CardioVascular Radiology
Cardiovasc. Radiol. 1, 21-26 (1978)
9 by Springer-Verlag 1978
Experience with Mechanical Contrast Medium Injection at Selective Coronary Angiography G . F r a n k e n a n d E. Z e i t l e r 1 Radiologic Department of the Aggertal Clinic, Clinic for Vascular Diseases, Engelskirchen, FRG
Abstract. T h i s is a r e p o r t o f o u r e x p e r i e n c e s w i t h t h e a u t o m a t i c c o n t r a s t m e d i u m i n j e c t o r at s e l e c t i v e c o r o n a r y a n g i o g r a p h y d u r i n g 836 e x a m i n a t i o n s , a n d t h e q u a n t i t a t i v e e v a l u a t i o n o f 193 single i n j e c t i o n s . U s i n g a v e r a g e i n j e c t i o n v o l u m e s p e r single i n j e c t i o n o f 5.0 m l f o r t h e left a n d 2.5 m l f o r t h e r i g h t c o r o n a r y artery, a clear reduction of the quantity of contrast m e d i u m at c o n s t a n t d e f i n i t i o n c a n be r e g i s t e r e d . T h e v a r i a b i l i t y in i n c r e a s e i n t h e i n j e c t i o n f l o w f r o m 0 u p to t h e p e a k f l o w a p p e a r s to be i m p o r t a n t a c c o r d i n g t o t h e a n a t o m i c a n d p a t h o l o g i c facts. F r e q u e n t l y a contrast medium reflux occurs out of the coronary o s t i u m i n t o t h e a o r t a . O n t h e w h o l e , a u t o m a t i c inject i o n at selective c o r o n a r y a n g i o g r a p h y is a r e p r o d u c ible a n d e x t e n s i b l e m e t h o d w i t h f e w risks.
Key words: C o r o n a r y a n g i o g r a p h y - A u t o m a t i c a n d manual injection techniques.
A l t h o u g h t h e m e c h a n i c a l i n j e c t o r is u s e d t o d a y f o r t h e a n g i o g r a p h i c d e m o n s t r a t i o n o f n e a r l y all v a s c u l a r z o n e s , t h e m a n u a l i n j e c t i o n o f c o n t r a s t m e d i u m is g e n e r a l l y u s e d in s e l e c t i v e c o r o n a r y a n g i o g r a p h y . O n e reason may be the limited requirements demanded of automatic injectors. There are only a small number o f p u b l i c a t i o n s a b o u t selective c o r o n a r y a n g i o g r a p h y w i t h a u t o m a t i c i n j e c t o r s [4, 5, 6]. T h e c o n d i t i o n s f o r i n j e c t i o n i n t o t h e c e r e b r a l arteries o r c o r o n a r y a r t e r i e s a r e : 1. T h e e x a c t l y p r e s e l e c t a b l e s m a l l q u a n t i t y o f c o n trast medium. 2. T h e v a r i a b l e i n c r e a s e in s p e e d o f i n j e c t i o n . 3. A n d the m o d i f i c a t i o n o f t h e i n j e c t i o n p r o c e s s . I n this p a p e r , w e r e p o r t o n o u r s y s t e m a t i c i n v e s t i 1 Present address and address for reprint requests." Prof. Dr. E. Zeitler, Radiologisches Zentrum der St~idtischen Krankenanstalten, FlurstraBe 17, D-8500 Ntirnberg, FRG
g a t i o n s w i t h a u t o m a t i c c o n t r a s t m e d i u m i n j e c t i o n at c o r o n a r y a n g i o g r a p h y in c o m p a r i s o n w i t h m a n u a l injection.
