Angiography

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Angiography
Cerebral angiography, arteria vertebralis sinister injection.JPG
Angiogram of the brain showing a transverse projection of the vertebro basilar and posterior cerebral circulation.
ICD-9-CM 88.40-88.68
MeSH D000792
OPS-301 code 3–60

Angiography or arteriography is a medical imaging technique used to visualize the inside, or lumen, of blood vessels and organs of the body, with particular interest in the arteries, veins, and the heart chambers. Modern angiography is performed by injecting a radio-opaque contrast agent into the blood vessel and imaging using X-ray based techniques such as fluoroscopy.

Contents

The word itself comes from the Greek words ἀγγεῖον angeion 'vessel' and γράφειν graphein 'to write, record'. The film or image of the blood vessels is called an angiograph, or more commonly an angiogram. Though the word can describe both an arteriogram and a venogram, in everyday usage the terms angiogram and arteriogram are often used synonymously, whereas the term venogram is used more precisely. [1]

The term angiography has been applied to radionuclide angiography and newer vascular imaging techniques such as CO2 angiography, CT angiography and MR angiography. [2] The term isotope angiography has also been used, although this more correctly is referred to as isotope perfusion scanning.

History

Renal artery angiography video

The technique was first developed in 1927 by the Portuguese physician and neurologist Egas Moniz at the University of Lisbon to provide contrasted X-ray cerebral angiography in order to diagnose several kinds of nervous diseases, such as tumors, artery disease and arteriovenous malformations. Moniz is recognized as the pioneer in this field. [3] He performed the first cerebral angiogram in Lisbon in 1927, and Reynaldo dos Santos performed the first aortogram in the same city in 1929. In fact, many current angiography techniques were developed by the Portuguese at the University of Lisbon. For example, in 1932, Lopo de Carvalho performed the first pulmonary angiogram via venous puncture of the superior member. In 1948 the first cavogram was performed by Sousa Pereira. With the introduction of the Seldinger technique in 1953, the procedure became markedly safer as no sharp introductory devices needed to remain inside the vascular lumen. Radial access technique for angiography can be traced back to 1989, when Lucien Campeau first cannulated the radial artery to perform a coronary angiogram. [4]

Technique

Depending on the type of angiogram, access to the blood vessels is gained most commonly through the femoral artery, to look at the left side of the heart and at the arterial system; or the jugular or femoral vein, to look at the right side of the heart and at the venous system. Using a system of guide wires and catheters, a type of contrast agent (which shows up by absorbing the X-rays), is added to the blood to make it visible on the X-ray images.

The X-ray images taken may either be still, displayed on an image intensifier or film, or motion images. For all structures except the heart, the images are usually taken using a technique called digital subtraction angiography or DSA. Images in this case are usually taken at 2–3 frames per second, which allows the interventional radiologist to evaluate the flow of the blood through a vessel or vessels. This technique "subtracts" the bones and other organs so only the vessels filled with contrast agent can be seen. The heart images are taken at 15–30 frames per second, not using a subtraction technique. Because DSA requires the patient to remain motionless, it cannot be used on the heart. Both these techniques enable the interventional radiologist or cardiologist to see stenosis (blockages or narrowings) inside the vessel which may be inhibiting the flow of blood and causing pain.

After the procedure has been completed, if the femoral technique is applied, the site of arterial entry is either manually compressed, stapled shut, or sutured in order to prevent access-site complications. [5]

Herzkatheterlabor modern.jpeg
Catheterization Lab
Catheterization selective angiography.JPG
Catheterization in selective angiography

Uses

Finger angioma seen on angiogram Angiome annulaire.JPG
Finger angioma seen on angiogram

Coronary angiography

One of the most common angiograms performed is to visualize the coronary arteries. A long, thin, flexible tube called a catheter is used to administer the X-ray contrast agent at the desired area to be visualized. The catheter is threaded into an artery in the forearm, and the tip is advanced through the arterial system into the major coronary artery. X-ray images of the transient radiocontrast distribution within the blood flowing inside the coronary arteries allows visualization of the size of the artery openings. The presence or absence of atherosclerosis or atheroma within the walls of the arteries cannot be clearly determined.

Coronary angiography can visualize coronary artery stenosis, or narrowing of the blood vessel. The degree of stenosis can be determined by comparing the width of the lumen of narrowed segments of blood vessel with wider segments of adjacent vessel. [5]

The coronary angiography is performed under local anaesthesia. The patient is awake during the procedure. An incision is made in the groin, wrist, or arm, and a catheter is inserted into the artery through it. An X-ray is used to guide the catheter to the area of blockage. A dye is inserted through the catheter to make the places of blockage visible.

