Spinal Angiography
3.1 Indications or Spinal
Angiography
1. Evaluation o patients with myelopathy and
suspected to have spinal dural arteriovenous
stulas (most common indication).
2. Evaluation o patients with known or sus-
pected spinal arteriovenous mal ormations or
vascular neoplasms (e.g., with spinal intra-
medullary or subarachnoid hemorrhages).
3. Rarely or the evaluation o suspected spinal
cord ischemia (since cord blood supply is so
variable, and treatment options or cord isch-
emia are so limited, angiography is mainly
done to rule out a stula as the cause o
symptoms).
4. Planning or neurointerventional procedures
on spine or spinal cord.
5. Preoperative mapping o cord vasculature
prior to spinal or aortic procedures that risk
occlusion o the spinal vessels.
6. Intraoperative assistance with surgery on spi-
nal vascular lesions.
7. Follow-up imaging a ter treatment (e.g., a ter
treatment o arteriovenous stulas or
mal ormations).
Spinal Imaging Strategy
Spinal angiography is invasive and can be techni-
cally challenging, particularly in older patients.
© The Author(s), under exclusive license to Springer Nature Switzerland AG 2023
M. R. Harrigan, J. P. Deveikis, Handbook of Cerebrovascular Disease and Neurointerventional
Technique, Contemporary Medical Imaging, https://doi.org/10.1007/978-3-031-45598-8_3
Adjunctive cross-sectional imaging techniques
can replace or complement catheter spinal angi-
ography. Also, a spine MRA or CTA can direct
attention to the pertinent segmental artery prior to
the catheter angiogram and save considerable
time during the angiogram.
1. Spinal MR angiography
2. Spinal CT angiography
(a) CTA combined with DSA [1]. This
approach combines the anatomic preci-
sion o DSA with high-resolution bony
imaging rom ne-cut CT. Technique: A
pigtail catheter is positioned in the aorta
proximal to the area o interest. Scanning
is done twice during the injection to
obtain arterial- and venous-phase images
to di erentiate between arterial and
venous structures. Selective catheteriza-
tion is then done based on the DSA/CT
ndings.
3.2 Complications o Diagnostic
Spinal Angiography
In ormed consent prior to an angiogram should
include a quantitative estimate o the risk o
complications.
157
158
Neurological Complications
Neurological complications in spinal angiogra-
phy may include the same risk o cerebral isch-
emic events that may occur during cerebral
angiography when the cervical region is being
studied (see Chap. 2). In addition, there is the risk
o vessel dissection, embolic occlusion with
thrombus, atherosclerotic plaque, or air emboli
occluding the spinal cord vessels and producing
myelopathy. In a study o 134 spinal angiograms,
there were three (2.2%) neurological complica-
tions, all transient [2]. Two more recent series,
with over 300 cases, ound zero neurological
complications rom diagnostic spinal angiogra-
phy [3, 4]. High-volume contrast injection in ves-
sels eeding the spinal cord (although not
necessarily per ormed as part o spinal
angiography) has also been shown to produce
temporary or permanent injury to the spinal cord
[5–7].
Non-neurological Complications
Non-neurological complications o spinal angi-
ography via the emoral artery include the same
local and systemic complications seen in cerebral
angiography. A recent study ound 1% rate o
puncture site complications and 0.7% rate o sys-
temic complications [4].
3.3 Selective Spinal
Angiography: Basic Concepts
Pre-procedure Evaluation
1. Brie neurological exam should be done to
establish a baseline, should a neurologic
change occur during or a ter the procedure.
2. The patient should be asked or a history o
iodinated contrast reactions.
3. The emoral pulse as well as the dorsalis pedis
and posterior tibialis pulses should be
examined.
4. Blood work, including a serum creatinine
level and coagulation parameters, should be
reviewed.
3 Spinal Angiography
Pre-angiogram Orders
1. NPO except medications or 6 h prior to the
procedure.
2. Place peripheral IV (two i an intervention is
anticipated).
3. Place Foley catheter (almost always, unlike
cerebral angiography).
Sedation/Analgesia/Anesthesia
The choice between general anesthesia and con-
scious sedation or spinal angiography depends
upon the circumstances. General anesthesia
allows or patient immobility including pro-
longed interruption o respiration, while imaging
tiny spinal vessels that are present in the thoracic
and lumbar region. General anesthesia also spares
