John

R. Waugh,

MBChB,

Arteriographic in the DSA

FRACR

9*4412

Angiography,

9*442

complications,

9*#{149}444, 9*448

tion angiognaphy, 9*1 angiography, comparative

.

1992;

FRACR,

FRCR

articles in the nonradiobogy literature have reviewed arteriographic complications in patients being investigated for cerebrovascuban disease (1,2). The reviewed studies and complication rates rebate princi-

when

pally to the angiography

During underwent

ECENT

tional

pre-digital (DSA)

subtraction of conven-

era

film angiognaphy.

This

large

series

docu-

ments the prevalence of all types of complications associated with intraarteniab DSA (IA-DSA) in a major Austrabian teaching hospital.

9*122

182:243-246

AND

menced Intravenous routinely, tients (serum

METHODS

four hundred patients were

January

patient

1988 and October

undergoing

IA-DSA

the complications

study.

tions

in both

and

inpatients

ferred

included.

mainly

units,

but

hydration it was

Alfred

a strong

Contrast

eral limb angiographic graphic procedures

Patients meal

were

or early

breakfast

angiography.

Mild

before

underwent

(David

orally),

in the

renal

function,

known or an

The

a light

Mel-

volume, technical

Milwaukee)

performed or by

an

with (GE

(Table

1). The

under

a state-of-the-art

Medical

by the rostered intern

arterioSystems,

studies

were

staff radiologist

supervision.

Diag-

nostic studies were routinely performed with 5-F catheters after retrograde femorab artery

puncture.

with

a heparinized

between

injections

Catheters

were

normal

saline

of contrast

radiobo-

a data

sheet

recording

of the arteriomaterial type

size and changes,

difficulties,

and

during

any

the

and

any

complica-

The patient tored record uation

data sheet was then attached to the record. Patients were closely moniby ward staff, with the complication being completed after clinical evabby the hospital unit on the follow-

procedure.

Review by the referring unit was to reduce bias by nonblinded All new clinical events or find-

occurring

within

24 hours

were

to the arteriography,

complications

anesthesia were

fled as transient if they hours and as reversible

resolved if they

for more

but resolved

than

24 hours

at-

provided

had not undergone

or surgery. Neurologic per-

staff

apparent

the patient Studies

unit

the

tions

tnibuted

techniques,

(ie,

catheter

ings

DSA

(eg, cerelimb).

the type and duration graphic study, contrast

in all inpatients.

DF5000

to contrast

ischemic

angiographer

performed

graphic

allergy

clinical

morphine

were

were

of impaired

Collection

ing day. designed observers.

All types of arteriography formed, by means of standard

media

absence

on local considerations

irritation

bourne) also being used when clinically appropriate for intenventional procedures. Routine serum biochemistry tests were

Arteriographic

ionic contrast

routinely

procedure,

10; Roche,

Bull Laboratories,

DSA

Media

at the end of each

routine

with

venous

re-

undergoing was

performed in pa-

impairment mmol/L).

> 0.13

completed

on periph-

[Valium

Australia]

sulfate

Hospital

sedation

(10 mg of diazepam Sydney,

were

to have

renal

gist or the intern)

and neuroangio(Table 1).

allowed

was not encouraged

complications arising from are not included in this re-

used

Complica-

emphasis

corn-

the same period, 260 patients conventional film angiography

86 patients

Data

was

the end of the procedure.

with preexisting creatinine level

studies. Any these studies view.

bral

was revealed

infusion

excluded

407 outpa-

Patients

from

with

1990. No

was

from

were

seventystudied be-

stenosis

a heparin

after

material,

Two thousand five consecutive

tients

From the Department of Radiology, Alfred Hospital, Commercial Road, Prahnan, Victoria 3181, Australia. Received January 3, 1991; revision requested February 4; revision received July 15; accepted August 2. Address reprint requests to J.R.W. 9* indicates generalized vein and artery involvement. ,- RSNA, 1992

carotid

IA-DSA,

Conventional MATERIALS

subtnac-

subtraction

a tight

with

and

prospective

Patients

#{149} Digital

Digital studies,

R

tween Radiology

MBBS,

Era’

data were collected on associated with intraartenal digital subtraction angiography in 2,475 consecutive patients at a 650-bed Melbourne teaching hospital. Carotid or cerebral studies were performed in 939 patients, and the prevalence of stroke (ie, permanent neurologic deficit) was 0.3%. The overall prevalence of systemic cornplications was 1.8%, with no patients requiring hemodialysis because of renal failure. Comparison was made with previously reported complication rates for conventional film angiography. terms:

Sacharias,

Complications

Prospective complications

Index

#{149} Nina

classi-

within persisted

24

within 10 days. Any new neurologic icit persisting for more than 10 days

defwas

regarded

as a

stroke

as permanent for

the

Abbreviations: giography,

IA

and defined

purpose

of this

study.

