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▪is a medical imaging technique used to

visualize blood vessels in the body,
particularly in the context of angiography.

▪ is a medical procedure that involves the

visualization of blood vessels, typically to diagnose
and treat conditions related to the circulatory
system. DSA is a more advanced and refined
version of traditional angiography.
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▪ The post-contrast images are digitally subtracted

from the pre-contrast images. This subtraction
process effectively removes the bones and tissues,
leaving only the contrast-filled blood vessels
visible in the resulting images.

▪ The subtracted images display the blood vessels

with greater clarity, as they eliminate the
interference from other structures. The
visualization of blood flow, potential blockages,
and abnormalities is greatly improved compared
to traditional angiography.
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▪By digitally subtracting the background

structures, DSA provides a clearer view of
blood vessels, aiding in the diagnosis and
treatment of vascular conditions.

▪DSA typically requires a shorter exposure to

X-rays compared to conventional angiography,
leading to reduced radiation exposure for the
patient.
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▪DSA can provide real-time images, allowing

physicians to monitor blood flow and the
effects of interventions in real time.

▪DSA can sometimes replace more invasive

procedures like exploratory surgeries, as it
provides detailed information about blood
vessel conditions without the need for
extensive incisions.
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▪ is a technique used in medical imaging,

specifically in the field of angiography, to enhance
the visualization of blood vessels and vascular
structures by selectively removing or highlighting
certain energy levels of X-ray photons.

▪ This technique is particularly useful for improving

the clarity of blood vessels, especially when
contrast agents are used to enhance their visibility.

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▪This method involves using two different energy

levels (often referred to as high and low kVp
settings) to acquire two sets of X-ray images. The
acquired images are then processed to create
subtracted images that highlight the contrast-
enhanced blood vessels while suppressing
other structures.

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▪ is a specialized technique used in medical imaging,

specifically in angiography, to detect changes in
blood vessels and vascular structures over time. This
technique involves comparing a current set of
angiographic images with a reference or baseline
set acquired earlier.
▪ The goal is to highlight differences or changes
between the two image sets, which can aid in the
diagnosis and monitoring of vascular conditions.

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▪ is a technique in medical imaging that involves

acquiring a series of angiographic images at
different time intervals and then subtracting these
images to enhance the visualization of blood vessels
and changes that occur over time. This technique is
particularly useful for assessing blood flow
dynamics, evaluating the effects of interventions, and
monitoring the progression or regression of vascular
conditions.

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Angiography
▪refers to radiologic imaging of blood vessels after
injection of a contrast medium.
▪To visualize these low-contrast structures, contrast
media is injected by a catheter that is placed in the
vessel of interest.
▪Positive contrast media are more commonly used, but
there are instances when use of negative contrast
media is indicated. Highly specialized imaging
equipment is required for these procedures.
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Angiography can be more specifically described as

follows:
▪ Arteriography: imaging of the arteries

▪ Venography: imaging of the veins

▪ Angiocardiography: imaging of the heart and

associated structures

▪ Lymphography: imaging of the lymphatic

vessels/nodes

Angiography is performed by a team of health

professionals, including:
(1) a radiologist (or other qualified angiographer),
(2) a “scrub” nurse or technologist who assists with
sterile and catheterization procedures, and
(3)a radiologic technologist.

Depending on the departmental protocol and the

specific situation, an additional physician, nurse,
technologist, and/or hemodynamic technologist also
may be available to assist with the procedure.
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1. Obtain Medical History

❑Assess patient’s ability to tolerate the procedure
❑Key areas to address:
▪ Allergy history (e.g., previous reactions to contrast
agents)
▪ Cardiac/Pulmonary status
▪ Renal function

❑Review medication history:

▪ Certain medications (e.g., anticoagulants) may increase
the risk of bleeding during and after the procedure.
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2. Review Laboratory Reports

❑Check previous lab results and other relevant
data
❑Ensure there are no contraindications to the
procedure
❑Verify kidney function if contrast is being used

▪ Complete Blood Count (CBC): To check for anemia, infection, or platelet

abnormalities.
▪ Coagulation Profile (PT/INR, aPTT): To assess blood clotting ability,
important for avoiding excessive bleeding during the procedure.
▪ Renal Function Tests (Blood Urea Nitrogen (BUN) and Creatinine): To
assess kidney function, especially important because the contrast dye used in
angiography can affect the kidneys.
▪ Electrolyte Panel: To check for imbalances in electrolytes like potassium,
sodium, and chloride, which could affect heart function.
▪ Blood Glucose Levels: Particularly important for diabetic patients to monitor
glucose control.
▪ Liver Function Tests (LFTs): Sometimes performed to assess liver health and
metabolism of medications.
▪ Type and Screen: Blood typing in case a transfusion is needed during or after
the procedure.

