RADIOLOGY
`
`A MONTHLY JOURNAL DEVOTED TO CLINICAL RADIOLOGY AND ALLIED SCIENCES
`
`EDITOR
`
`Howard P. Doub, MD.
`Detroit, Michigan
`
`Llil
`J‘FK.
`
`Vqume 85
`
`JuIy—December 1965
`
`Owned and Published as its Official Journal by
`
`THE RADIOLOGICAL SOCIETY OF NORTH AMERICA
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`Copyrighted, 1965, by the
`Radiological Society of North America, Inc.
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`VOL. 85 NO. 2
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`Radiology
`
`AUGUST 1965
`
`0 monlhly journal devoled to clinical radiology and allied sciences
`PUBLISHED BY THE RADIOLOGICAL SOCIETY OF NORTH AMERICA, INC.
`
`
`
`Guided Catheterization of the Bronchial Arteries
`Part I:
`Technical Considerations1
`
`MANUEL VIAMONTE, IR, M.D., RAYMOND E. PARKS, M.D., and WILLIAM M. SMOAK, III, MD.
`
`ELEcrn-‘E catheterization of small vascu—
`
`lar branches; is easily accomplished since
`the development of especially constructed
`catheters with minute tips, optimal torque
`control, and tip deflection by external
`manipulation (5). We have called this
`technic “guided angiography.”
`Explora—
`tion of the bronchial arteries by this method
`has been prompted by recognition of the
`part these small arteries play in diseases
`of
`the bronchial
`tree and mediastinal
`
`organs and in abnormalities of the pul-
`monary arterial
`circulation. The pro-
`cedure and preliminary findings in guided
`eatheterization of
`the bronchial arteries
`
`were reported earlier (6). Our experience
`with a larger group of cases has enhanced
`our knowledge and technic, and it is the
`intent of this paper to expand on these
`technical considerations and mention some
`
`of the pitfalls encountered in the procedure
`and its interpretation.
`
`TECHNICAL CONSIDERATIONS
`
`l
`
`mflamwfl—
`
`'
`
`Despite the variability in number and
`site of origin (Fig. 1), selective catheteriza—
`tion of bronchial arteries is easily ac—
`complished, especially With the catheter—
`deflector assembly previously mentioned.
`'Frmn the Department of Radiology. University of Miami School of Medicine, Jackson MIemorial Hospital,
`Miflmi. Fh‘L. 1M. \'.. Associate Professor of Radiology; R. E. P., Professor and Chairman of Radiology; W. M. 5.,
`instructor of Radiology }_
`Presented in part :tt the Fifth-ill Annual Meeting of the Radiological Society of North America, Chicago, 111,
`Km: flea-Dec. 4, mus-1.
`This \rnrk ha? been sponsored in purl by NIH Grant No. HE 08546-011“ and the American Cancer Society
`[\V. NI
`5'3.
`\
`
`Fig. 1. Diagram showing levels of origin of the right
`and left bronchial arteries and of common trunks
`(central circles) that were studied. Lateral circles indi—
`cate the number of lesions studied on each side.
`In the
`squares are the number of bilateral lesions.
`In the
`triangles, the number of midline lesions is indicated.
`NOTE: First 71 studies.
`
`205
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`New Instruments for Catheterization and Angiocardiography1
`B'iORN NORDENSTR‘OM, M.D.
`
`N ONTINUOUS improvements of the instru—
`(/ ments used in angiocardiography are
`of great importance for the extension of
`possibilities of examination and for the
`safety of such examination.
`CATHETERS FOR THE INJECTION OF
`CONTRAST MEDIUM INTO THE RIGHT AND
`LEFT VENTRICLES
`
`Some of the risks connected with the
`selective injection of contrast medium into
`the heart cavities have been discussed in
`earlier works (1, 3). Under certain'condi—
`tions quick injections of contrast fluid into
`the heart cavities may result in a perfora—
`tion of the heart wall by the jets of con
`trast material (4). This appears to be the
`case when a catheter with open terminal
`hole is used and its tip is resting against the
`wall of
`the heart. The axially flowing
`stream of fluid through the tip of the cathe—
`ter seems to have considerable penetrative
`force. Further,
`the stream through the
`terminal hole may easily cause an apprecia—
`ble recoil of the catheter, so that the con,
`trast medium may be deposited at a point
`in the heart or in a vessel other than that
`intended. The recoil of the catheter, if it
`takes place in a ventricle, may also give
`rise to rhythm disturbances of the heart.
`Such considerations led to the construc-
`tion of the so—called recoil—proof catheter
`(2) with multiple lateral holes near the
`completely closed tip.
`In this way it was
`possible to practically eliminate the recoil
`of the catheter even with a quick injection
`of contrast medium. Because the tip of
`the catheter is closed, however, it is not
`possible to introduce it with the percutane-
`ous catheterization technic of Seldinger
`(5). As the percutaneous catheterization
`technic has offered many advantages, the
`author has in recent years been using
`catheters with terminal hole and multiple
`
`
`lateral holes near the tip, while the recoil—
`proof catheter with closed tip has been
`used only sporadically.
