• Medications

  • Anesthesia

    • Local anesthetic: 1% lidocaine

    • Conscious sedation: Fentanyl, midazolam

    • General anesthesia (if needed)

  • Blood products

  • Fluid resuscitation

  • Prophylactic antibiotics

    • Based to local protocol

  • Management of co-morbidities  (allergy, blood glucose, blood pressure, nausea, etc)

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• Trolley/Equipment​

  • Catheters

    • Flush and directional catheters 4-5-Fr

      • Cobra, Rim, Sim 1, SOS

    • Microcatheter

  • Closure Devices

  • Embolic agents

    • Amplatzer Plug

    • Coils (Pushable or detachable)

    • Gelfoam slurry (resorbed within a month)

    • Particles

  • Stents (Covered)

  • Sheaths

    • 6Fr short or long

  • Wires

    • 0.018”

    • 0.035” (standard, hydrophilic, Amplatz)

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• Checklist

  • CIRSE (IR Patient Safety Checklist)

  • LocSSIPs (Local Safety Standards for Invasive Procedures)

  • NatSSIPs (National Safety Standards for Invasive Procedures)

  • WHO (World Health Organization Surgical Safety Checklist)

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• Access

  • Supine position for CFA approach (most common)

    • Consider radial approach, if CFA is not accessible

  • Ultrasound guided is recommended

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• Technique

  • Cleanse the access site and cover with sterile drape

  • Administer the local anesthetic

  • Ultrasound guided access to the CFA with seldinger technique

    • Contralateral access for up and over technique

    • Ipsilateral access with a reversed curved catheter or Waltman’s loop

  • 6Fr sheath insertion over the wire (Flush the sheath)

  • Catheter and wire negotiated above the aortic bifurcation

  • Exchange the catheter with a diagnostic pigtail catheter

  • Remove the wire and connect the catheter to the contrast injector

  • Perform angiograms at AP (and oblique views if needed)

  • Assess vascular anatomy and evidence of vascular injury

    • Observe for irregular vessel, blush/extravasation, pseudoaneurysm

  • Use the wire to exchange the pigtail for a RIM catheter

  • Negotiate the RIM catheter with a hydrophilic wire to the contralateral side

    • A long 6Fr sheath can provide further support, if needed

      • Tip of sheath at the contralateral common iliac artery

  • Perform selective angiograms to reassess the target and to position catheter/microcatheter appropriately​

  • Proceed to embolization:

    • Prepare the embolic agent​

    • Bleeding source:

      • Coils (most common)

        • Position the tip of the catheter/microcatheter into the target artery

        • Advance pushable or detachable coils

        • Pack the coils

      • Gelfoam slurry

        • For urgent non-selective embolization

    • Pseudoaneurysm:

      • Embolize with from distal to proximal, across the pseudoaneurysm

      • Covered stent can be used, if deployment is feasible

  • Hand injections of contrast help for guidance, diagnosis and completion

  • Wait 5 minutes and perform final angiogram from the parent catheter or sheath

    • To assess adequacy of embolization

  • Use a closure device at the access artery, if indicated

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• Tips​

  • Optimize coagulation otherwise the bleeding might continue/recur

  • Ask for the patient to hold breath during angiograms

  • Optimize contrast injection volume and flow rate for each angiogram

  • AP and oblique angiograms help to depict the source of bleeding

  • Oversize Amplatzer plug (~30%), coils (~20%), stents (~10%)

  • Use combination of soft and stiff wires to reach distal targets or to provide sufficient support 

 

• Report

  • Describe the findings

  • Report the technique

  • Mention used embolic agents

  • Post-procedure instructions if needed