When the catheter is in position, a thin wire with a balloon is guided to the place of blockage. The balloon is inflated to widen the artery, allowing the blood to flow freely. Often, a stent is used, and as the balloon is inflated, the stent in place expands and holds open the artery. The balloon is then deflated and removed, leaving the stent in place.

After the completion of the procedure, the catheter is removed, and the plug area is sealed using angio-seal.

The procedure takes around two hours, and the patient can be discharged after an overnight stay in the hospital, depending on the condition. [6]

Cerebral angiography

Cerebral angiography provides images of blood vessels in and around the brain to detect abnormalities, including arteriovenous malformations and aneurysms. [7] One common cerebral angiographic procedure is neuro-vascular digital subtraction angiography. [8] [9]

Pulmonary angiography

Pulmonary angiography is used to visualise the anatomy of pulmonary vessels. Pulmonary angiography may be used during embolization of pulmonary arteriovenous malformations. [10] In addition, pulmonary angiography may be performed during treatment of pulmonary embolisms. [11]

Peripheral angiography

Angiography is also commonly performed to identify vessels narrowing in patients with leg claudication or cramps, caused by reduced blood flow down the legs and to the feet; in patients with renal stenosis (which commonly causes high blood pressure) and can be used in the head to find and repair stroke. These are all done routinely through the femoral artery, but can also be performed through the brachial or axillary (arm) artery. Any stenoses found may be treated by the use of balloon angioplasty, stenting, or atherectomy.

Visceral angiography

A common indication for angiography is to evaluate and guide treatment for internal (e.g. gastrointestinal) bleeding. [12] Angiography may also be used during hemorrhoidal artery embolization for treatment of symptomatic hemorrhoids. [13]

Fluorescein angiography

Fluorescein angiography is a medical procedure in which a fluorescent dye is injected into the bloodstream. The dye highlights the blood vessels in the back of the eye so they can be photographed. This test is often used to manage eye disorders. [14]

OCT angiography

Optical coherence tomography (OCT) is a technology using near-infrared light to image the eye, in particular penetrate the retina to view the micro-structure behind the retinal surface. Ocular OCT angiography (OCTA) is a method leveraging OCT technology to assess the vascular health of the retina. [15]

Microangiography

Microangiography is commonly used to visualize tiny blood vessels.

Post mortem CT angiography

Post mortem CT angiography for medicolegal cases is a method initially developed by a virtopsy group. Originating from that project, both watery [16] and oily [17] solutions have been evaluated.

While oily solutions [17] require special deposition equipment to collect waste water, watery [16] solutions seem to be regarded as less problematic. Watery solutions also were documented to enhance post mortem CT tissue differentiation whereas oily solutions were not. Conversely, oily solutions seem to only minimally disturb ensuing toxicological analysis, while watery solutions may significantly impede toxicological analysis, thus requiring blood sample preservation before post mortem CT angiography. [18]

Complications

Angiography is a relatively safe procedure. But it does have some minor and very few major complications. After an angiogram, a sudden shock can cause a little pain at the surgery area, but heart attacks and strokes usually do not occur, as they may in bypass surgery. The risk of complications from angiography can be reduced with a prior CT scan by providing clinicians with more information about number and positioning of the clots in advance. [19] [20]

Cerebral angiography

Major complications in cerebral angiography such as in digital subtraction angiography or contrast MRI are also rare but include stroke, an allergic reaction to the anaesthetic other medication or the contrast medium, blockage or damage to one of the access veins in the leg, pseudoaneurysm at the puncture site; or thrombosis and embolism formation. Bleeding or bruising at the site where the contrast is injected are minor complications, delayed bleeding can also occur but is rare. [21]

Additional risks

The contrast medium that is used usually produces a sensation of warmth lasting only a few seconds, but may be felt in a greater degree in the area of injection. If the patient is allergic to the contrast medium, much more serious side effects are inevitable; however, with new contrast agents the risk of a severe reaction is less than one in 80,000 examinations. Additionally, damage to blood vessels can occur at the site of puncture/injection, and anywhere along the vessel during passage of the catheter. If digital subtraction angiography is used instead, the risks are considerably reduced because the catheter does not need to be passed as far into the blood vessels; thus lessening the chances of damage or blockage.

