Chapter 20: Peripheral Angiography

PERIPHERAL ANGIOGRAPHY

Peripheral arterial disease (PAD) comprises a host of noncoronary arterial syndromes due to various pathophysiological mechanisms resulting in stenosis or aneurysms in various vascular beds. Atherosclerosis (AS) remains by far the most common cause of this disease process. According to the recently released ACC/AHA guidelines for the management of patients with PAD, it is a major cause of decrement of functional capacity, quality of life, limb amputation, and increased risk of death.¹

Millions of people worldwide are afflicted with this syndrome.^2,3 While awareness for coronary artery disease (CAD) has significantly increased in the last decade, the awareness, diagnosis, and treatment of PAD remain much underappreciated. With improvement in catheter-based and imaging technology, it was only natural that all specialties involved in the management of vascular disease would involve endovascular therapy of this potentially disabling and lethal disorder.^4,5,6

Excellent reviews on PAD are already available in the literature. The ACC/AHA guidelines, Trans Atlantic Society Conference (TASC) Working Group document,⁷ the ACC COCATS-2 Paper,⁸ provide the basic fundamental material for a physician interested in the management of patients suffering from PAD. Based on literature review and our own experience at the Washington Hospital Center, Washington, DC, and University of Louisville, Louisville, KY, we have tried to focus in this chapter on the general principles of performing invasive peripheral angiography. We have also briefly described noninvasive imaging modalities of computed tomographic angiography (CTA), magnetic resonance angiography (MRA), and carbon dioxide (CO₂) angiography as their utility relates to each vascular bed. The full details of these other modalities are, however, out of the scope of this chapter. We hope that this chapter will provide the basic understanding in catheter angiography to an operator interested in treating patients with PAD.

Training Requirements

There are considerable differences of opinion that exist among various specialties regarding the optimal training required before certifying operators to safely perform peripheral vascular procedures.^{9,10,11,12,13,14,15,16} Specialties including interventional cardiology, interventional radiology, vascular surgery, interventional neuroradiology, interventional nephrology, and interventional neurosurgery all possess basic and unique knowledge that positions them to advance their skills into peripheral angiography and interventions. The ACC COCATS-2 (Tables 20-1 and 20-2) provides guidelines for a cardiovascular trainee who wishes to be certified in the performance of such procedures.