Standards of Practice

Quality Improvement Guidelines for Adult Diagnostic Cervicocerebral Angiography: Update Cooperative Study between the Society of Interventional Radiology (SIR), American Society of Neuroradiology (ASNR), and Society of NeuroInterventional Surgery (SNIS)

Preamble

The membership of the Society of Interventional Radiology (SIR) Standards of Practice Committee represents experts in a broad spectrum of interventional procedures from both the private and academic sectors of medicine. Generally, Standards of Practice Committee members dedicate the vast majority of their professional time to performing interventional procedures; as such, they represent a valid broad expert constituency of the subject matter under consideration for standards production.

Methodology

SIR produces its Standards of Practice documents using the following process. Standards documents of relevance and timeliness are conceptualized by the Standards of Practice Committee members. A recognized expert is identified to serve as the principal author for the standard. Additional authors may be assigned dependent upon the magnitude of the project.

An in-depth literature search is performed by using electronic medical literature databases. Then, a critical review of peer-reviewed articles

Definition and Procedural Overview

Cervicocerebral catheter angiography is a process by which intracranial and extracranial head and neck vasculature, hemodynamics, and pathologic conditions are evaluated. It consists of placement of a catheter selectively into extracranial cervical vessels under fluoroscopic guidance, followed by serial/sequential image acquisition during intravascular injection of contrast material to delineate anatomy of interest and to identify pathologic conditions. The catheter is usually inserted via a

Indications

Imaging of cerebrovascular disease has evolved into a multimodal, multiparametric model in which noninvasive imaging techniques such as CT angiography and MR angiography are complemented by CCA depending on the indication and individual patient situation. Also, it should be noted that the utility of CCA may vary based on locally available tools, technique, and expertise in each institution. Indications for CCA may include the following (1, 4, 6, 7, 8, 28, 41, 64, 65, 66, 67, 68, 69, 70, 71, 72,

Contraindications

There are no absolute contraindications to adult diagnostic CCA. Relative contraindications include iodinated contrast media allergy, hypotension, severe hypertension, coagulopathy, renal insufficiency, and congestive heart failure. Patients should be screened for these predisposing and perpetuating risk factors and conditions, and every effort should be made to control or correct them periprocedurally (43, 161).

Success Rate

A successful examination is defined as sufficient selective technical evaluation and image interpretation to establish or exclude pathologic conditions of the extracranial and intracranial circulation. Successful CCA routinely is performed in one session. Rarely, more than one session may be necessary because of limitation of vascular access, contrast media dose limit, patient intolerance, inadequate anesthesia, or comorbid illness such as congestive heart failure, which prevents prolonged

Complications

The complications of CCA can be divided into neurologic complications specific to this procedure and complications associated with catheter angiography in general (Table 1) (42, 58, 59, 143, 149, 161, 166, 167, 168, 169, 170, 171, 172, 173, 174, 175, 176, 177, 178, 179, 180, 181, 182, 183, 184, 185, 186, 187, 188, 189, 190, 191, 192, 193, 194, 195, 196, 197, 198, 199, 200, 201, 202, 203, 204, 205, 206, 207).

Overall Procedure Threshold

The overall procedure threshold for major complications resulting from adult diagnostic cervicocerebral angiography is 2%. This threshold refers to any complication that requires additional therapy, results in prolonged hospitalization, or causes permanent adverse sequelae as defined in Appendix B.

Consensus Methodology

Reported complication-specific rates in some cases reflect the aggregate of major and minor complications. Thresholds are derived from critical evaluation of the literature, evaluation of empirical data from Standards of Practice Committee members’ practices, and, when available, the SIR HI-IQ System national database.

Consensus on statements in this document was obtained by using a modified Delphi technique (208, 209).

SIR Disclaimer

The clinical practice guidelines of the Society of Interventional Radiology attempt to define practice principles that generally should assist in producing high quality medical care. These guidelines are voluntary and are not rules. A physician may deviate from these guidelines, as necessitated by the individual patient and available resources. These practice guidelines should not be deemed inclusive of all proper methods of care or exclusive of other methods of care that are reasonably

Acknowledgments

Joan C. Wojak, MD, authored the first draft of this document and served as topic leader during the subsequent revisions of the draft. T. Gregory Walker, MD, and James Silberzweig, MD, are cochairs of the SIR Standards of Practice Committee, and Sean R. Dariushnia, MD, is the chair of the SIR Revisions Subcommittee. Boris Nikolic, MD, MBA, is Councilor of the SIR Standards Division. All other authors are listed alphabetically. Other members of the Standards of Practice Committee and SIR who