Infection

Antibiotic prophylaxis may be given in those procedures that are not clean, or clean procedures that results in generation of infarcted or necrotic tissues such as embolisation. Routine diagnostic angiography is often considered a clean procedure. Prophylaxis is also given to prevent infection from infected space into blood stream. [22]

Thrombosis

There are six risk factors causing thrombosis after arterial puncture: low blood pressure, small arterial diameter, multiple puncture tries, long duration of cannulation, administration of vasopressor/inotropic agents, [23] and the usage of catheters with side holes. [24]

See also

Related Research Articles

<span class="mw-page-title-main">Arteriovenous malformation</span> Abnormal connection between arteries and veins, bypassing the capillaries

An arteriovenous malformation (AVM) is an abnormal connection between arteries and veins, bypassing the capillary system. Usually congenital, this vascular anomaly is widely known because of its occurrence in the central nervous system, but can appear anywhere in the body. The symptoms of AVMs can range from none at all to intense pain or bleeding, and they can lead to other serious medical problems.

<span class="mw-page-title-main">Interventional radiology</span> Medical subspecialty

Interventional radiology (IR) is a medical specialty that performs various minimally-invasive procedures using medical imaging guidance, such as x-ray fluoroscopy, computed tomography, magnetic resonance imaging, or ultrasound. IR performs both diagnostic and therapeutic procedures through very small incisions or body orifices. Diagnostic IR procedures are those intended to help make a diagnosis or guide further medical treatment, and include image-guided biopsy of a tumor or injection of an imaging contrast agent into a hollow structure, such as a blood vessel or a duct. By contrast, therapeutic IR procedures provide direct treatment—they include catheter-based medicine delivery, medical device placement, and angioplasty of narrowed structures.

<span class="mw-page-title-main">Coronary catheterization</span> Radiography of heart and blood vessels

A coronary catheterization is a minimally invasive procedure to access the coronary circulation and blood filled chambers of the heart using a catheter. It is performed for both diagnostic and interventional (treatment) purposes.

Intravascular ultrasound (IVUS) or intravascular echocardiography is a medical imaging methodology using a specially designed catheter with a miniaturized ultrasound probe attached to the distal end of the catheter. The proximal end of the catheter is attached to computerized ultrasound equipment. It allows the application of ultrasound technology, such as piezoelectric transducer or CMUT, to see from inside blood vessels out through the surrounding blood column, visualizing the endothelium of blood vessels.

<span class="mw-page-title-main">Cerebral angiography</span> Angiography that produces images of blood vessels in and around the brain

Cerebral angiography is a form of angiography which provides images of blood vessels in and around the brain, thereby allowing detection of abnormalities such as arteriovenous malformations and aneurysms. It was pioneered in 1927 by the Portuguese neurologist Egas Moniz at the University of Lisbon, who also helped develop thorotrast for use in the procedure.

<span class="mw-page-title-main">Cardiac catheterization</span> Insertion of a catheter into a chamber or vessel of the heart

Cardiac catheterization is the insertion of a catheter into a chamber or vessel of the heart. This is done both for diagnostic and interventional purposes.

<span class="mw-page-title-main">Embolization</span> Passage and lodging of an embolus within the bloodstream

Embolization refers to the passage and lodging of an embolus within the bloodstream. It may be of natural origin (pathological), in which sense it is also called embolism, for example a pulmonary embolism; or it may be artificially induced (therapeutic), as a hemostatic treatment for bleeding or as a treatment for some types of cancer by deliberately blocking blood vessels to starve the tumor cells.

<span class="mw-page-title-main">Pulmonary angiography</span>

Pulmonary angiography is a medical fluoroscopic procedure used to visualize the pulmonary arteries and much less frequently, the pulmonary veins. It is a minimally invasive procedure performed most frequently by an interventional radiologist or interventional cardiologist to visualise the arteries of the lungs.

Transcatheter arterial chemoembolization (TACE) is a minimally invasive procedure performed in interventional radiology to restrict a tumor's blood supply. Small embolic particles coated with chemotherapeutic drugs are injected selectively through a catheter into an artery directly supplying the tumor. These particles both block the blood supply and induce cytotoxicity, attacking the tumor in several ways.

<span class="mw-page-title-main">Magnetic resonance angiography</span> Group of techniques based on magnetic resonance imaging (MRI) to image blood vessels.