Methods Until 1974, 528 patients in the Radiologic Department of the Aggertal Clinic had been submitted to selective coronary angiography using manual contrast medium injection. The quantities of contrast medium injected were 8 to 10 ml into the left and 3 to 6 ml into the right coronary artery. From 1974 to 1976, 836 patients received the contrast medium injection using the Viamonte-Hobbs injector 2000 [7]. Besides the possibility of ECG triggering and the time choice for a delayed start of the injection, there are three variables with the Viamonte-Hobbs injector (Fig. 1): 1. The injection flow rate within the range 1-50 mt/s. 2. The increase in rate of the injection flow between 0 and the preselected maximal flow (acceleration). The increase in rate of injection can be selected infinitely between M=minimum and N=normal/maximum (Fig. 3). These are on a scale from A to G (Fig. 1). 3. Variable injection time between 0.5 and 6 s. These three variables determine the effective injection volume. In'order to make an exact quantitative evaluation of the applied contrast medium within the range of a diagnostic routine examination, the injection process was recorded on the electrocardiograph so that the spindle pushing the syringe piston forward was connected by a shaft to a .tachometer generator. The speed of the push and, therefore, of the flow is proportional to the number of revolutions of the spindle. The alternating v61tage of the tachometer thus determines the height of deflection of the pointer. The registered injection processes for 29 patients at 193 injections have been quantitatively evaluated. There were 114 injections into the left and 79 injections into the right coronary artery. During the course of 85 injection processes, large radiographs were taken. Cineangiographs were made during 10~ injections. The coronary angiography was always carried out after transfemoral catheterization using the catheter mentioned by Judkins (3). The procedure was as follows: first the left and then the right coronary artery were injected, and finally, the left ventricle was catheterized. The following values were determined quantitatively: I. Peakflow 2. Injection time 3. The time to reach the peakflow 4. Flow increase (out of 1 and 3)
22
G. Franken and E. Zeitler: Mechanical Contrast Medium Injection at Selective Coronary Angiography
Fig. 1. Part of the dashboard of the Viamonte-Hobbs injector with the control knobs which determine the parameters of injection, injection time, injection flow, and increase in flow.
E b j
-
9
E -
normal
minimum
61
l"s
'
time/s
l*s
, 'time/s
A/,A>,~A"~
2L,,j 9
B #
time/-s Fig. 2. Simplified scheme of the registration of the injected contrast medium bolus.
Fig. 3. Original registrations of contrast medium injections with a flow rate of 6 ml/s. In the upper range the extreme acceleration modes " m i n i m u m " and " n o r m a l " and below the most frequently used modes " B " and " C " are shOwn.
The injection mode (acceleration stage) was recorded, and an eventual reflux of the contrast medium out of the coronary ostium into the aorta was registered in the cineangiographs and divided into five degrees of severity:
II =reflux upon reaching the peakflow III =reflux of the contrast medium during the whole injection time IV =jet effect
O = n o contrast medium reflux I =initial contrast medium reflux when starting injection
The injection volumes corresponding to the zones under the injection curves were determined planimetrically (Fig. 2). Test in-
G. Franken and E. Zeitler: Mechanical Contrast Medium Injection at Selective Coronary Angiography jections for comparison were made using 76% Urografin as contrast medium through a coronary catheter of 7 Charri6re against atmospheric pressure. The average values were mathematically evaluated. The standard deviations were determined if required, and depending on the formulation of the question, the data have been compared with the tests of Student or Wilcoxon respectively, using the z-square test. A probability of 95% (/)6,5 6
2
a. in 51% of the e x a m i n a t i o n s the flow rates were less than 1.5 ml/s (mean value 1.1 ml/s) b. in 30% of the e x a m i n a t i o n s the flow rates were 1.5 to 2.5 ml/s ( m e a n value 1.9 ml/s) c. in 19% of the e x a m i n a t i o n s the flow rates were more t h a n 2.5 ml/s ( m e a n value 3.0 ml/s)
3. Increase in Flow The following acceleration stages have been used: Into the left coronary artery A = 6% B =32% C =25% D=26% E = 6% F = 3% N= 2%
RIGHT CORONARY ARTERY
LEFT CORONARY ARTERY >4
RIGHT CORONARY ARTERY
5
>3,5
-
~3
Into the right coronary artery A= 9% B =44% C =23% D = 24%
The acceleration stages A to D have been used statistically just as often for the right as for the left c o r o n a r y artery. I n our test series (65 injections), the following increases in flow (Fig. 6) at flow rates be-
4,5-5,5
_~4- 2,5
2,6-4,0 m q,.