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3. Patient Education and Informed Consent

▪ Detailed explanation of the procedure provided to

the patient.
▪ Ensures full understanding and cooperation.
▪ Includes discussion of possible risks and
complications.
▪ Informed decision-making before signing consent.

4. Fasting Requirements
❑Fasting Before Procedure
▪ Solid food is withheld for ~8 hours
▪ Purpose: Reduce risk of aspiration
▪ Ensure patient hydration
▪ Goal: Minimize risk of contrast-induced renal
damage

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5. Premedication and Comfort

❑Premedication: Helps patient relax
❑Vital Signs:
▪ Recorded before procedure
▪ Pulse check distal to puncture site
❑Comfort Measures:
▪ Sponge under knees to reduce back strain
▪ The puncture site is shaved, cleaned, and draped.
▪ Continual communication and monitoring of the patient
by the technologist and the rest of the angiography team
will greatly alleviate patient discomfort and fear.

To visualize the vessel(s) of interest, a catheter must be

introduced into the patient's vasculature, through which
the contrast media will be injected. A commonly used
method for catheterization is the Seldinger technique.

This technique was developed by Dr. Sven Seldinger in

the 1950s and remains popular today. It is a
percutaneous (through the skin) technique that can be
used for arterial or venous access.

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Four vessels are typically considered for

catheterization:
1. Femoral
2. Axillary
3. Brachial, and
4. Radial

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▪ Site selection based on strong pulse and absence of

vessel disease.
▪ Femoral artery: Preferred for arterial puncture due
to size and accessibility.
▪ Puncture made just below the inguinal ligament.
▪ Alternative sites: Axillary, brachial, or radial
arteries (if femoral access is contraindicated).
▪ Femoral vein: Preferred for venous access.

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A sterile tray contains the basic equipment necessary for a Seldinger

catheterization of a femoral artery Basic sterile items include the
following:
1. Hemostats
2. Prep sponges and antiseptic solution
3. Scalpel blade
4. Syringe and needle for local anesthetic
5. Basins and medicine cup
6. Sterile drapes and towels
7. Band-Aids
8. Sterile image intensifier cover

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Contraindications for patients to experience

angiography include:
▪contrast media allergy
▪impaired renal function
▪blood-clotting disorders or taking anticoagulant
medication, and
▪unstable cardiopulmonary/neurologic status.

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Angiographic procedures are not performed without always involving

some level of risk for the patient. Some of the most common risks and
complications include the following:
▪ Bleeding at the puncture site: this usually can be controlled by
applying compression
▪ Thrombus formation: a blood clot may form in a vessel and disrupt
the flow to distal parts
▪ Embolus formation: a piece of plaque may be dislodged from a
vessel wall by the catheter. A stroke or other vessel occlusion may
result
▪ Dissection of a vessel: the catheter may tear the intima of a vessel
▪ Infection of puncture site: this is caused by contamination of the
sterile field
▪ Contrast media reaction: this may be mild, moderate, or severe
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▪After the angiographic procedure has been completed, the

catheter is removed, and compression is applied to the
puncture site.

▪The patient remains on bed rest for a minimum of 4 hours,

but the head of the bed/stretcher may be elevated
approximately 30°. During this time, the patient is
monitored, and vital signs and the peripheral pulse distal to
the puncture site are regularly checked.

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▪ The extremity is also checked for warmth, color, and

numbness to ensure that circulation has not been
disrupted. Oral fluids are given and analgesics are
provided if required.

▪ Patients should be instructed on what to do if the puncture

site spontaneously begins to bleed: apply pressure and
call for help.

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As contrast media is injected into the circulatory

system, it is diluted by blood. The contrast
material must be injected with sufficient pressure
to overcome the patient's systemic arterial
pressure and to maintain a bolus to minimize
dilution with blood. To maintain the flow rates
necessary for angiography, an automatic
electromechanical injector is used. The flow rate
is affected by many variables, such as the
viscosity of the contrast medium, the length and
diameter of the catheter, and injection pressure.
Depending on these variables and the vessel to
be injected, the desired flow rate can be selected
before injection.
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Cerebral angiography is a radiologic study of the blood vessels of the

brain.