the patient the potential discom ort o a long,
involved angiographic procedure. Using non-
ionic, iso-osmolar contrast, procedures can be
done under local anesthesia with minimal seda-
tion, and adequate image quality is possible in
cooperative patients. The advantage o local
anesthesia is the avoidance o any o the potential
complications o general anesthesia and the abil-
ity to monitor the neurological status o the
patient during the procedure. The limited ability
to monitor the neurological status o the patient
during general anesthesia may be partially miti-
gated by the use o neurophysiological monitor-
ing, such as somatosensory and/or motor evoked
potentials [3]. However, neurophysiological
monitoring adds to the cost and complexity o the
procedure, and may not be readily available or
reliable, depending on the institution.
Contrast Agents
Nonionic contrast agents are almost always used
due to their lower osmolality and better tolerance
when injected into the small vessels eeding the
spine. Iodixanol (Visipaque™, GE Healthcare,
Princeton, NJ), an iso-osmolar and a nonionic con-
trast agent, is more expensive and more viscous
than other contrast agents commonly used but is
the best tolerated agent or spinal angiography.
3.3 Selective Spinal Angiography: Basic Concepts
1. Diagnostic angiogram: Omnipaque ®, 300 mg
I/mL, or Visipaque™, 320 mg I/mL.
2. Neurointerventional procedure: Omnipaque®,
240 mg I/mL or Visipaque™, 270 mg I/mL.
Patients with normal renal unction can toler-
ate up to 400–800 mL o Omnipaque®, 300 mg I/
mL without adverse e ects [8]. Contrast volumes
in spinal angiography can routinely approach
these limits, given the large number o injections
required.
Femoral Artery Sheath Versus No
Sheath
Spinal angiography is almost always done with a
emoral artery sheath.
1. Sheath
(a) Advantages: allows the rapid exchange o
catheters and less potential or blood loss
rom the arteriotomy site. Spinal angiog-
raphy requently requires several di er-
ent catheters per case.
(b) Unlike cerebral angiography, catheter
position is o ten tenuous in the vessels
being selected, and the sheath allows or
more precise manipulation and position-
ing o the catheter.
(c) Short sheath (10–13-cm arterial sheath) is
used most commonly.
(d) Longer sheath (25 cm) is use ul when
iliac or emoral artery tortuosity or ath-
erosclerosis can impair catheter naviga-
tion. Longer sheaths may need to be
pulled back, partially out o the iliac
artery, when selective catheterization o
the ipsilateral internal iliac artery is
needed.
(e) Technique: Standard arterial puncture
techniques are used. Most commonly, a 5
or 6F sheath (Pinnacle® Sheath; Terumo
Medical, Somerset, NJ) is used. The
lumen o the sheath (and the angiographic
catheter) is continuously per used with
heparinized saline (10,000 U heparin/L o
saline) under arterial pressure.
159
2. No sheath
(a) Spinal angiography without a sheath
o ers the advantage o a slightly smaller
arteriotomy, but is rarely done.
(b) Situations in which a sheath may not be
needed include pediatric cases in which a
smaller arteriotomy is desired and very
limited ollow-up angiograms in which
only one catheter may be used or a quick
procedure.
Suggested Wires and Catheters
or Diagnostic Spinal Angiography
1. Guidewires
(a) Use a 0.035 or 0.038 J-tip wire or
sheath insertion.
(b) The 0.035 angled Glidewire® (Terumo
Medical, Somerset, NJ) is so t, fexible,
and steerable.
(c) The 0.038 angled Glidewire® (Terumo
Medical, Somerset, NJ) is slightly sti er
than the 0.035 in. may be help ul when
added wire support is needed.
2. Catheters
(a) In general, catheters or spinal angiography
(Table 3.1 and Fig. 3.1) are the same shapes
typically used or visceral angiography,
although cerebral-type catheters may be
used or catheterization o brachiocephalic
vessels. Occasionally, straight catheters may
be steam-shaped to an appropriate curve or
a particular application. Straight catheters
may also be used as-is or retrograde fush
aortic injections (see below).
Table 3.1 Catheters or spinal angiography
Catheter Use
5F Angled Good all-purpose diagnostic catheter
Taper or supra-aortic vessels
5F Good all-purpose catheter or
Mikaelsson intercostal and lumbar arteries
5F Simmons Alternative to Mikaelsson
1
4 or 5F Cobra Intercostal and lumbar arteries in
younger patients
5.5F RDC Very stable and torqueable, but sti
5F Straight For retrograde fush aortic runs
160 3 Spinal Angiography