2
Cardiovasc. Radiol. 1, 21-26 (1978)
9 by Springer-Verlag 1978
Experience with Mechanical Contrast Medium Injection at Selective Coronary Angiography G . F r a n k e n a n d E. Z e i t l e r 1 Radiologic Department of the Aggertal Clinic, Clinic for Vascular Diseases, Engelskirchen, FRG
Abstract. T h i s is a r e p o r t o f o u r e x p e r i e n c e s w i t h t h e a u t o m a t i c c o n t r a s t m e d i u m i n j e c t o r at s e l e c t i v e c o r o n a r y a n g i o g r a p h y d u r i n g 836 e x a m i n a t i o n s , a n d t h e q u a n t i t a t i v e e v a l u a t i o n o f 193 single i n j e c t i o n s . U s i n g a v e r a g e i n j e c t i o n v o l u m e s p e r single i n j e c t i o n o f 5.0 m l f o r t h e left a n d 2.5 m l f o r t h e r i g h t c o r o n a r y artery, a clear reduction of the quantity of contrast m e d i u m at c o n s t a n t d e f i n i t i o n c a n be r e g i s t e r e d . T h e v a r i a b i l i t y in i n c r e a s e i n t h e i n j e c t i o n f l o w f r o m 0 u p to t h e p e a k f l o w a p p e a r s to be i m p o r t a n t a c c o r d i n g t o t h e a n a t o m i c a n d p a t h o l o g i c facts. F r e q u e n t l y a contrast medium reflux occurs out of the coronary o s t i u m i n t o t h e a o r t a . O n t h e w h o l e , a u t o m a t i c inject i o n at selective c o r o n a r y a n g i o g r a p h y is a r e p r o d u c ible a n d e x t e n s i b l e m e t h o d w i t h f e w risks.
Key words: C o r o n a r y a n g i o g r a p h y - A u t o m a t i c a n d manual injection techniques.
A l t h o u g h t h e m e c h a n i c a l i n j e c t o r is u s e d t o d a y f o r t h e a n g i o g r a p h i c d e m o n s t r a t i o n o f n e a r l y all v a s c u l a r z o n e s , t h e m a n u a l i n j e c t i o n o f c o n t r a s t m e d i u m is g e n e r a l l y u s e d in s e l e c t i v e c o r o n a r y a n g i o g r a p h y . O n e reason may be the limited requirements demanded of automatic injectors. There are only a small number o f p u b l i c a t i o n s a b o u t selective c o r o n a r y a n g i o g r a p h y w i t h a u t o m a t i c i n j e c t o r s [4, 5, 6]. T h e c o n d i t i o n s f o r i n j e c t i o n i n t o t h e c e r e b r a l arteries o r c o r o n a r y a r t e r i e s a r e : 1. T h e e x a c t l y p r e s e l e c t a b l e s m a l l q u a n t i t y o f c o n trast medium. 2. T h e v a r i a b l e i n c r e a s e in s p e e d o f i n j e c t i o n . 3. A n d the m o d i f i c a t i o n o f t h e i n j e c t i o n p r o c e s s . I n this p a p e r , w e r e p o r t o n o u r s y s t e m a t i c i n v e s t i 1 Present address and address for reprint requests." Prof. Dr. E. Zeitler, Radiologisches Zentrum der St~idtischen Krankenanstalten, FlurstraBe 17, D-8500 Ntirnberg, FRG
g a t i o n s w i t h a u t o m a t i c c o n t r a s t m e d i u m i n j e c t i o n at c o r o n a r y a n g i o g r a p h y in c o m p a r i s o n w i t h m a n u a l injection.
