ABSTRACT
Selective Angiography of the Right CCA From the IA, selective right CCA angiographymay be performed after advancing the IA catheter into the right CCA. This is most easily accomplished in the RAO projection by clockwise rotation (from the IA) and advancement of a simple catheter using fluoroscopy, pressure monitoring, and test injections (Fig. 26.31). If a complex catheter was used to engage the IA, gentle retraction of the catheter and clockwise rotation will point the catheter tip into the right CCA. If these maneuvers do not work, a J-tip guidewire can be advanced into the mid-CCA followed by advancement of any suitable coaxial catheter. For images of the carotid bifurcation and intracranial circulation, hand injections usually result in contrast streaming and suboptimal image quality, so a power injector is preferred (Fig. 26.26). If the catheter position is not ideal or the catheter recoils into the arch, the catheter can be repositionedwith a guidewire or exchanged for amore coaxial catheter, such as a modified tennis racquet, multipurpose or glide catheter (Figs. 26.27 and 26.29). In most patients, the best images of the right CCA and cervical ICA are obtained in AP, lateral, and ipsilateral oblique (RAO) projections (Figs. 26.20 and 26.32). Depending on the individual patient, contralateral oblique (LAO) and cranial or caudal angulation may be useful to image highly eccentric stenoses, straighten bends, or eliminate overlying branches of the ECA. For the intracranial circulation, the best images are AP-cranial and lateral projections (Figs. 26.20, 26.25, and 26.32). In some patients, highly angulated or tortuous sections of the cerebral ICA may appear aneurysmal, in which case an ipsilateral (RAO) caudal projection may prove very useful.