Fig. 3.1 Recommended diagnostic catheters used or spinal arteriography

Vessel Catheterization Table 3.2 Blood supply to various spinal regions

Level Feeding arteries
Selective spinal angiography may be either com- Upper cervical Vertebral, ascending pharyngeal,
plete spinal angiography, or a partial, ocused occipital, deep cervical
Lower cervical Vertebral, deep cervical, ascending
study or a speci c lesion. Complete spinal angi- cervical
ography is a major undertaking, in which all ves- Upper thoracic Supreme intercostal, superior
sels that may relate to the spinal canal are intercostal
selectively catheterized and studied. This is most Mid-lower Intercostal
o ten used in the evaluation o a patient with a thoracic
Upper-to-mid Lumbar
suspected dural arteriovenous stula causing
lumbar
myelopathy. The vascular lesion can be anywhere Lower lumbar Iliolumbar
rom the head to the sacrum, and evaluation o all Sacrum Anterior and lateral sacral
vessels supplying these structures may be
required (Table 3.2). When the lesion is obvi-
Roadmapping
ously con ned to a speci c region o the spine, a
more ocused study may be more appropriate.
Roadmapping aids catheterization o the supra-
This should include all the vessels that supply the
aortic vessels, such as vertebral arteries, and the
area o interest, and the levels above and below
thyrocervical and costocervical trunks.
the lesion, given the possibility o collateral fow
Roadmapping is less help ul in catheterizing the
rom adjacent spinal vessels. Another use ul rule
intercostal and lumbar arteries, since respiratory
o thumb is to visualize normal spinal cord ves-
motion degrades the image.
sels above and below any lesion a ecting the
cord. Assessing spinal cord blood supply may
require selective angiography o the vertebral
Double Flushing
arteries (Fig. 3.2), thyrocervical and costocervi-
cal trunks, subclavian arteries, intercostal arteries Catheter fushing technique is discussed in Chap.
(Fig. 3.3), lumbar arteries (Fig. 3.4), and lateral 2. Although some operators use double fushing
and medial sacral arteries. o catheters only in the supra-aortic arteries, it
3.3 Selective Spinal Angiography: Basic Concepts 161

Fig. 3.2 Lateral vertebral artery angiogram showing

anterior spinal artery (arrows)

makes more sense to use a meticulous fushing

technique anywhere in the vascular system. This
ensures that one will not orget to use good tech-
nique when it is most needed. Moreover,
thrombus or air emboli in spinal cord vessels can
be just as disabling as cerebral ischemia.

Continuous Saline In usion

Three-way stopcock or mani olds can be used to

provide a heparinized saline drip through the
Fig. 3.3 Typical intercostal artery
catheter. This is particularly use ul or long spi-
nal angiographic procedures. In-line air lters
(B. Braun, Bethlehem, PA) on the saline drip tub-
Hand Injection
ing provide added protection rom bubbles (as
Frequent small injections (“pu ng”) o contrast
discussed in Chap. 4). A rotating adapter on the
can be used to help manipulate the catheter into
stopcock is needed to prevent the stopcock rom
the desired lumbar and intercostal arteries. A
being a drag on ree manipulation o the catheter.
20 mL syringe containing contrast can be le t
Using both a rotating three-way stopcock and a
attached to the catheter or these injections, and
rotating hemostatic valve on the catheter allows
then used immediately or hand injections o
or two pivot points to allow ree rotation o the
contrast or angiographic runs. As is done in the
catheter. This is important, as the catheter may
cerebral vasculature, the syringe is held vertically
not be in a stable position in the small lumbar and
and care is taken not to allow bubbles to enter the
intercostal arteries.
162 3 Spinal Angiography

graphic run, but the phase o respiration at which

the breath-holding should occur depends on the
spinal level being imaged (see below).

Mechanical Injection

A power contrast injector is necessary or tho-

racic or lumbar aortic angiograms, and or large
vessels such as subclavian or iliac arteries. As
stated in Chap. 2, the pressure and fow rate set-
tings should not exceed the ratings o the stop-
cock or catheter. Common power injector settings
or vessels studied in spinal angiograms using a
5F catheter are listed in Table 3.3. Note that one
may need to increase or decrease these rates and
volumes, depending on the size o the vessels, the
stability o the catheter, and the quickness o the
runo o the contrast on a test injection. Use
extreme caution i the catheter is wedged in the
vessel and be especially care ul i there is a pos-
sibility that a spinal cord vessel is arising rom
the branch one is injecting, since high-pressure
power injections can damage the cord [7]. When
in doubt, use careful hand-injections of contrast.

