Human Anatomy, Part 2 - K. A. Diubenko, A. K. Kolomiitsev, Yu. B. Chaikovsky 2008

Special Part
Cardiovascular system, systema cardiovasculare - Venous system
Veins of the systemic circulation - X-ray examination of blood vessels

X-ray Examination of Blood Vessels — angiography [vasography] (from Greek angeion — vessel, grapho — to write) — is performed following the administration of contrast agents. Angiography is conducted for diagnostic purposes to detect Vascular System anomalies and disorders, as well as tumor involvement in specific Organs. It enables the evaluation of topographo-anatomical vascular features, their functional state, blood flow velocity, and collateral pathways.

Angiography utilizes Water-soluble triiodinated agents (such as Shpak's solution, Urografin, Verografin, Triodtrast, and others), administered via percutaneous puncture or by introducing a special radiopaque catheter using the Seldinger technique. These catheters are flexible and retain their pre-shaped curvature within the vascular lumen, allowing them to be guided into a specific blood vessel.

In recent years, angiography has incorporated image intensifiers with television equipment, providing sharp vascular imaging while significantly reducing the patient's radiation exposure.

Clinical practice utilizes several distinct types of angiography:

1. Coronary angiography — real-time visualization of The Heart vessels.

2. Angiopulmonography — examination of pulmonary artery branches following contrast enhancement.

3. Aortography — examination of the aortic segments (ascending, arch, thoracic, abdominal) and major abdominal Arteries.

4. Carotid angiography — visualization of the cerebral vascular system after injecting a contrast agent into the carotid artery.

5. Vertebral angiography — visualization of the cerebral vascular system after injecting a contrast agent into the vertebral artery.

6. Renal angiography — examination of the renal vessels.

7. Pelvic angiography — examination of the pelvic organs' vasculature.

8. Phlebography — examination of Veins.

1. Coronary angiography — X-ray examination of the heart chambers and great vessels following the Introduction of a contrast agent into the bloodstream (Fig. 88 A; B). Angiocardiography is widely used to diagnose congenital and Acquired heart defects and great vessel anomalies. It allows for the identification of The Nature and localization of the defect, as well as associated hemodynamic changes, thereby facilitating the Selection of the most rational Surgical Treatment strategy. High-concentration aqueous solutions of organic iodine compounds are used to contrast the heart chambers and vessels, including Hypaque, Urokon, Urografin, and Triodtrast.

2. Angiopulmonography — X-ray examination of pulmonary artery branches following contrast administration. It is indicated when pulmonary developmental anomalies, pulmonary vascular lesions, or Pulmonary Embolism are suspected, as well as to assess the functional integrity of lung tissue.

3. Renal angiography — X-ray imaging of the Kidney and its blood vessels following the administration of a radiopaque agent (Fig. 89). Renal angiography is employed to evaluate the state of the Kidneys and their vasculature when conventional X-ray Methods fail to determine the nature and localization of the pathological process, or when the feasibility and scope of surgical intervention remain unclear. Renal angiography has become paramount in the detection and Cytology/practical/136.html">Differential Diagnosis OF various renal and perirenal tissue disorders, malignant and benign tumors, cysts, Hydronephrosis, as well as Traumatic injuries of renal vessels of diverse Etiology.

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Fig. 88 A. Angiogram of the left coronary artery in the anteroposterior projection (Amosov National Institute of Cardiovascular Surgery)

Fig. 88 B. Angiogram of the left coronary artery in the lateral projection (Amosov National Institute of Cardiovascular Surgery)

4. Pelvic angiography — a contrast X-ray method for examining pelvic blood vessels (Fig. 90). It is most widely used in diagnosing tumor and vascular lesions of the lesser pelvis. Pelvic angiography is also utilized during pelvic artery catheterization, reconstructive Procedures, and catheter-based vascular embolization. A distinction is made between pelvic arteriography and phlebography. Pelvic arteriography is used to clarify the localization, nature, and extent of lesions in the iliac arteries and their branches. The Procedure involves femoral artery puncture followed by retrograde catheterization of the iliac arteries and aorta via the Seldinger technique. Depending on the diagnostic objective, practitioners may perform a common pelvic arteriography by injecting the contrast medium into the Abdominal Aorta above the bifurcation, or administer the contrast agent simultaneously or sequentially into the common iliac arteries on both sides, followed by selective arteriography of the pelvic vessels: contrast enhancement of the internal iliac, uterine, or ovarian arteries.

Fig. 89. Renal angiogram

Fig. 90. Pelvic angiogram

Selective arteriography of the internal iliac arteries (unilateral or bilateral) or superselective arteriography of its branches is performed to visualize small intraorgan Vessels of the Uterus, Ovaries, Prostate Gland, Urinary Bladder, and Penis.

