when the catheter is being removed at the end of the examination (Mani and Costin, 1977; Feigenbaum and Grollman, 1980; Weinshelbaum and Carson, 1980). Mani and Costin (1977) suggested that reinsertion of the guide wire before removing the catheter would prevent this complication, but Feigenbaum and
118
CLINICAL RADIOLOGY
Fig. 1 - The abdominal aorta is shown by injection of contrast through a Sheldon cannula inserted into the dacron graft in the right groin. The left external iliac part of the dacron trouser graft is occluded.
Fig. 2 - Same patient as shown in Fig. 1. The left femoral and popliteal arteries are weU filled through collateral vessels. Two runs were performed as the flow of contrast down the left leg was much slower than on the right. The lower limb arteries were well shown from the level of L3 vertebra to the ankles.
Grollman (1980) encountered problems in two patients despite the reinsertion of the guide wire; one patient requiring surgical removal of 5 cm of broken catheter from the graft. Weinshelbaum and Carson (1980) lost 10cm of catheter in a graft because the catheter could not stand the torque stresses placed upon it during manipulation through the tough fibrous tissue round the graft, and the high friction between the catheter and the graft. Retrograde aortography has been used extensively to investigate lesions of the heart and thoracic aorta by inserting a needle into the exposed brachial artery (Catellanos and Pereiras, 1950; Abrams, 1971). There are fewer reports of perfemoral retrograde aortography but Castellanos and Pereiras (1939, 1950) and Farinas (1946) produced excellent radiographs of the abdominal aorta and its branches by this technique.
We have found that percutaneous direct puncture of the aorto-femoral graft is the quickest and easiest method o f performing lower limb aortography in patients with aorto-femoral bypass grafts. The dacron graft is usually straight so that the Sheldon cannula directed retrogradely will result in contrast easily reaching the lower abdominal aorta and showing all the arteries in both lower limbs. The technique is extremely easy and safe to perform, avoiding the complications sometimes encountered when manipulating a catheter through a dacron graft.
Acknowledgements. We would like to thank Miss Y. Williams for typing the manuscript and the Meidcal Illustration Department of the John Radcliffe Hospital for the photographs.
ASSESSING A O R T O - F E M O R A L BYPASS G R A F T S REFERENCES Abrams, H. L. (1974). Angiography, Vol. 1, p. 288. Little, Brown & Company. Bron, K. M. (1971). Femoral arteriography. In Ang~ography, ed. H. Abrams, pp. 1223-1225. Little, Brown & Company. CasteUanos, A. & Pereiras, R. (1939-40). Revista de la sociedad cubana de cardiologiea. Quoted by Castellanos and Pereiras (1950). American Journal of R oentgenology, 134, 559. Castellanos, A. & Pereiras, R. (1950). Retrograde or countercurrent aortography. American Journal of Roentgenology, 68, 559-565. Eisenberg, R. L., Mani, R. L. & McDonald, J. C. E. S. (1976). The complication rate of catheter angiography by direct puncture through aorto-femoral bypass grafts. American Journal of Roentgenology, 126, 814-816. Farinas, P. L. (1946). Retrograde abdominal aortography. American Journal of Roentgenology. 5 5 , 4 4 8 - 4 5 1 .
119
Feigenbaum, L. & GroUman, J. H. (1980). Catheter separation in aorto-fernoral grafts despite wire protecttion. American Journal of Roentgenology, 134, 5 8 1 582. Gammill, S. & Graighead, C. (1975). Translumbar aortography updated. Surgery, Gynaecology and Obstetrics, 140, 59-64. Mani, R. L. & Costin, B. S. (1977). Catheter angiography through aorto-femoral grafts: prevention of catheter separation during withdrawal. American Journal of Roentgenology, 128, 328-329. Marks, W. M., Akin, S. R., Eisenberg, R. L. & Gooding, G. A. W. (1977). Direct puncture and angiographic evaluation of axillary-to-femoral bypass grafts. British Journal of Radiology, 50, 256-260. Weinshelbaum, A. & Carson, S. N. (1980). Separation of angiographic catheter during arteriography through vascular graft. American Journal of Roentgenology, 134, 583-584.