Vessel Selection

I the exact level o the lesion is known rom non-

invasive imaging, the spinal angiogram should
begin with those vessels supplying that area.
Fig. 3.4 Typical lumbar artery Following catheterization o the vessel o inter-
est, it is then customary to work systematically
catheter. Most spinal vessels are best imaged above and below the lesion to include normal ter-
with hand injections o contrast, to allow or
modulation o the injection rate and volume, Table 3.3 Standard power injector settingsa
depending on the size o the vessel and stability
Vessel Power injector settings
o the catheter. An adequate angiographic run can Aortic arch 20 mL/s; total o 25 mL
be usually done with a single 2–3 s injection o Retrograde aortic 10 mL/s; total o 30 mL
4–6 mL (100% contrast) o contrast. The goal is fush
to adequately opaci y the vessel o interest with- Iliac artery 10 mL/s; total o 20 mL
out displacing the catheter or refuxing too much Subclavian artery 6 mL/s; total o 15 mL
Vertebral artery 6 mL/s; total o 8 mL
into the aorta or into the ever-present collaterals
Lumbar or 2 mL/s; total o 6 mL
to other spinal vessels. Patients should be warned intercostal artery
that they will experience warmth and/or cramp- For 3D imaging 0.5–2 mL/s; total 7–30 mL (higher
ing in the territory o the injected vessel, and doses or high fow AVF)
breathing should be suspended during the angio- a
For digital subtraction angiography using a 5F catheter
3.3 Selective Spinal Angiography: Basic Concepts
ritory adjacent to the lesion. Lesions o the cord
itsel usually require mapping o the spinal cord
supply above and below the lesion. For complete
spinal angiography, it is particularly important to
image the intercostal and lumbar arteries in a
systematic ashion so that one does not inadver-
tently miss or repeat a level. It is help ul to main-
tain a worksheet during the procedure, and list
the sides and vessels injected during each angio-
graphic run. Radio-opaque marker rulers can be
placed under the patient on the table or marker
tapes can be a xed to the patient’s back, slightly
o midline to have a re erence available on each
lm to help con rm the levels studied.
Additionally, bony landmarks, such as the 12th
rib, can also help with keeping track o the ves-
sels being studied.
Angiographic Images and Standard
Views
Spinal angiography has a number o eatures that
make it less desirable to use biplane imaging rou-
tinely. The vascular anatomy is usually quite
simple compared to cerebral vessels. Moreover,
lateral views require higher doses o X-rays to
adequately penetrate the thoracic or lumbar
region to give good visualization o the struc-
tures. To limit the radiation dose to the patient
and operator, and to prevent over-heating the
X-ray tube, obtain single plane rontal images o
the thoracic, lumbar, and sacral spine. Later,
obtain lateral views when the vessels supplying
the lesion are ound. Additionally, when a com-
plex vascular lesion is ound, 3D rotational imag-
ing can add use ul in ormation. 3D imaging is
better than conventional angiography or deter-
mining the relationship o AVMs to the spinal
cord and detecting intranidal aneurysms [9]. 3D
spine angiography requires general anesthesia to
ensure immobility during the 15 s imaging acqui-
sition and contrast must be slowly injected in the
vessel o interest or approximately 15–17 s
beginning 1 s prior to starting the acquisition to
ensure that the vessels are opaci ed throughout
the ull rotation o the gantry.
163
1. When viewing the spinal angiographic images,
the normal anatomic eatures should be recog-
nized. Segmental spinal vessels have osseous
branches that supply the vertebra at that level,
radicular branches, variable radiculomedul-
lary branches that connect to the anterior spi-
nal artery, variable radiculopial branches that
eed the posterolateral spinal arteries, muscu-
lar branches, and anastomoses to the contra-
lateral and cephalad and caudal adjacent
segmental branches.
2. Other imaging eatures worthy o attention dur-
ing the per ormance o a spinal angiogram:
(a) Vessel contour and size
(angioarchitecture).
(b) Presence or absence o evident contribu-
tion to spinal cord. Look or the hair-pin
turn o the artery o Adamkiewicz
(Fig. 3.5) and airly straight ascending
and/or descending vessels in the spinal
canal.
(c) Presence o abnormal or unexpected
vascular channels (neovascularity).
(d) Presence or absence o an abnormal vas-
cular blush. Note that normal muscle
and bone normally display a vascular
blush.
(e) Early venous lling indicates an AV
shunt.
( ) When there is a shunt, you must ask
yoursel : where do the veins drain to?
(g) Injection o intercostal or lumbar arteries
that ll the anterior spinal artery should
be examined or the appearance o the
coronal venous plexus o the spinal cord
within about 15 s a ter contrast injection.