flushed solution

material;

DSA =

=

digital

intraarterial,

subtraction

IV

=

an-

intravenous. 243

Table 1 Types of Artenographic

Table Procedures

Cerebral

No.of Patients

Type =

Carotid

Prevalence

lesiont Selective interventional cerebral diagnostics

interventionalt Total

Arch

*

300

12.1

622

25.1

Complication Type

17 1,252 284

0.7 50.6 11.5

Local Systemic

intracranial

2,475 only,

69%; selective, arteriovenous

t Aneurysm,

Neurologic

31%. malformation,

tumor, and others. * All peripheral limb studies, others. § Angioplasty, embolization,

renal

studies,

and others.

Acute renal dysfunction was defined increase of 50% on greater in serum

atinine

level (compared

reading)

to a level

mmob/L)

within

with

above

tients

the study

underwent

After

hours

the

procedure,

were

clini-

same radiology consent and

they

ininter-

by the obtained

viewed

in the morning.

them

received

detailed

structions,

verbal

in lay

on

(US),

written

in-

management

of

for

number

reporting

then

for any inquiries

complications.

taken

home,

and

their

referring

sequently

hospital

reported

any

ing or immediately it is unlikely that

tions

were

When

using

delayed

by sub-

complica-

conference. apparent

dur-

after arteriography (4), significant complica-

the

returned

for subsequent

this was considered examination. deficit data were Fisher

the complication and ent

who

overlooked.

a patient

angiography, rate patient Neurobogic by

any

were

Outpa10 days

clinician,

tion at the radiology review As most adverse effects are

selective indications

exact

frequency studies and for cerebral

test

a sepaanalyzed to compare

between between studies.

arch differ-

RESULTS We reviewed all complications occunning in 2,475 consecutive patients undergoing IA-DSA. These are prescnted in summary form in Table 2, with figures from the literature for conventional angiography provided 244

being

person

remained with them overnight. tients were usually seen within

#{149} Radiology

Angina Acute renal Death

6.18 0.20 0.00

11

0.44

10

0.40

I 1

0.04 0.04

17 10 6 4 3

0.69 0.40 0.24 0.20 0.16 0.12

3 3 3

0.Y 0.31 #{216}#{149}31

vasova(minor)

dysfunction

24 hI Other (eg, transient Neurologic deficit Transient ( 1 week) of our series of 939 carotid studies, the prevalence

days

has

rate

(5,6).

failure or required dialysis as a result of their angiographic studies. Acute renal dysfunction was found in five patients (0.20%) with preexisting ne-

were reported by the clinicians. The reported prevalence of delayed hemornhage after outpatient arteriography is bow; Wolfel et al documented one case in a series of 2,029 patients, which was controlled with compression at the arterial site (14).

DSA

the review

0.3%.

vascubopathy

(mean age, 75 years) who clinically stable condition

recently,

ct ab of eight prospective patients, 2,227) with

ventionab film 4% prevalence plications and

nized since the large series reported by Shehadi and Toniobo (13). Four patients (0.16%) died within 24 hours of their

More

by Hankey series (total

events,

including

were

at

cantly

studpunc-

tune site hematoma, is well rccognized, with retrospective studies tending to underestimate these events and place a heavier emphasis on deaths and major complications (1). In prospective studies in the literature, the prevalence of local complications varies from 4.1% to 23.2%

As in other

series,

local

compli-

cations-pnincipally hematomawere relatively common in our series but were without clinical consequence (ic, resulted in no additional surgery or therapy) in 99.3% of the patients. Bypass surgery after complicated balloon angioplasty represents the treatment patients would otherwise have received. Intravenous DSA (IV-DSA) has never been routinely used in our departmcnt for the demonstration of either carotid on peripheral arteries. IV-DSA can be associated with a high rate of systemic side effects, which were experienced by 15% and 44% of patients, respectively, in two series (21,22). Hankey ct al noted that this factor and imprecise resolution detract from the usefulness of IV-DSA in the investigation of carotid bifurcation disease (1). Katzcn et al commentcd in regard to outpatient femonab angiography that the limitations of IV-DSA were inconsistent with their goal of achieving the highest quality examination with the beast risk and with no need for repeat studies (23). While Stevens et ab reported a zero prevalence of stroke in oven 3,000 patients undergoing IV-DSA for suspected carotid disease (24), other authors have reported that IV-DSA does not necessarily prevent the complication of neurobogic deficit (21,22). Can complication rates be further reduced? Theoretically, some ncduction in systemic complications may be possible if more stringent patient selection criteria are applied. But, while elderly patients with vascubopathy remain operative candidates, the rebevance of stricter criteria (eg, cardiac history or age limit) would almost certainly be questioned by surgical colleagues. Routine use of pulse oximctry in this patient group would alert the radiologist to impaired oxygenation and would have the potential to reduce periarteniographic morbidity. Transient renal dysfunction was found in 0.20% of our patients, with no patients having permanent renal dysfunction or a major reaction to contrast material. It seems unlikely that these figures could be signifireduced

until

angiography-

which is performed with injection of nonphysiobogic material-is itself replaced by a noninvasivc imaging modality. Ncurobogic complications could likewise be reduced if only patients definitely proceeding to surgery (eg, carotid cndartcrcctomy) underwent arteriography or if antcriography could be replaced by a reliable noninRadiology

