Chapter 3: Approach to Patients with Extracranial Carotid Artery Disease

Video 3.1 (Still Frame): B-mode image of the right internal carotid artery (ICA) showing a small calcified plaque at the origin of the ICA (white arrow) and a severe, homogenous plaque (outlined by red dots) at the proximal right ICA causing luminal narrowing (red arrow).

Video 3.2 (Still Frame): Duplex ultrasound of the right internal carotid artery (ICA) showing markedly elevated velocities in the proximal right ICA, with peak systolic velocity of 541 cm/sec and an end diastolic velocity of 155 cm/sec. These velocities are consistent with a severe (80%‒99%) stenosis. There is color aliasing on color Doppler indicative of turbulent blood flow, a finding suggestive of hemodynamically significant narrowing.

Video 3.3 (Still Frame): Duplex ultrasound of the right external carotid artery (ECA) showing laminar flow on color Doppler and a high resistive signal on spectral Doppler with little to no diastolic flow. The ECA can be differentiated from the ICA by 3 characteristics: high resistive spectral Doppler signal, evidence of branch vessels (*), and demonstration of a Doppler signal when the temporal artery is tapped during imaging (positive “temporal tap” sign) (arrows).

Video 3.4: Color Doppler of the right external carotid artery (ECA) and right internal carotid artery (ICA) showing marked color turbulence both at and beyond the point of luminal narrowing by severe homogenous plaque in the ICA. In contrast to the turbulence seen in the ICA, the ECA shows pulsatile laminar flow.


Chapter 7, Abdominal Aortic Aneurysms: Diagnosis and Catheter-Based Approaches

Video 7.1: Angiogram obtained prior to EVAR.

Video 7.2: Completion angiogram obtained after EVAR.

Video 7.3: Angiogram showing deployment of main body of endograft.


Chapter 12: Technical Issues: Arterial Access, Anatomy, Performing Diagnostic Angiography, Catheters, Guidewires, Balloons, and Stents

Video 12.1: Example of parallax. The fluoroscopic loop demonstrates the hemostat appearing to move “over the femoral head” with movement of the table. When using fluoroscopic guidance, the hemostat should always be positioned in the center of the field of view to minimize the effects of parallax.

Video 12.2: Example of the importance of arm maneuvers during venography, when evaluating for thoracic outlet syndrome. This venogram demonstrates left subclavian vein compression in a patient with Paget-Schroetter syndrome, status post catheter- directed thrombolysis.

Video 12.3: Example of the importance of a “bent leg” angiogram when stenting the femoropopli- teal segment. This fluoroscopic loop demonstrates dramatic foreshortening and kinking of a highly calcified, superficial femoral artery distal to a self- expanding stent.

Chapter 14: Infrainguinal Intervention

Video 14.1: A 70-year-old man complains of severe, bilateral calf pain after walking one block. Angiography of the right lower extremity shows an occluded proximal superficial femoral artery that reconstitutes at Hunter’s canal via collaterals from the profunda femoris. There is one-vessel runoff from the peroneal artery.

Video 14.2: A 4-Fr Glide catheter is advanced over a Glidewire to the level of Hunter’s canal. The wire remains in the subintimal space. An Outback reentry catheter is delivered over a stiff 0.014-inch wire to just beyond the level where the SFA reconstitutes. The angiogram shows that the reentry catheter remains outside the true lumen.

Chapter 14 Still Frames: The Outback needle is deployed and the true lumen entered (a). The 0.014-inch wire is advanced. A 2.0-mm balloon is inflated at the reentry point to facilitate passage of a Glide cath- eter, which is delivered to the popliteal artery (b). Contrast injection confirms that the catheter is within the true lumen. The wire is exchanged for a 0.035-inch wire to provide more support for the remainder of the intervention. Balloon angioplasty of the SFA is performed (c), followed by placement of 2 self-expanding stents.

Video 14.3: Completion angiography showing widely patent superficial femoral artery.


Chapter 16: Acute Limb Ischemia and Thrombolysis (videos for the Chapter 16 Case Study)

Video 16.1A:  A 55 y/o man presented with sudden onset of right hand pain and pallor in the right index and ring fingers. Diagnostic angiography showed normal appearance of the innominate, subclavian and axillary arteries. Angiogram of the distal brachial artery and its bifurcation (Video 1A) showed normal flow in the ulnar and interosseus arteries. The flow in the radial artery is markedly delayed. Video 1B showed angiography of the distal forearm. The ulnar artery fills the palmar arch. The radial artery is occluded at the wrist. Angiogram of the hand after administration of vasodilators (Video 1B) showed a filling defect and occlusion of the radial artery and reduced perfusion of the index and ring fingers. Further evaluation revealed a patent foramen ovale as a possible cause of acute arterial embolism.

Video 16.1B

Video 16.1C

Video 16.2A: A 70 y/o man with prior history of left femoro-popliteal bypass graft presented with acute onset of pain in the right foot and calf. Clinical exam was consistent with acute limb ischemia and presumed graft thrombosis. Angiogram of the left common femoral artery (Video 2A) showed patent common femoral and profunda femoris arteries. A vestigial stump of the bypass graft is seen originating medially from the common femoral artery. The profunda collaterals did not reconstitute infrapopliteal vessels. Video 2B shows positioning of the rheolytic thrombectomy catheter in the proximal graft. Pulse-spray thrombectomy re-established flow through the graft and revealed residual thrombus in the distal popliteal artery (Video 2C). Despite the residual thrombus in the popliteal artery, pedal perfusion is restored (Video 2D and 2E), allowing addition catheter directed thrombolysis. After 12 hours of therapy, brisk arterial flow is reestablished through the proximal, mid and distal graft segments (Video 2 F,G,H) and in the popliteal artery.

Video 16.2B

Video 16.2C

Video 16.2D

Video 16.2E

Video 16.2F

Video 16.2G

Video 16.2H