❑PURPOSE
The primary purpose of cerebral angiography is to provide a vascular “road
map” that will enable physicians to localize and diagnose pathology or other
anomalies of the brain and neck regions.

❑CATHETERIZATION
The femoral approach is preferred for the catheter insertion. The catheter is
advanced to the aortic arch, and the vessel to be imaged is selected. Vessels
commonly selected for cerebral angiography include the common carotid
arteries, internal carotid arteries, external carotid arteries, and
vertebral arteries.

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❑PATHOLOGIC CONDITIONS
Pathologic indications for cerebral angiography
include the following:
▪Vascular stenosis and occlusions
▪Aneurysms
▪Trauma
▪Arteriovenous malformations
▪Neoplastic disease

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❑PATHOLOGIC
CONDITIONS
Pathologic indications for
cerebral angiography
include the following:

▪ Vascular stenosis
and occlusions
▪ Aneurysms
▪ Trauma
▪ Arteriovenous
malformations
▪ Neoplastic
disease

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❑PURPOSE
▪Thoracic angiography demonstrates the contour and integrity of
the thoracic vasculature. Thoracic aortography is an angiographic
study of the ascending aorta, the arch, the descending portion
of the thoracic aorta, and the major branches.
▪Pulmonary arteriography is an angiographic study of the
pulmonary vessels that usually is done to investigate for
pulmonary embolus. As was mentioned earlier, pulmonary
angiography is performed infrequently because of the availability
of alternative modalities.

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❑CATHETERIZATION
The preferred puncture site for a thoracic aortogram is the
femoral artery. The catheter is advanced to the desired
location in the thoracic aorta. Selective procedures may be
performed with the use of specially designed catheters to
access the vessel of interest.

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Because of the location of the pulmonary artery, the

femoral vein is the preferred site for catheter
insertion. The catheter is advanced along the venous
structures, into the inferior vena cava, through the
right atrium of the heart into the right ventricle, and
into the pulmonary artery. Typically, both pulmonary
arteries are examined.

❑PATHOLOGIC INDICATIONS
Pathologic indications for thoracic and
pulmonary angiography include the
following:
▪ Aneurysms
▪ Congenital abnormalities
▪ Vessel stenosis
▪ Embolus
▪ Trauma
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❑PURPOSE
Angiocardiography refers specifically to radiologic imaging of the
heart and associated structures. Coronary arteriography typically
is performed at the same time to visualize the coronary arteries.

Cardiac catheterization is a more general term that is used to

describe placing a catheter in the heart; it includes studies in addition
to radiologic imaging ones, such as obtaining blood samples to
measure oxygen saturation (oximetry) and measuring hemodynamic
pressures and gradients. Specialized physiologic monitoring
equipment is required for these sensitive measurements.

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❑PATHOLOGIC INDICATIONS
▪ Coronary artery disease and angina
▪ Myocardial infarct
▪ Valvular disease
▪ Atypical chest pain
▪ Congenital heart anomaly
▪ Other heart and aorta pathology

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❑CATHETERIZATION
As for other angiograms, the femoral artery is the
preferred site for catheterization. The catheter is
advanced to the aorta and along its length into the left
ventricle for the left ventriculogram. A pigtail catheter
is used because a large volume of contrast media will be
injected. For the coronary arteriogram, the catheter is
changed and the coronary artery is selected; both right
and left coronary arteries are routinely examined.
Specially shaped catheters are designed to fit each of the
coronary arteries.
After injection of contrast media into the coronary
arteries, the catheter is immediately removed to prevent
occluding the vessel.
Access to the right side of the heart is obtained by
catheterizing the femoral vein and advancing the catheter
through the venous structures until the right side of the
heart is reached.
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❑PURPOSE
Abdominal angiography demonstrates the contour and integrity of abdominal
vasculature. This means that the placement or displacement of abdominal vessels
being studied and possible obstructions or vessel tears (e.g., aneurysm ballooning)
will be demonstrated. Any displacement of vessels may indicate a space-occupying
lesion.
Aortography refers to an angiographic study of the aorta, and selective studies refer
to the catheterization of a specific vessel.
Venacavography demonstrates the superior and/or inferior vena cava.