#{149} 245

2.

vasive imaging modality. Despite the widespread use of Doppler US, all patients who underwent carotid endarterectomy

at our

hospital

3.

during

the 34-month study period underwent artcnography before surgery. Similarly, Hankcy ct ab observed in 1990 that “almost all” United Kingdom surgeons require angiography to be performed before considering carotid endanterectomy (1).

4.

5.

SUMMARY This study emphasizes the safety of IA-DSA as an imaging modality, finding a bow rate of systemic and neurologic complications. The prevalence of local complications resulting in altered patient management was 0.7%, the majority of which resulted from interventional procedures. With IADSA and an appropriately trained staff, the complication of stroke can be anticipated

to occur

in less

than

1%

era

(1,2).

Acknowledgments: to Andrew

assistance cock

U

The authors

Watson,

with

MBBS,

and

data collection

for maintenance

7.

8.

9.

10.

11.

colleagues

of excellent

12.

radiographic

standards.

1.

Hankey

13. JH, Warlow

bral angiographic culan

246

disease.

#{149} Radiology

CP, Sellar

RJ.

Cere-

risk in mild cerebrovasStroke

1990;

21:209-222.

14.

angiography

the risks.

15.

Br

Sung 1988; 75:428-430. Cramer BC, Parfrey PS, Hutchinson TA, et al. Renal function following infusion of radiologic contrast material: a prospective controlled study. Arch Intern Med 1985; 145:87-89. Redman HC. Has the time for outpatient peripheral angioplasty come? AIR 1987;

16.

17.

Katzen BT. Peripheral, abdominal, and interventional applications of DSA. Radio! Clin North Am 1985; 23:227-241. Mani RL, Eisenberg RL. Complications of catheter cerebral arteriography: analysis of 5000 procedures. III. Assessment of arteries injected, contrast medium used, duration of procedure, and age of patient. AJR 1978; 131:871-874. Skalpe 10, Ankle IM. Complications in

148:1241-1242.

cerebral

Swanson PD, Calanchini PR, Dyken ML, et al. A cooperative study of hospital ftcquency and character of transient ischemic attacks. II. Performance of angiography among six centers. JAMA 1977; 237:22022206. Olivecrona H. Complications of cerebral angiography. Neuroradiology 1977; 14: 175-181. Reilly LM, Ehrenfeld WK, Stoney RJ. Carotid digital subtraction angiography: the

tween hexol

roles of intra-arterial

contrast

media.

diology 18.

N Engi I Med

320:149-153.

Faught

angiography: the non-ionic and meglumine

a comparison

be-

contrast medium iometrizoate. Neurora-

1983; 25:157-160. E, Trader

SD, Hanna

GR.

Cerebral

complications of angiography for ischemia and stroke: prediction of risk. Neurology 19.

1979; 29:4-15. Dawson P. Trewhella

contrast 20.

and in-

travenous imaging. Surgery 1984; %:909917. Mclvor J, Steiner TJ, Perkin GD, Greenhalgh RM, Rose FC. Neurological morbidity of arch and carotid arteriography in ccrebrovascular disease: the influence of contrast medium and radiologist. Br J Radiol 1987; 60:117-122. Earnest F, Forbes C, Sandok BA, et al. Complications of cerebral angiography: prospective assessment of risk. AJNR 1983; 4:1191-1197. Parfrey PS, Griffiths SM, Barrett BJ, et al. Contrast material-induced renal failure with diabetes mellitus, renal insufficiency, or both. N EnglJ Med 1989; 320:143-149. Schwab SJ, Hlatky MA, Pieper KS, et al. Contrast nephrotoxicity: a randomized controlled trial of a nonionic and an ionic 1989;

for

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disease:

radiographic

are grateful

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K, MuriejA.

for cerebrovascular

comparative

of

patients undergoing carotid or cerebral studies. A stroke rate of 0.3% was found in our patients, which contrasts with the results of two recent review studies suggesting stroke rates of 1% and 2.4%, respectively, with data drawn from the conventional film angiography

6.

Leow

21.

22.

23.

24.

agents

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January

1992