Magnetic resonance angiography (MRA) is a group of techniques based on magnetic resonance imaging (MRI) to image blood vessels. Magnetic resonance angiography is used to generate images of arteries in order to evaluate them for stenosis, occlusions, aneurysms or other abnormalities. MRA is often used to evaluate the arteries of the neck and brain, the thoracic and abdominal aorta, the renal arteries, and the legs.

<span class="mw-page-title-main">Uterine artery embolization</span>

Uterine artery embolization is a procedure in which an interventional radiologist uses a catheter to deliver small particles that block the blood supply to the uterine body. The procedure is primarily done for the treatment of uterine fibroids and adenomyosis. Compared to surgical treatment for fibroids such as a hysterectomy, in which a woman's uterus is removed, uterine artery embolization may be beneficial in women who wish to retain their uterus. Other reasons for uterine artery embolization are postpartum hemorrhage and uterine arteriovenous malformations.

<span class="mw-page-title-main">Digital subtraction angiography</span> Method for delineating blood vessels using contrast medium

Digital subtraction angiography (DSA) is a fluoroscopy technique used in interventional radiology to clearly visualize blood vessels in a bony or dense soft tissue environment. Images are produced using contrast medium by subtracting a "pre-contrast image" or mask from subsequent images, once the contrast medium has been introduced into a structure. Hence the term "digital subtraction angiography. Subtraction angiography was first described in 1935 and in English sources in 1962 as a manual technique. Digital technology made DSA practical starting in the 1970s.

<span class="mw-page-title-main">Computed tomography angiography</span> Medical investigation technique

Computed tomography angiography is a computed tomography technique used for angiography—the visualization of arteries and veins—throughout the human body. Using contrast injected into the blood vessels, images are created to look for blockages, aneurysms, dissections, and stenosis. CTA can be used to visualize the vessels of the heart, the aorta and other large blood vessels, the lungs, the kidneys, the head and neck, and the arms and legs. CTA can also be used to localise arterial or venous bleed of the gastrointestinal system.

Fractional flow reserve (FFR) is a diagnostic technique used in coronary catheterization. FFR measures pressure differences across a coronary artery stenosis to determine the likelihood that the stenosis impedes oxygen delivery to the heart muscle.

Embolectomy is the emergency interventional or surgical removal of emboli which are blocking blood circulation. It usually involves removal of thrombi, and is then referred to as thromboembolectomy or thrombectomy. Embolectomy is an emergency procedure often as the last resort because permanent occlusion of a significant blood flow to an organ leads to necrosis. Other involved therapeutic options are anticoagulation and thrombolysis.

<span class="mw-page-title-main">Hybrid cardiac surgery</span>

A hybrid cardiac surgical procedure in a narrow sense is defined as a procedure that combines a conventional, more invasive surgical part with an interventional part, using some sort of catheter-based procedure guided by fluoroscopy imaging in a hybrid operating room (OR) without interruption. The hybrid technique has a reduced risk of surgical complications and has shown decreased recovery time. It can be used to treat numerous heart diseases and conditions and with the increasing complexity of each case, the hybrid surgical technique is becoming more common.

<span class="mw-page-title-main">Prostatic artery embolization</span> Non-surgical technique for treatment of benign prostatic hypertrophy

Prostatic artery embolization is a non-surgical technique for treatment of benign prostatic hypertrophy (BPH).

Transarterial bland embolization is a catheter-based tumor treatment of the liver. In this procedure, embolizing agents can be delivered through the tumor's feeding artery in order to completely occlude the tumor's blood supply. The anti-tumor effects are solely based on tumor ischemia and infarction of tumor tissue, as no chemotherapeutic agents are administered. The rationale for the use of bland embolization for hepatocellular carcinoma (HCC) and/or other hyper-vascular tumors is based on the fact that a normal liver receives a dual blood supply from the hepatic artery (25%) and the portal vein (75%). As the tumor grows, it becomes increasingly dependent on the hepatic artery for blood supply. Once a tumor nodule reaches a diameter of 2 cm or more, most of the blood supply is derived from the hepatic artery. Therefore, bland embolization and transarterial chemoembolization (TACE) consist of the selective angiographic occlusion of the tumor arterial blood supply with a variety of embolizing agents, with or without the precedence of local chemotherapy infusion. The occlusion by embolic particles results in tumor hypoxia and necrosis, without affecting the normal hepatic parenchyma.