Lack o visualization or delayed visual-
ization o the veins along the cord and
the radicular veins that anastomose with
the epidural veins can be evidence o
severe spinal venous hypertension.
Pearl
Remember that the anterior spinal artery is
in the midline. The posterolateral spinal
arteries are slightly o midline.
164
Fig. 3.5 L1 lumbar artery injection showing the artery o
Adamkiewicz (black arrows), with the characteristic hair-
pin turn, ollowed by the anterior spinal artery (white
arrow)
Frame Rates or Digital Subtraction
Angiography
Most spinal angiography can be done with rela-
tively slow rame rates o 1 or 2 rames per sec-
ond ( ps). Most arteriovenous stulas in the spine
are relatively slow lling. Only very high fow
arteriovenous shunts would require 3 ps or aster
imaging. Routine use o ast rame rate while
imaging the spine below the cervical region will
soon overheat the X-ray tube and may not even
be possible with lower quality imaging equip-
ment. For most spinal arteriography, a 10–12 s
imaging sequence allows or visualization o
3 Spinal Angiography
arterial, capillary, and venous phases. However,
when screening or causes o spinal venous
hypertension, such as a spinal dural AVF, injec-
tion o the segmental vessel supplying the artery
o Adamkiewicz may require imaging or 20 s to
visualize the venous phase o the spinal cord
vasculature.
Calibration and Measurement
Size measurements and calibration can be done as
described in Chap. 2. In spinal angiography, radio-
opaque rulers may be placed under the patient or
re erence and can also be utilized or calibration.
Spinal Angiographic Procedures
Femoral Artery Puncture
1. Standard arterial access is obtained (see Chap.
2).
2. A emoral arterial sheath is placed (5 or 6F).
Radial Artery Access
1. Very rarely, spinal angiography may require
access rom the arm i there are emoral, iliac,
or aortic occlusions.
2. For the most part, radial access is only used
when a ocused study is needed.
3. I lower lumbar arteries must be imaged using
an upper extremity artery or access, use an
axillary approach, since even 100 cm cathe-
ters may not reach rom a radial or even bra-
chial approach.
Aortic Imaging
1. Screening aortic injections by pigtail catheter
are a way to get a rough idea o vascular anat-
omy in the thoracic and lumbar region.
2. It is most help ul in elderly patients with aor-
tic atherosclerosis or aortic aneurysms to see
which segmental vessels may be occluded.
3. As a rule, aortic injections provide poor visu-
alization o small spinal vessels, so they do
not eliminate the need or selective spinal
angiography.
4. In the lumbar region, pigtail catheter injec-
tions ll all the visceral vessels as well as the
3.3 Selective Spinal Angiography: Basic Concepts
lumbar arteries. This can obscure even airly
extensive vascular abnormalities in the spine.
5. For most cases, it is not worth wasting the
time or contrast on aortic injections.
Retrograde Aortic Flush
1. Better visualization o the segmental spinal
arteries can be obtained with a retrograde
aortic fush, as opposed to standard pigtail
injections [10, 11].
2. Bilateral emoral arterial sheaths are required
(5 or 6F).
3. A straight catheter (5 or 6F) is positioned in
each common iliac artery.
4. Simultaneous power injection o contrast in
each catheter is needed. A sterile Y-connector
that is rated or high pressure can connect the
tubing rom the injector to both catheters.
Alternatively, two separate injector machines
may be used.
5. 20 mL/s or a total o 50 mL distributed
equally between the two catheters is injected.
6. Contrast usually streams up the posterior wall
or the aorta, providing visualization o the
lumbar, and lower intercostal arteries, with less
obscuration o the anterior visceral arteries.
7. More viscous contrast, such as Omnipaque
350 or Visipaque 320 works best with this
technique.
8. Usually no more than ve vertebral levels are
well imaged by this technique. The catheters
may need to be positioned in the upper lumbar
aorta to visualize the higher thoracic levels.
9. This technique is still not a replacement or
selective spinal angiography.
10. Retrograde aortic fush is contraindicated in
very tortuous aorta or iliac vessels, in the
presence o extensive atherosclerosis, or aor-
tic or iliac aneurysmal disease, due to a risk
o dissection or plaque disruption.
Intercostal and Lumbar Artery
Catheterization
1. For complete spinal angiography, spinal seg-
mental vessels constitute the majority o the
vessels to be studied.
165
2. Unless the exact site o a lesion is known
rom other imaging studies, the segmental
spinal vessels should be studied in a system-
atic ashion to ensure that all are being
visualized.
3. Using a Mikaelson or Simmons catheter, it is
o ten most e cient to go rom caudal to cra-
nial, to avoid un- orming the curve o the
catheter.
4. Using most other catheters, such as Cobra