❑PATHOLOGIC INDICATIONS
Pathologic indications for abdominal angiography include the following:
•Aneurysm
•Congenital abnormality
•GI bleed
•Stenosis or occlusion
•Trauma
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❑CATHETERIZATION
For an aortogram, the aorta typically is accessed by the femoral artery. The type and size of
catheter required depend on the structure, but a pigtail catheter usually is used because a
larger amount of contrast, as is needed for an abdominal aortogram, will be delivered.

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❑CATHETERIZATION
Selective angiographic studies require the use of specially shaped
catheters to access the vessel of interest. Common selective studies
performed include the celiac artery, the renal arteries, and the
superior and inferior mesenteric arteries, which are selected when a
GI bleed is investigated. A superselective study involves selecting a
branch of a vessel. A common example of this is selection of the
hepatic or splenic artery; these are two of the branches of the celiac
artery.

Catheterization for venacavography is obtained by a femoral vein

puncture. The catheter then is advanced to the desired level.
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❑PURPOSE
Peripheral angiography is a radiologic examination of the peripheral
vasculature after the injection of contrast media. Peripheral angiography may be
an arteriogram, in which case the injection is administered by a catheter in an
artery, or a venogram, in which the injection is placed into a vein of the extremity
being examined. It should be noted, however, that venograms now are rarely
performed because of the increased sensitivity of ultrasound (color duplex) to
demonstrate pathology.
❑PATHOLOGIC INDICATIONS
Pathologic indications for peripheral angiography include the following:
•Atherosclerotic disease
•Vessel occlusion and stenosis
•Trauma
•Neoplasm
•Embolus and thrombus

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❑CATHETERIZATION
The Seldinger technique is
used to access the femoral
artery or an alternate
injection site for a
peripheral arteriogram.
For a lower limb
arteriogram, the catheter is
advanced just superior to
the aortic bifurcation.

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❑ PURPOSE
Lymphography is performed to visualize
the lymph vessels and nodes.
Although CT has largely replaced
lymphography in the assessment of nodes,
lymphography is indicated in certain
situations.
❑ PATHOLOGIC INDICATIONS
Pathologic indications for lymphography
include the following:
•Assessment of the lymphatics in the
staging of malignancies, especially cervical
and prostate cancers
•Assessment of Hodgkin's lymphoma
•Peripheral swelling
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Interventional imaging procedures

▪ A Radiologic procedures that intervene in a disease

process, providing a therapeutic outcome.

▪ Simply stated, interventional procedures use

angiographic techniques for the treatment of disease,
in addition to providing certain diagnostic information.

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The purpose of these procedures and benefits to the

patient and health care system include the following:
▪ Techniques that are minimally invasive with lower risk
compared with traditional surgical procedures
▪ Procedures that are less expensive than traditional
medical and surgical procedures
▪ Shorter hospital stays for the patient
▪ Shorter recovery time because of a safer, less invasive
procedure
▪ Alternatives for patients who are not candidates for
surgery

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▪ These procedures typically are performed in an angiographic

suite under the direction of an interventional radiologist.
Fluoroscopic guidance is crucial to follow the path of the
required needles and catheters.

▪ The increase in complexity of the type of interventional

procedures currently performed has resulted in the upgrading
of many angiography units to meet operating room
specifications. This reduces the risk for infection and allows
rapid surgical management in case of complications.

▪ Interventional procedures may be categorized as vascular or

nonvascular procedures
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Embolization

Transcatheter embolization is a procedure that uses an

angiographic approach to create an embolus in a vessel, thus
restricting blood flow.
A number of clinical indications for this procedure exist, including
the following:

•Stop blood blow to a site of pathology.

•Reduce blood flow to a highly vascular structure and tumor before
surgery.
•Stop active bleeding at a specific site.
•Deliver a chemotherapeutic agent
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Uterine fibroid embolization

This procedure is used to treat symptomatic fibroids.
Embolization of the uterine artery can shrink the fibroids
and eliminate associated pain and bleeding, thus
replacing a hysterectomy.

Uterine artery embolization

The uterine artery also may be embolized to stop life-
threatening postpartum bleeding, potentially preventing
hysterectomy.

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Chemoembolization
▪ This is used most commonly for hepatic
malignancies. The chemotherapy agent is injected
into the tumor vasculature.
▪ Chemoembolization is a specialized form of
vascular embolization used primarily to treat
cancer, especially liver tumors. In this procedure,
chemotherapy drugs are delivered directly to the
tumor through a catheter, and an embolic agent is
used to block the blood supply to the tumor,
trapping the drugs at the site and depriving the
tumor of nutrients.

