Outpatient DSA in Cerebrovascular Disease Using Transbrachial Arch Injections

Abstract

Experience with intravenous digital subtraction angiography (DSA) has proven disappointing in the outpatient evaluation of cerebrovascular disease. Vessel superimposition, patient motion, and poor vascular opacification all prevent definitive studies in a significant percentage of patients. These problems were addressed by turning to an intraarterial outpatient DSA technique composed of several elements: (1) right transbrachial catheterization of the ascending aorta using a thin, multiple side-hole, straight catheter; (2) arch injections of relatively small volumes of contrast material; (3) pulsed digital image acquisition with multiple projections; and (4) a limited period of postprocedure observation. A total of 43 outpatients and 16 inpatients was studied in this manner with only two complications, both local. Images of definitive quality and completeness were obtained in 82%–98% of cases, and included the major intracranial as well as the extracranial vessels and their circulatory dynamics. Because the iodine load per injection was relatively low, up to 10 angiograms per case were available for delineating superimposed anatomy and motion degradation. Variations in cardiac output had little impact on image quality, and the average case required less than 60% of the contrast load routinely used for intravenous DSA. The transbrachial approach proved as safe and convenient as intravenous DSA but was more thorough and dependable.