catheters, it works best to go rom cranial to
caudal.
5. From one level to the next, the segmental
vessels come o at similar positions along
the wall o the aorta, so it is best to go rom
one level to the next and do all on one side
be ore going back and doing all on the other
side. This is much quicker than rotating the
catheter rom one side to the other at each
level.
6. The catheter is slowly rotated and moved or-
ward or backward, while pu ng small
amounts o contrast until the desired vessel is
engaged.
7. The catheter is gently pulled back to ensure it
is seated in the vessel.
8. The catheter should be held in position with
one hand to prevent it rom rotating out o
the vessel, and contrast injected or an angio-
graphic run, during transient arrest o
respiration.
9. Keeping the catheter at the same angle o
rotation, it is then gently pushed orward ( or
Mikaelsson or Simmons) or withdrawn ( or
Cobra) to disengage rom the vessel.
10. Again keeping the same angle o rotation, the
catheter is moved to the next vertebral level
and it should just pop into the lumbar or
intercostal branch.
11. Alternatively, the catheter can be le t in
the branch, then slowly rotated toward the
right or le t until it enters the contralateral
segmental branch at the same vertebral
level.
12. Continue the process in a systematic ashion
until all the desired vessels are studied.
166
Optimizing Images by Reducing
Respiratory and Other Motion
General anesthesia can be used to prevent patient
motion. With or without general anesthesia,
imaging the intercostal and lumbar arteries
should be done during breath-holding. For lower
lumbar imaging, the patients can hold their breath
in either inspiration or expiration, whichever
moves aerated bowel away rom the area o inter-
est. Upper lumbar and lower thoracic imaging is
best i the patients hold in expiration, to keep the
inter ace o lung and diaphragm out o the imag-
ing eld. In the mid-thoracic region above the
diaphragm, the patients should hold their breath
in inspiration, to keep the diaphragm below the
area o interest. In the upper thoracic region,
catheter positioning is requently very tenuous,
and deep respirations in anticipation o breath
holding can displace the catheter. In this region, it
is best to have the patient suspend respiration
without deep inspiration or expiration.
In the lumbar region, bowel peristalsis can
sometimes degrade subtraction images. Bowel
movement can be temporarily slowed by inject-
ing 1 mg o glucagon or 40 mg o hyoscine-N-
butylbromide (Buscopan®; Boehringer Ingelheim
GmbH, Germany) IV just prior to acquiring the
images [12].
Pearls
To acilitate catheterization o the intercos-
tal and lumbar arteries, remember the ol-
lowing acts:
1. The more caudal the spinal level, the
more posterior the origins o the seg-
mental vessels [13] and the more sym-
metrical the origin o the right and le t
segmental vessels.
2. Upper thoracic right-sided intercostal
arteries arise rom the lateral wall o the
aorta; the le t is more posterior. Right
and le t lower lumbar arteries both arise
rom the posterior wall o the aorta
(Fig. 3.6).
3 Spinal Angiography
3. The right and le t lower lumbar arteries
may have a common origin rom the
aorta.
4. In lumbar and lower thoracic regions,
segmental branches usually arise just
below the level o the pedicle.
5. In the more cephalad levels in the tho-
racic region, the intercostal arteries are
closer together, and slope cephalad to
supply vertebral levels above the level
o the aorta rom which they arise.
6. The highest intercostal arteries are close
together, and their angulation o ten
makes it di cult to keep the catheter in
a stable position in the vessel.
7. Just below the aortic arch, the superior
intercostals ascend and variably supply
two or three thoracic vertebral levels
above the origins o the vessels
(Fig. 3.7).
8. Do not orget that the supreme intercos-
tals are at the costocervical trunks
(hence, the name “costo-” cervical) and
supply the most cranial two or three
thoracic levels.
Sacral and Iliolumbar Artery
Catheterization
1. The anterior sacral artery arises rom the aor-
tic bi urcation and can be catheterized with
any reverse-curve catheter (like Mikaelsson
or Simmons).
2. Iliolumbar and lateral sacral arteries come
o the internal iliac arteries.
3. Common iliac injections can be done to
locate the spinal vessels to be selected.
4. Iliac arteries and their branches contralateral
to the emoral puncture site are catheterized
by engaging the iliac with the catheter, then
advancing a hydrophilic wire well down into
the contralateral emoral artery. The catheter
is then advanced antegrade over the wire into
the external iliac. While injecting small
amounts o contrast, it is slowly pulled back
and rotated until the desired vessel is
catheterized.
3.3 Selective Spinal Angiography: Basic Concepts 167