5. Phlebography (from Greek phlebs — vein, and grapho — to write, to image) is an X-ray examination method of veins using artificial contrast enhancement (Figs. 85, 86). Phlebography is used to examine the Structure and function of veins, as well as to diagnose their pathological conditions (thrombophlebitis, thromboembolism, impaired patency of major venous collectors, vascular injuries, and congenital vascular malformations and anomalies).

Depending on the route of contrast administration, the following types of phlebography are distinguished: direct, indirect (retrograde), visceral, transorgan catheter-based, intraosseous, and others. In direct phlebography, a radiopaque contrast agent is injected into a superficial vein either by direct puncture or via percutaneous catheterization using the Seldinger technique. Upon injection, the contrast medium mixes with the blood and circulates with the blood flow, allowing for the sequential opacification of small peripheral veins, medium-sized veins, large veins, and ultimately the venae cavae. Indirect venous opacification is achieved during the venous phase of angiography by injecting a radiopaque agent into an artery; the contrast medium first passes through the capillary bed and reaches the veins within 6-8 seconds (retrograde phlebography). The time of appearance and The rate of clearance of the radiopaque substance in the veins provide valuable insight into the regional hemodynamics of the given vascular bed.

Fig. 91. Selective cerebral angiography (by V. I. Shchehlov and Ye. O. Annin). (Clinic of Endovascular Surgery)

A — Right-sided selective cerebral angiography. Arterial phase. Anteroposterior projection. Arteries of the vertebrobasilar basin. B — Right-sided selective cerebral angiography. Arterial phase. Anteroposterior projection. Course of the trunks and Branches of the Internal Carotid Artery. C — Selective cerebral angiography. Arterial phase. Lateral projection. Internal carotid artery and its intracranial branches. D — Selective cerebral angiography. Arterial phase. Lateral projection. Internal carotid artery and its intracranial branches.

Pelvic phlebography is performed to diagnose pelvic venous disorders (developmental anomalies, thrombosis, varicosities, etc.). Pelvic phlebography can be carried out using several methods: intravenous administration of a contrast agent into the femoral veins or the great saphenous VEINS OF THE thigh, as well as percutaneous injection of the contrast medium into the cancellous bone of the pubic or ischial bones (intraosseous phlebography).

7. Cerebral angiography (from Latin cerebrum — Brain, Greek angeion — vessel, and grapho — to write) is an X-ray imaging method used to examine The vascular system of the brain through contrast enhancement (Figs. 26, 91). Cerebral angiography was first performed clinically in 1927 by E. Moniz via injection of a contrast medium into the common carotid artery, and in 1933 he achieved visualization of the vertebrobasilar system by injecting contrast into the vertebral artery.

Fig. 92. Carotid angiogram (extracranial and intracranial segments). (Clinic of Endovascular Surgery)

Cerebral angiography allows for the detection of arterial and arteriovenous aneurysms, stenosis, thrombosis, embolism, rupture of cerebral vessels, abscesses, and epiduritis. A distinction is made between selective cerebral angiography, which enables the visualization of specific vascular territories of the brain, and general approaches. It can be performed by selectively administering a radiopaque agent into the carotid artery (carotid angiography) and the vertebral artery (vertebral angiography). Total angiography is used for an Overview examination of the major cerebral vessels by injecting the contrast medium into the aortic arch. Catheterization of the cerebral vessels is performed under fluoroscopic guidance using specialized X-ray equipment (serial angiographs). To obtain high-quality images, pharmacoangiography with the administration of vasoactive agents is employed.

A). Carotid angiography (from Latin carotis, carotidis [arteria] — carotid artery, Greek angeion — vessel, and grapho — to write) is a contrast-enhanced X-ray examination method of the vascular System of the HEAD, brain, and neck* (Fig. 92). It is used to diagnose Developmental Anomalies and Vascular Diseases of the Head and Neck. Angiography of both the external and internal carotid arteries is distinguished. Carotid angiography can be performed using the following techniques: direct puncture angiography of the common carotid artery, selective angiography of the external and internal carotid arteries, superselective (differential) angiography of the cerebral arteries or branches of the External Carotid Artery, and retrograde puncture and catheterization angiography via the carotid, brachial, inguinal, subclavian, and femoral arteries.

B). Vertebral angiography is a specialized interventional radiological procedure used to examine the vascular system of the brain, performed by filling the vertebral artery with a contrast medium followed by serial radiography. Vertebral angiography is widely used in specialized neurosurgical clinics for the identification and differential diagnosis of vascular lesions in the cervical spine, Spinal Cord, posterior cranial fossa, and occipital lobes of the brain. Three main approaches to vertebral angiography are used: direct puncture, retrograde, and catheterization techniques.

* Carotid angiography was first performed by Professor P. I. Dyakonov in 1897 on cadavers, and was introduced into clinical practice by E. Moniz in 1927.