`A possibility of closing the terminal hole
`of a catheter introduced percutaneously
`(Seldinger
`technic) has been communi—
`cated by Tornvall (6). He introduces in
`the lumen of the catheter a steel wire,
`terminally provided with a knob or cylinder
`occluding the terminal hole. The draw—
`backs of this device are:
`first,
`the Wire
`occupies a part of the lumen, with conse—
`quent increased resistance to the injection
`of contrast meditun and,
`second,
`the
`catheter will acquire a stiffness or rigidity
`which may imply a considerable disadvan-
`tage when introduced into a heart cavity.
`It would seem that catheters with too
`much stiffness cause rhythm disturbances
`more easily than do soft ones. They are
`probably also more apt
`to bring about
`Valvular
`insufficiency through displace—
`ment of a valvular leaflet.
`to combine the
`In order,
`if possible,
`advantages of the percutaneous catheteri-
`zation technic with those of
`the recoil—
`proof catheter with closed tip, a new cathe-
`ter made of radiodense Teflon has been
`constructed (Fig. 1, A). This is in the
`first place intended to be used for the ill—
`jection of contrast medium into the right
`ventricle.
`It has a terminal hole and,
`about (3‘ cm proximal to this, a lateral hole.
`Behind the latter, the lumen of the catheter
`is occluded over a section a good centime»
`ter in length. Proximal to this blocking
`the catheter is cleft
`longitudinally with
`two slits about 1.5 cm in length.
`The catheter is introduced percutane—
`ously in the fashion previously described
`by the author for the percutaneous intro-
`duction of balloon catheters (3). After the
`puncture of the femoral vein and the intro-
`duction of a flexible metal guide into the
`
`1 From the Department of Roentgenology (Director: Bjiirn Nordenstrém), Tlmraxkliniken, Karolinska SjukhuSCt.
`Stockholm, Sweden. Accepted for publication in March 1965.
`256
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`Vol. 85
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`NEW INSTRUMENTS FOR CATHETERIZATION AND ANGIOCARDIOGRAPHY
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`.4
`957
`
`A
`
`F
`
`Fig. l. Recoil-proof catheter for percutaneous catheterization.
`A. The catheter is intended for the injection of contrast medium into the
`right ventricle. The tip of the catheter is placed in the pulmonary artery and
`the injection of contrast fluid is made via two large slits, which are placed
`within the right ventricle.
`In front of the slits the lumen of the catheter is
`occluded. By this construction the risks of intramural contrast injection in
`the ventricular wall are practically eliminated, nor can disturbances in rhythm
`be caused by the catheter tip, which is placed in the pulmonary artery.
`B. For the injection of contrast medium in the left ventricle a Teflon catheter
`is used. The instrument is provided with long slits which make the tip soft and
`prevent the occurrence of hard, thin, perforating jets of contrast fluid, such as
`may be frequently observed when catheters with small multiple lateral holes
`are employed.
`
`vessel, the instrument is slipped on to the
`guide as shown in Figure 1, A.
`Its intro—
`duction into the vessel with the help of the
`guide is then easy. The catheter is pro—
`vided with a relatively long tip to facilitate
`its exchange if required.
`In this event, it
`is necessary only to withdraw the catheter
`to the point at which the proximal lateral
`hole is visible in the puncture-hole in the
`skin. A new guide may then be introduced
`into the lumen of the vessel, after which the
`catheter may be withdrawn and a new one
`introduced with the help of the mandrin in
`place.
`The intention here is that the tip of the
`catheter shall be pushed up to the pulmo—
`nary artery, while the slit—openings are
`placed in the right ventricle. When the
`tip of a heart catheter is resting in the
`light or left ventricle there is a tendency to-
`ward disturbances in rhythm; these gener—
`ally cease when the tip of the instrument is
`introduced into the pulmonary artery.
`For this reason there may sometimes be an
`
`advantage in injecting contrast medium
`into the ventricle with the tip of the cathe—
`ter remaining in the pulmonary artery.
`With this device it should, furthermore, be
`possible to eliminate the risks of contrast
`injection into the myocardium. The cath—
`eter cannot be placed in any trabeeular
`pocket or be wedged fast in the apex of the
`right ventricle. When the ventricle con-
`tracts around the catheter, the risk of per—
`foration of the heart wall by the injection
`should be minimal. Because of the strong
`Teflon material relatively long slits are
`possible instead of small
`lateral holes.
`This reduces the risk of hard, thin, per-
`forating jets of contrast medium.
`The above—described catheter cannot be
`
`used for the retrograde catheterization of
`the left ventricle from the aorta, as the
`distance from the tip of the catheter to the
`slits is too great.
`In case of retrograde
`catheterization of the left ventricle with
`
`injection of contrast medium into the veni
`tricle, a modified, simpler catheter has been
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`25d
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`BJO’RN NORDENSTRGM
`
`August 1965
`
`employed (Fig. 1, B). This is constructed
`of the same Teflon material as the above-
`deseribed instrument for the right ventricle.