<span class="mw-page-title-main">Carbon dioxide angiography</span> Diagnostic radiographic technique

Carbon dioxide angiography is a diagnostic radiographic technique in which a carbon dioxide (CO2) based contrast medium is used - unlike traditional angiography where the contrast medium normally used is iodine based – to see and study the body vessels. Since CO2 is a non-radio-opaque contrast medium, angiographic procedures need to be performed in digital subtraction angiography (DSA).

<span class="mw-page-title-main">Arterial occlusion</span>

Arterial occlusion is a condition involving partial or complete blockage of blood flow through an artery. Arteries are blood vessels that carry oxygenated blood to body tissues. An occlusion of arteries disrupts oxygen and blood supply to tissues, leading to ischemia. Depending on the extent of ischemia, symptoms of arterial occlusion range from simple soreness and pain that can be relieved with rest, to a lack of sensation or paralysis that could require amputation.

References

  1. ↑ G. Timothy Johnson, M.D. (1986-01-23). "Arteriograms, Venograms Are Angiogram Territory". Chicago Tribune. Retrieved 12 September 2011.
  2. ↑ Martin, Elizabeth (2015). "Angiography". Concise Medical Dictionary (9th ed.). Oxford: Oxford University Press. doi:10.1093/acref/9780199687817.001.0001. ISBN   9780199687817.
  3. ↑ Berrios GE (March 1997). "The origins of psychosurgery: Shaw, Burckhardt and Moniz". History of Psychiatry. 8 (29 pt 1): 61–81. doi:10.1177/0957154X9700802905. PMID   11619209. S2CID   22225524.
  4. ↑ Campeau, L (1989). "Percutaneous radial artery approach for coronary angiography". Catheterization and Cardiovascular Diagnosis. 16 (1): 3–7. doi: 10.1002/ccd.1810160103 . PMID   2912567.
  5. 1 2 Masters, Barry R. (2012-05-25). Longo, Dan L.; Fauci, Anthony S.; Kasper, Dennis L.; Hauser, Stephen L.; Jameson, J. Larry; Loscalzo, Joseph (eds.). Harrison's Principles of Internal Medicine (18th ed.). McGraw Hill. pp. 1407–1408. doi:10.1007/s00417-012-1940-9. ISBN   9780071748896. ISSN   0721-832X.
  6. ↑ Procedure of Coronary Angioplasty Treatment in India by Dr. Manjinder Sandhu, a leading cardiologist in Gurugram
  7. ↑ Colman, Andrew M. (2015). A Dictionary of Psychology (Fourth ed.). Oxford: Oxford University Press. ISBN   9780191744358 . Retrieved 24 August 2022.
  8. ↑ Glick, Yair. "Digital subtraction angiography | Radiology Reference Article | Radiopaedia.org". Radiopaedia. Retrieved 2021-09-29.
  9. ↑ Eddy AC, Nance DR, Goldman MA, et al. (May 1990). "Rapid diagnosis of thoracic aortic transection using intravenous digital subtraction angiography". Am. J. Surg. 159 (5): 500–3. doi:10.1016/S0002-9610(05)81255-3. PMID   2334014.
  10. ↑ Cusumano, Lucas R.; Duckwiler, Gary R.; Roberts, Dustin G.; McWilliams, Justin P. (January 2020). "Treatment of Recurrent Pulmonary Arteriovenous Malformations: Comparison of Proximal Versus Distal Embolization Technique". CardioVascular and Interventional Radiology. 43 (1): 29–36. doi:10.1007/s00270-019-02328-0. ISSN   0174-1551. PMID   31471718.
  11. ↑ Palm, Viktoria; Rengier, Fabian; Rajiah, Prabhakar; Heussel, Claus Peter; Partovi, Sasan (January 2020). "Acute Pulmonary Embolism: Imaging Techniques, Findings, Endovascular Treatment and Differential Diagnoses". RöFo - Fortschritte auf dem Gebiet der Röntgenstrahlen und der bildgebenden Verfahren (in German). 192 (1): 38–49. doi:10.1055/a-0900-4200. ISSN   1438-9029. PMID   31137046.
