B-24: Pulmonary Angiography
  • Indications
    • Intermediate or indeterminate V/Q scan
    • Low probability V/Q scan with high clinic suspicion for pulmonary embolus
    • Preoperative for chronic pulmonary embolism
    • Pulmonary arteriovenous fistula (i.e., Osler-Weber-Rendu)
  • Contraindications
    • Contrast allergy (premedicate)
    • Pulmonary hypertension with right ventricle end diastolic pressure > 20mmHg.
    • Left bundle branch block (requires temporary pacemaker)
    • Congestive heart failure (relative contraindication)
  • Patient Evaluation
    • Ability of lie supine, hold breath and cooperate with examination
    • Adequate renal function (contrast load of up to 300ml in 1 hr.)
  • Preprocedure Orders
  • Tools
    • Micropuncture or Seldinger needle
    • .038" movable core guide wire, .035" or .038" deflecting wire
    • Montepheur, Grollman, or other pulmonary catheter
    • Pressure transducer setup
    • Cut film
  • Entry site
    • Femoral vein
  • Technique
    • After venous entry, advance catheter over wire to right atrium. Withdraw wire to allow catheter curve to form. Rotate catheter to direct tip anteriorly through the tricuspid valve. EKG must be monitored closely during intracardiac catheter manipulations. The catheter must be withdrawn quickly if runs of PVC's occur. If the EKG is stable with the catheter in the right ventricle, pressure measurements can be obtained. If RVEDP is >20mmHg., the procedure should be aborted. If the catheter position is producing ectopy, advance the guide wire to straighten the back curve (but not the pigtail!) and rotate to direct the tip posteriorly through the pulmonic valve. Pressure measurements can then be made in the pulmonary artery. If pulmonary hypertension is present (i.e., pulmonary systolic pressure > 30mmHg.), technical modifications are needed. With moderate pulmonary hypertension (systolic pressure = 40-70mmHg.), forego a full volume main pulmonary artery injection. A 20ml main injection with high speed DSA will suffice to rule out central thrombus. The remainder of the study can be done with selective right and left pulmonary artery injections. In severe pulmonary hypertension (systolic pressure >70mmHg.) it is prudent to return to the right ventricle and obtain an end diastolic pressure measurement. The search for a pulmonary embolus should be exhaustive including main and selective left and right injections with both lungs evaluated in at least 2 projections. However, the study is terminated upon demonstration of an embolus.
  • Post-procedure Note
    • Record all pressure measurements obtained
  • Post-procedure Orders
    1. Resume previous medication and diet orders.
    2. Check and record vital signs (BP, HR, Respiratory Rate), _____groin puncture site for bleeding, hematoma, and check distal pulses (dorsalis pedis and posterior tibial)
      • q 15 min x 2, then
      • q 30 min x 4, then
      • q 1 hour x 4, then
      • q 4 hours if stable
    3. Bed rest x __ hr. keeping ____hip and leg straight (no flexion of hip) x 8 hr
    4. May turn slightly (less than 30°) to side of puncture after 2 hr - log-roll with assistance
    5. May elevate HOB 30 after 6 hr
    6. May have BRP with assistance after 8 hr (check puncture site after ambulating)
    7. Notify H/O if any changes occur

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