Methods Until 1974, 528 patients in the Radiologic Department of the Aggertal Clinic had been submitted to selective coronary angiography using manual contrast medium injection. The quantities of contrast medium injected were 8 to 10 ml into the left and 3 to 6 ml into the right coronary artery. From 1974 to 1976, 836 patients received the contrast medium injection using the Viamonte-Hobbs injector 2000 [7]. Besides the possibility of ECG triggering and the time choice for a delayed start of the injection, there are three variables with the Viamonte-Hobbs injector (Fig. 1): 1. The injection flow rate within the range 1-50 mt/s. 2. The increase in rate of the injection flow between 0 and the preselected maximal flow (acceleration). The increase in rate of injection can be selected infinitely between M=minimum and N=normal/maximum (Fig. 3). These are on a scale from A to G (Fig. 1). 3. Variable injection time between 0.5 and 6 s. These three variables determine the effective injection volume. In'order to make an exact quantitative evaluation of the applied contrast medium within the range of a diagnostic routine examination, the injection process was recorded on the electrocardiograph so that the spindle pushing the syringe piston forward was connected by a shaft to a .tachometer generator. The speed of the push and, therefore, of the flow is proportional to the number of revolutions of the spindle. The alternating v61tage of the tachometer thus determines the height of deflection of the pointer. The registered injection processes for 29 patients at 193 injections have been quantitatively evaluated. There were 114 injections into the left and 79 injections into the right coronary artery. During the course of 85 injection processes, large radiographs were taken. Cineangiographs were made during 10~ injections. The coronary angiography was always carried out after transfemoral catheterization using the catheter mentioned by Judkins (3). The procedure was as follows: first the left and then the right coronary artery were injected, and finally, the left ventricle was catheterized. The following values were determined quantitatively: I. Peakflow 2. Injection time 3. The time to reach the peakflow 4. Flow increase (out of 1 and 3)
22
G. Franken and E. Zeitler: Mechanical Contrast Medium Injection at Selective Coronary Angiography
Fig. 1. Part of the dashboard of the Viamonte-Hobbs injector with the control knobs which determine the parameters of injection, injection time, injection flow, and increase in flow.
E b j
-
9
E -
normal
minimum
61
l"s
'
time/s
l*s
, 'time/s
A/,A>,~A"~
2L,,j 9
B #
time/-s Fig. 2. Simplified scheme of the registration of the injected contrast medium bolus.
Fig. 3. Original registrations of contrast medium injections with a flow rate of 6 ml/s. In the upper range the extreme acceleration modes " m i n i m u m " and " n o r m a l " and below the most frequently used modes " B " and " C " are shOwn.
The injection mode (acceleration stage) was recorded, and an eventual reflux of the contrast medium out of the coronary ostium into the aorta was registered in the cineangiographs and divided into five degrees of severity:
II =reflux upon reaching the peakflow III =reflux of the contrast medium during the whole injection time IV =jet effect
O = n o contrast medium reflux I =initial contrast medium reflux when starting injection
The injection volumes corresponding to the zones under the injection curves were determined planimetrically (Fig. 2). Test in-
G. Franken and E. Zeitler: Mechanical Contrast Medium Injection at Selective Coronary Angiography jections for comparison were made using 76% Urografin as contrast medium through a coronary catheter of 7 Charri6re against atmospheric pressure. The average values were mathematically evaluated. The standard deviations were determined if required, and depending on the formulation of the question, the data have been compared with the tests of Student or Wilcoxon respectively, using the z-square test. A probability of 95% (/)6,5 6
2
a. in 51% of the e x a m i n a t i o n s the flow rates were less than 1.5 ml/s (mean value 1.1 ml/s) b. in 30% of the e x a m i n a t i o n s the flow rates were 1.5 to 2.5 ml/s ( m e a n value 1.9 ml/s) c. in 19% of the e x a m i n a t i o n s the flow rates were more t h a n 2.5 ml/s ( m e a n value 3.0 ml/s)
3. Increase in Flow The following acceleration stages have been used: Into the left coronary artery A = 6% B =32% C =25% D=26% E = 6% F = 3% N= 2%
RIGHT CORONARY ARTERY
LEFT CORONARY ARTERY >4
RIGHT CORONARY ARTERY
5
>3,5
-
~3
Into the right coronary artery A= 9% B =44% C =23% D = 24%
The acceleration stages A to D have been used statistically just as often for the right as for the left c o r o n a r y artery. I n our test series (65 injections), the following increases in flow (Fig. 6) at flow rates be-
4,5-5,5
_~4- 2,5
2,6-4,0 m q,.
2