Fig. 3.6 Orientation o

segmental arteries.
Upper thoracic: Right
intercostal arises rom
lateral aspect o aorta,
the right rom posterior
sur ace. Thoracolumbar:
both intercostal/lumbar
arteries arise rom lateral
aspect o aorta. Lower
lumbar: Both lumbar
arteries arise rom
posterior wall o aorta. A
anterior, P posterior

5. Iliac arteries ipsilateral to the emoral punc-

ture require a ully ormed Mikaelsson or
Simmons in the aorta, which is slowly with-
drawn and rotated so that it points back into
the ipsilateral iliac. As small amounts o con-
trast are injected, it is withdrawn and rotated
into the vessel o interest.
6. The ipsilateral iliac vessels can o ten be well
imaged rom a retrograde injection o a cath-
eter or sheath with its tip in the distal external
iliac artery.
7. I a emoral artery sheath is being used, it
may have to be pulled back into the external
iliac to allow catheterization o the iliac
branches.
8. Truly selective injections o the iliolumbar
and lateral sacral arteries may require the use
o a microcatheter/micro-guidewire assem-
bly placed coaxially through the 5F catheter
positioned with its tip at the origin o the
internal iliac artery.
9. Iliolumbar arteries are at the very proximal
internal iliac and the lateral sacral a little
more distally o the posterior division o the
internal iliac.
10. Warn patients that they will eel the heat o
Fig. 3.7 Superior intercostal artery. This is the most cepha-
lad intercostal artery arising rom the aorta, ascending to the contrast in very private places when
supply several vertebral levels. Not to be con used with injected in the iliac arteries and their
supreme intercostal arising rom the costocervical trunk branches.
168
Vertebral Artery Catheterization
1. For complete spinal angiography, the verte-
bral arteries must be studied.
2. Vertebral artery catheterization is discussed in
detail in Chap. 2.
3. The vertebral arteries ll the anterior spinal
arteries at the vertebrobasilar junction and the
posterolateral spinal arteries proximal to, or
directly rom, PICA.
4. Remember that segmental branches o the
vertebral may contribute also to the spinal
cord. I the catheter tip is positioned too high
up in the vertebral artery, lower segmental
eeders to the cord may be overlooked.
Thyrocervical/Costocervical Trunk
Catheterization
1. For complete spinal angiography, these sub-
clavian artery branches must be studied.
2. For most cases, a simple curve on the catheter
(Angled Taper, Vertebral, or Berenstein curve)
works best.
3. Advance the catheter over a wire into the sub-
clavian artery well beyond the origin o the
vertebral artery.
4. Double fush the catheter, then slowly with-
draw the catheter, keeping the tip pointed
cephalad, while gently injecting small quanti-
ties o contrast until the catheter engages the
desired vessel.
5. The costocervical trunk is just distal to the
thyrocervical trunk, which is just distal to the
vertebral artery.
6. There may be an anomalous artery o the cer-
vical enlargement, supplying the cord directly
rom the subclavian.
7. With tortuous vessels or con using anatomy, a
subclavian injection, using a slight ipsilateral
oblique view can help.
Carotid Artery Catheterization
1. For complete spinal angiography, branches o
the carotid arteries must be studied.
2. Carotid artery catheterization is discussed in
detail in Chap. 2.
3. External and internal carotid injections, and
pre erably, selective injections o ascending
pharyngeal and occipital arteries are needed.
3 Spinal Angiography
The middle meningeal artery may also con-
tribute to AV stulas that drain to the spinal
cord veins.
Reconstituting a Mikaelsson Catheter
The Mikaelsson catheter has a reverse curve that
must be reconstituted a ter the catheter is intro-
duced into the aorta, similar to the Simmons
catheter. The Simmons 2 catheter is discussed in
detail in Chap. 2. The Mikaelsson can be recon-
stituted i a wire is advanced into the contralat-
eral iliac artery or a renal artery. The catheter is
then advanced over the wire until the primary
curve is just into the iliac or renal artery. Then the
wire is pulled back and the catheter gently
advanced, re orming the shape o the reverse
curve. As the catheter continues to advance, it
will pull out o the engaged renal or iliac artery
and be ully ormed in the aorta. Sometimes the
catheter will spontaneously re orm its shape i it
is advanced up to the aortic arch distal to the le t
subclavian artery, and then rotated. Reconstitution
in the le t subclavian or the aortic valve is usually
not an option due to the short length o the
catheter.
Remember that pulling back on the Mikaelsson
can engage intercostal arteries, lumbar arteries,
and those pesky visceral vessels, which can un-
orm the catheter curve i it is pulled back urther.
The catheter should always be pulled back slowly
under fuoroscopic visualization as the catheter is
constantly rotated to avoid snagging vessels
along the way.
Femoral Artery Puncture Site
Management
Arterial puncture site management and closure
techniques and devices are discussed in Chap. 2.
Postangiogram Orders
1. Bed rest with accessed leg extended, head o
bed ≤30°, or 6 h, then out o bed or 1 h. (I
3.4 Special Techniques and Situations
a closure device is used, bed rest, with head
o bed ≤30°, or 1 h, then out o bed or 1 h).
2. Vital signs: Check on arrival in recovery
room, then Q 1 h until discharge. Call
physician or SBP ≤90 mmHg or decrease
25 mmHg; pulse ≥120.
3. Check puncture site and distal pulses upon
arrival in recovery room, then Q 15 min × 4,
Q 30 min × 2, then Q 1 h until discharge. Call
physician i :
(a) Bleeding or hematoma develops at punc-
ture site.
(b) Distal pulse is not palpable beyond the
puncture site.
(c) Extremity is blue or cold.
4. Check puncture site a ter ambulation.
5. IVF: 0.9 N.S. at 100 mL/h until patient is
ambulatory.
6. Resume pre-angiogram diet.
7. Resume routine medications.
8. PO fuids at least 500 mL.
9. D/C Foley catheter and IV prior to
discharge.
10. Check BUN and creatinine 24–48 h post-