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Angioplasty

Percutaneous transluminal angioplasty (PTA) uses an

angiographic approach and specialized catheters to dilate a
stenosed vessel. This procedure is a long-standing
interventional technique that has applications for a wide
variety of vessel types and sizes (e.g., coronary, iliac, renal
arteries).
A catheter with a deflated balloon is advanced to the vessel
of interest. Hemodynamic pressures proximal and distal to
the stenosis are obtained, and a pre- angioplasty angiogram
is performed.
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▪ The balloon portion of the catheter is placed at the vessel stenosis,

and the balloon is inflated.

▪ The pressure of the inflation is monitored by a pressure gauge to

prevent vessel rupture, and more than one inflation may be
required. The duration of the inflations is carefully timed to
eliminate damage to distal tissue because the blood supply is
temporarily occluded.

▪ Final steps of the procedure include obtaining arterial pressures

proximal and distal to the dilated portion of the vessel and
performing a post-angioplasty angiogram. This allows assessment
of the effectiveness of the procedure.

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Stent placement

▪ To assist in maintaining patency of the vessel, a stent is inserted

across the treated area during the angioplasty.

▪ A stent is a cagelike metal device that is placed in the lumen

of a vessel to provide support.

▪ It can be a self-expanding type or a balloon-expandable type.

The self-expanding type automatically expands when the stent
cover is removed from the vessel, and the balloon-expandable
type (the compressed stent covers the balloon on the catheter) is
positioned during the balloon inflation phase of the angioplasty.

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▪ Currently, many stents are impregnated with a

pharmacologic agent that inhibits the regrowth of
vascular tissue within the artery and interferes with
the process of restenosis.
• Scar Tissue Formation: When a balloon is inflated to open the artery,
it can cause injury to the arterial wall. The healing process may
result in excess scar tissue, leading to restenosis.
• In-Stent Restenosis: In cases where a stent has been placed to keep
the artery open, restenosis may occur within the stent as tissue
grows through and around it.

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Inferior vena cava filter placement

▪ is indicated for patients who have recurrent pulmonary emboli
or who are at high risk for developing them (e.g., post trauma
with pelvic and lower extremity fractures).

▪ A filter is placed in the inferior vena cava to trap potentially fatal

emboli that originate in the lower limbs. A variety of filter
designs are available for this procedure

▪ A femoral or jugular vein puncture is used to gain access to the

inferior vena cava. An angiographic technique then is used to
deploy the filter by a catheter. The filter has struts that anchor it
to the walls of the vessel. The filter must be placed inferior to the
renal veins to prevent renal vein thrombosis.
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Risks and complications:

Besides the usual angiographic complications (e.g.,

infection, bleeding), the added risk that the filter may
migrate into the heart and lungs exists. The filter also
may become occluded in the long term.

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Vertebroplasty

▪ Percutaneous vertebroplasty is used to treat patients who

have vertebral pain and instability caused by osteoporosis,
spinal metastases, compression fractures, or vertebral
angiomas. Percutaneous injection of acrylic cement into the
vertebral body under fluoroscopic guidance contributes to
stabilization of the spine and long-term pain relief.
▪ This procedure is performed in the OR or in the interventional
suite. The surgeon will place a small hollow needle through
the patient's back until it reaches the affected area of the
vertebrae.

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▪ Once the needle is in place and this has been verified by C-arm
fluoroscopy (PA and lateral views), the surgeon injects an
orthopedic cement mixture that also may include contrast (for
better visibility on the monitor). The surgeon usually will ask for
continuous fluoro while the cement mixture is being injected. At
this point, the surgeon checks to ensure that the cement has filled
the entire affected vertebral area and withdraws the needle.
▪ The orthopedic cement hardens quickly and stabilizes the
fractured vertebrae, which results in pain relief.

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Kyphoplasty

▪ The vertebroplasty technique has been modified

recently, resulting in a procedure known as
kyphoplasty. Through small incisions, a kyphoplasty
balloon is inserted into a collapsed vertebral body.
The balloon is inflated for the purpose of restoring the
collapsed portion of the vertebrae Acrylic cement
then is injected to stabilize the vertebrae.

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Risks and complications:

▪ Complications of vertebroplasty include leakage of the
cement into adjacent structures, which may require
emergency surgery.
▪ A less common complication is pulmonary embolus,
which causes migration of the cement into perivertebral
veins.
▪ Complications associated with kyphoplasty are less than
with vertebroplasty because less cement is required and
it is injected in a more controlled fashion.

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