  12. ↑ Seyferth, Elisabeth; Dai, Rui; Ronald, James; Martin, Jonathan G.; Sag, Alan A.; Befera, Nicholas; Pabon-Ramos, Waleska M.; Suhocki, Paul V.; Smith, Tony P.; Kim, Charles Y. (March 2022). "Safety Profile of Particle Embolization for Treatment of Acute Lower Gastrointestinal Bleeding". Journal of Vascular and Interventional Radiology. 33 (3): 286–294. doi:10.1016/j.jvir.2021.11.006. PMID   34798292.
  13. ↑ Hemorrhoidal Artery Embolization Minimally Invasive Treatment for Symptomatic Internal Hemorrhoids. YouTube. 2024-06-24. Retrieved 2024-07-14– via UCLA Health.
  14. ↑ "Fluorescein Angiography". Empire Retina Consultants. Retrieved 22 August 2016.
  15. ↑ Kashani AH, Chen CL, Gahm JK, Zheng F, Richter GM, Rosenfeld PJ, Shi Y, Wang RK (September 2017). "Optical coherence tomography angiography: A comprehensive review of current methods and clinical applications". Progress in Retinal and Eye Research. 60: 66–100. doi:10.1016/j.preteyeres.2017.07.002. PMC   5600872 . PMID   28760677.
  16. 1 2 Ross S, Spendlove D, Bolliger S, Christe A, Oesterhelweg L, Grabherr S, Thali MJ, Gygax E (2008). "Postmortem whole-body CT angiography: evaluation of two contrast media solutions". AJR Am. J. Roentgenol. 190 (5): 1380–9. doi:10.2214/AJR.07.3082. PMID   18430859.
  17. 1 2 Grabherr S, Djonov V, Friess A, Thali MJ, Ranner G, Vock P, Dirnhofer R (2006). "Postmortem angiography after vascular perfusion with diesel oil and a lipophilic contrast agent". AJR Am. J. Roentgenol. 187 (5): W515–23. doi:10.2214/AJR.05.1394. PMID   17056884.
  18. ↑ Rutty GN, Smith P, Visser T, Barber J, Amorosa J, Morgan B (2012). "The effect on toxicology, biochemistry and immunology investigations by the use of targeted post-mortem computed tomography angiography". Forensic Sci. Int. 225 (1–3): 42–7. doi:10.1016/j.forsciint.2012.05.012. PMID   22704555.
  19. ↑ Jones, Daniel A.; Beirne, Anne-Marie; Kelham, Matthew; Rathod, Krishnaraj S.; Andiapen, Mervyn; Wynne, Lucinda; Godec, Thomas; Forooghi, Nasim; Ramaseshan, Rohini; Moon, James C.; Davies, Ceri; Bourantas, Christos V.; Baumbach, Andreas; Manisty, Charlotte; Wragg, Andrew (2023-10-31). "Computed Tomography Cardiac Angiography Before Invasive Coronary Angiography in Patients With Previous Bypass Surgery: The BYPASS-CTCA Trial". Circulation. 148 (18): 1371–1380. doi:10.1161/CIRCULATIONAHA.123.064465. ISSN   0009-7322. PMC   11139242 . PMID   37772419.
  20. ↑ "CT scan reduces the complications of angiography after bypass surgery". NIHR Evidence. 6 August 2024. doi: 10.3310/nihrevidence_63153 .
  21. ↑ "Angiography – Complications". Health A-Z. NHS Choices. 2009-06-01. Retrieved 2010-03-24.
  22. ↑ Venkatesan, Aradhana M.; Kundu, Sanjoy; Sacks, David; Wallace, Michael J.; Wojak, Joan C.; Rose, Steven C.; Clark, Timothy W.I.; d'Othee, B. Janne; Itkin, Maxim; Jones, Robert S.; Miller, Donald L. (November 2010). "Practice Guideline for Adult Antibiotic Prophylaxis during Vascular and Interventional Radiology Procedures". Journal of Vascular and Interventional Radiology. 21 (11): 1611–1630. doi: 10.1016/j.jvir.2010.07.018 . PMID   21029949.
  23. ↑ Cousins, Teresa R.; O'Donnell, John M. (August 2004). "Arterial cannulation: a critical review". AANA Journal. 72 (4): 267–271. ISSN   0094-6354. PMID   15354915.
  24. ↑ Owen, David G.; de Oliveira, Diana C.; Qian, Shuang; Green, Naomi C.; Shepherd, Duncan E. T.; Espino, Daniel M. (2020-08-07). Tian, Fang-Bao (ed.). "Impact of side-hole geometry on the performance of hemodialysis catheter tips: A computational fluid dynamics assessment". PLOS ONE. 15 (8): e0236946. Bibcode:2020PLoSO..1536946O. doi: 10.1371/journal.pone.0236946 . ISSN   1932-6203. PMC   7413473 . PMID   32764790.
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