procedure i very large volumes o contrast
were used.
3.4 Special Techniques
and Situations
Intraoperative Spinal Angiography
Intraoperative spinal angiography can be done
during surgery or spinal AV stulas and arterio-
venous mal ormations [14]. It can localize small
lesions and to con rm complete removal o
lesions. It correlates well with postoperative
angiography in the angiography suite, and can
show an unexpected residual AV shunt in up to
33% o cases [15].
Intraoperative spinal angiography poses tech-
nical challenges compared to intraoperative cere-
bral angiography:
1. Patient is usually prone during the operation.
(a) This requires that a long (at least 25 cm)
sheath be placed in the emoral artery prior
169
to the patient being positioned prone. The
sheath is only inserted a short distance and
is positioned so that its hub is along the
lateral aspect o the hip, so it can be
accessed a ter the patient is turned prone.
(b) An alternative or arterial access is a tran-
sradial approach [16]. This will allow
catheterization o cervical or upper tho-
racic eeders, but lumbar eeders may
require extra, extra-long catheters.
(c) Popliteal artery access may be a better
option or lumbar and low thoracic eed-
ers. Ultrasound guided puncture o the
popliteal artery with placement o a 4F
sheath can be easily done in the prone
position [17].
2. Another challenge is the act that most operat-
ing room tables are not radiolucent, which can
make it a challenge getting the right C-arm
angle to visualize the catheter and the desired
vessels.
(a) A Jackson rame should be used instead
o an operating table i possible.
3. Prone positioning can also con use the angi-
ographer and make catheterization o the
desired vessels di cult [18].
(a) An easy aid to catheterization is to reverse
the fuoroscopic image side-to-side when
working the catheter on a prone patient.
4. These challenges may be overcome, but are
one reason why intraoperative spinal angiog-
raphy is not more commonly practiced.
Tips or Imaging Specifc Lesions
Type I Spinal Dural Arteriovenous
Fistulas
1. By ar the most common indication or spinal
angiography.
2. Noninvasive imaging such as MRI may sug-
gest the diagnosis, but the sensitivity o MR in
detecting stulae is only 51% [4].
3. Even i the area o myelopathy is known rom
clinical symptoms and noninvasive imaging,
the site o the arteriovenous stula may be
remote rom the area a ected, so be prepared
to do complete spinal angiography.
170
4. Look or an enlarged vein lling rom a radic-
ular o a lumbar or intercostal artery in most
cases.
5. Occasionally, the stula may be ound at the
craniocervical junction [19], intracranially
[20], or in the paraspinal region [16].
6. Seek out and care ully study the artery sup-
plying the artery o Adamkiewicz (Fig. 3.5).
7. In cases o thoracic myelopathy rom a dural
AV stula, lack o visualization o the coronal
venous plexus and radicular veins a ter injec-
tion o the artery o Adamkiewicz provides
convincing evidence or venous hypertension
and suggests the diagnosis o an AV stula
[21].
8. Conversely, good visualization o normal spi-
nal cord veins within 15 s a ter seeing the
artery o Adamkiewicz makes the diagnosis o
AV a stula much less likely. Caveat: there
may still be visualization o the venous phase
in 25% o dural AV stulas [22].
9. An exception to this rule is the cranial dAVF
draining into cord veins. Injection o the
artery o Adamkiewicz may look normal
[23].
Spinal Intramedullary or Perimedullary
Arteriovenous Mal ormations
1. All eeding arteries and draining veins should
be identi ed; this requires visualization o the
spinal cord vessels at the level o the lesion,
and several segmental levels above and below
the lesion.
2. Normal spinal arteries should be seen above
and below the lesion to ensure all eeders have
been seen.
3. Biplane, magni ed runs are use ul to evaluate
the architecture and relationship to the cord.
4. Rapid imaging rates o 3–5 ps can sometimes
provide a better visualization o the angioar-
chitecture o the lesion.
5. Images should be care ully evaluated to deter-
mine how the lesion relates to the anterior and
posterolateral spinal arteries.
6. Look or intranidal aneurysms and
pseudo-aneurysms.
7. 3D imaging can be use ul.
3 Spinal Angiography
Type IV Spinal Perimedullary
Arteriovenous Fistulas
1. These are uncommon congenital stulas that
are usually obvious on noninvasive imaging.
2. Like other vascular mal ormations, normal
spinal arteries should be seen above and below
the lesion to ensure all eeders have been seen.
3. Biplane, magni ed runs are use ul to evaluate
the architecture and relationship to the cord.
4. These are high fow lesions, requiring rapid
imaging rates o 3–15 ps.
5. 3D imaging may be use ul.
Spinal Intramedullary Vascular Tumors
1. The most common indication is spinal heman-
gioblastoma, usually preoperative and/or
pre-embolization.
2. All eeding arteries and draining veins should
be identi ed; this requires visualization o the
spinal cord vessels at the level o the lesion,
and several segmental levels above and below
the lesion.
3. Biplane, magni ed runs are use ul to evaluate
the architecture and relationship to the cord.
Spinal Extradural Vascular Tumors
1. Common indications are in cases o preopera-
tive evaluation o patients with aneurysmal
bone cyst or vascular metastases such as renal
or thyroid cancer.
2. All eeding arteries should be identi ed; this
requires visualization o the segmental spinal
vessels bilaterally at the level o the lesion,
and several segmental levels above and below
the lesion.
3. Normal spinal arteries at the level o the lesion
or at nearby levels should be identi ed so that
they can be care ully spared during any antici-
pated embolization procedure or at the time o
surgery.
Preoperative Angiography or Surgery
That May Risk Occlusion o the Spinal
Cord Blood Supply
1. Major spinal surgery, aortic aneurysm repair,
or stent-gra ts may carry a risk o myelopathy
i radiculomedullary contributors to the ante-
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