`About 1 cm from the terminal hole, two
`slits about 2 cm in length have been made
`in the catheter. The lumen is completely
`open right up to the tip, The long slits
`close to the tip of the catheter increase the
`flexibility and softness of
`the catheter,
`which, as the Teflon material is relatively
`hard, are highly desirable. This will re
`duce the risks of perforating a vascular
`wall or the wall of the heart with the
`
`help of a “handle” in the form of a loop.
`This part of the instrument may be seen
`in Figure 2, B.
`Figure 2, A shows the tip of the instru-
`ment. The cannula is here somewhat
`curved over a couple of millimeters, and
`the resilient steel wire can be pushed out or
`withdrawn through the hole of the cannula.
`As the steel wire is curved in the form of a
`semicircle at
`the tip and sufficiently
`springy, it curves on account of this resil-
`ience when pushed outside the tip of the
`cannula. To prevent the steel wire from
`
`
`
`
`lLlulluLi.win.
`
`aC
`
`Fig. 2. Cathetcreguide for changing the curve of the tip of a catheter. A
`metal cannula has a slight curve at the tip (A) and at the other end a transverse
`handle (B).
`In the cannula runs a springy steel wire which can be moved with
`a ring-Shaped handle. When the resilient wire is pushed out through the tip of
`the cannula the catheter can be curved as shown in C, D, and E.
`
`catheter. With the slits it is also intended
`to avoid hard, perforating jets of contrast
`fluid.
`
`A CATHETER GUIDE WITH FLEXIBLE TIP
`
`For the catheterization of small vessels
`leaving the aorta one sometimes needs to
`perform very exact movements, and it is,
`moreover, often desirable in this connection
`to be able to change the curve and form of
`the catheter tip. This can be attained
`with the instrument shown in Figure 2.
`In
`one end of a straight metal cannula (which
`may be up to 80790 cm in length) a trans—
`verse handle is
`fixed. A resilient steel
`wire can be moved in the cannula with the
`
`completely disappearing through the can—
`nula hole or from damaging the catheter
`material or getting stuck in the latter, the
`tip of the wire is furnished with a small
`metal knob.
`
`In Figure 2, A, a transparent plastic
`catheter is shown with the catheter—guide
`inserted. The steel Wire is withdrawn into
`the cannula. The guide is now completely
`straight, like the catheter itself,
`In Figure
`2, C the steel wire with the knob has been
`pushed a good 05 cm outside the tip of the
`cannula. When the catheter is moved in
`relation to the guide it assumes the direc-
`tion of tip observable in Figure 2, C. By
`Varying (a) the distance between the tip
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`Vol. 85
`
`NEW INSTRUMENTS FOR CATHETERIZATION AND ANGIOCARDIOGRAPIIY
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`259
`
`of the cannula and the springy steel Wire
`and (b)
`the position of the catheter tip
`in relation to the guide, it is possible to
`give the catheter different tip curves as
`shown in Figure 2, C and D. The guide
`has been employed in connection with
`selective catheterizations of different small
`vessels from the aorta in man and has
`
`proved to be a very useful tool.
`Karoliuska Sjukhuset
`Stockholm, Sweden
`
`REFERENCES
`
`l. BAGGER, M., ET AL.
`
`011 Methods and Complica-
`
`films ill Cullictcriznlinn (If ilcnrt and Large Vessels,
`with and without Contrast Injection. Am. Heart I.
`54: 76!??77. November 1957.
`2. NORDENSTROM, B.: Temporary Unilateral Oc—
`clusion of the Pulmonary Artery: Method of Roentgen
`Examination of the Pulmonary Vessels. Auto radiol.
`Suppl. 108, 1954.
`3. NORDENSTROM, B.: Balloon Catheters for Per-
`cutaneous Insertion into the Vascular System. Acta
`radial. 57: 411—415, November 1962.
`4, NunnExs‘erM, B.:
`Innninent Heart Tampon-
`ade Following Contrast Examination of the Heart. To
`be published in Acta radiol.
`5.
`SELDINGER, S. I.: Catheter Replacement of the
`Needle in Pereutaneous Arteriography: A New Tech—
`nique. Acta radiol. 39: 3687376, May 1953.
`6.
`TORNVALL, G,: A Modified Catheter for Per-
`cutaneous Angiography. Acta radiol 47: 470—472,
`June 1957.
`
`SUMMARIO IN INTERLINGUA
`
`Nove Insirumentos pro 1e Catheterisation e le Angiocardiographia
`
`Le continue melioration del instrumentos
`
`usate in 1e angiocardiographia es del prime
`importantia pro le extension del possibil-
`itates examinatori e pro 1e innocentia de
`tal examines.
`
`In 1e presente articulo, 1e autor describe
`nove catheteres 1e quales ille ha ideate
`e trovate utilissime.
`11105 include in par-
`ticular catheteres que modifica certes del
`
`riscos connectite con 1e injection selective
`de substantia de contrasto ad in le cavi-
`tates cardiac 6 un guida de catheter con
`un puncta flexibile que permitte precise
`movimentos in le catheterisrno de micre
`vasos exiente ab 1e aorta.
`Iste ultime dis—
`
`positivo etiam render possibile un alteration
`del curva e del
`forma del puncta del
`catheter.
`
`%%
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