Pulmonary Arteriogram

(Angiogram-Pulmonary, Pulmonary Angiography, Pulmonary Arteriogram, Pulmonary Arteriography, Angiogram of the Lungs)

Procedure overview

What is a pulmonary angiogram?

An angiogram, also called an arteriogram, is an X-ray image of the blood vessels. It is performed to evaluate various vascular conditions, such as an aneurysm (ballooning of a blood vessel), stenosis (narrowing of a blood vessel), or blockages.

A pulmonary angiogram is an angiogram of the blood vessels of the lungs. A pulmonary angiogram may be used to assess the blood flow to the lungs. One of the primary indications for the procedure is the diagnosis of a pulmonary embolus (clot). It may also be used to deliver medication into the lungs to treat cancer or hemorrhage.

In order to obtain a radiographic (X-ray) image of a blood vessel, an intravenous (IV) access is necessary so that a contrast dye can be injected into the body's circulatory system, which includes the pulmonary (lungs) circulatory system. This contrast dye causes the blood vessels to be visible on X-ray film. This allows the doctor to see the size, shape, and many branches of the pulmonary vessels, in particular, the pulmonary artery that circulates blood to the lungs.

Fluoroscopy is often used during a pulmonary angiogram. Fluoroscopy is the study of moving body structures, similar to an X-ray "movie." A continuous X-ray beam is passed through the body part being examined, and is transmitted to a TV-like monitor so that the body part and its motion can be seen in detail.

An additional technology that may be used with an angiogram is called digital subtraction angiography (DSA). DSA still requires a contrast dye to be injected into the pulmonary circulation. However, with DSA, a masked image is made prior to the injection of the dye with fluoroscopy. A computer digitally subtracts (or removes) everything from the image except that which is injected with the contrast dye, so that the computer image remaining is one of the pulmonary blood vessels only.

Other related procedures that may be used to diagnose problems of the chest and respiratory tract include chest X-rays, computed tomography (CT scan) of the chest, bronchoscopy, bronchography, chest fluoroscopy, chest ultrasound, lung biopsy, lung scan, mediastinoscopy, positron emission tomography (PET scan) of the chest, pleural biopsy, and thoracentesis. Please see these procedures for additional information.

Anatomy of the respiratory system

Respiratory System - Click to Enlarge

The respiratory system is made up of the organs involved in the interchanges of gases, and consists of the:

• Nose

• Pharynx

• Larynx

• Trachea

• Bronchi

• Lungs

The upper respiratory tract includes the:

• Nose

• Nasal cavity/nasopharynx 

• Oral cavity/oropharynx 

• Ethmoidal air cells

• Frontal sinuses

• Maxillary sinus

• Sphenoid sinuses 

• Larynx

• Trachea

The lower respiratory tract includes the lungs, bronchi, and alveoli.

What are the functions of the lungs?

The lungs take in oxygen, which cells need to live and carry out their normal functions. The lungs also get rid of carbon dioxide, a waste product of the body's cells.

The lungs are a pair of cone-shaped organs made up of spongy, pinkish-gray tissue. They take up most of the space in the chest, or the thorax (the part of the body between the base of the neck and diaphragm).

The lungs are enveloped in a membrane called the pleura.

The lungs are separated from each other by the mediastinum, an area that contains the following:

• The heart and its large vessels

• Trachea (windpipe)

• Esophagus

• Thymus

• Lymph nodes

The right lung has three sections, called lobes. The left lung has two lobes. When you breathe, the air enters the body through the nose or the mouth. It then travels down the throat through the larynx (voice box) and trachea (windpipe) and goes into the lungs through tubes called main-stem bronchi.

One main-stem bronchus leads to the right lung and one to the left lung. In the lungs, the main-stem bronchi divide into smaller bronchi and then into even smaller tubes called bronchioles. Bronchioles end in tiny air sacs called alveoli.

Reasons for the procedure

A pulmonary angiogram may be performed to visualize the pulmonary vascular system, to evaluate for abnormalities, and to determine pressures within the pulmonary circuit. One of the most common reasons is to confirm the presence of a pulmonary embolus (clot) in one or more of the blood vessels in the lungs. A clot may be treated, if present. Pulmonary angiograms are rarely performed anymore, as CT angiography (CTA) of the chest has largely replaced this procedure. Pulmonary angiograms are typically only performed if simultaneous treatment of a known clot is to be performed. 

Abnormalities that may be detected by a pulmonary angiogram include, but are not limited to, the following:

• Aneurysms

• Arteriovenous malformation. A direct communication of an artery to a vein

• Congenital heart and/or vascular anomalies. Structural defects present at birth

• Foreign body in the blood vessels

• Stenosis. Narrowing of a blood vessel wall

• Pulmonary embolism

A pulmonary angiogram may be used to evaluate the blood vessels and blood flow in the lungs before and/or after surgery or other procedures involving the blood vessels.

There may be other reasons for your doctor to recommend a pulmonary angiogram.

Risks of the procedure

You may want to ask your doctor about the amount of radiation used during the procedure and the risks related to your particular situation. It is a good idea to keep a record of your past history of radiation exposure, such as previous scans and other types of X-rays, so that you can inform your doctor. Risks associated with radiation exposure may be related to the cumulative number of X-ray examinations and/or treatments over a long period of time.

If you are pregnant or suspect that you may be pregnant, you should notify your health care provider. Radiation exposure during pregnancy may lead to birth defects.

There is a risk for allergic reaction to the dye. Patients who are allergic to or sensitive to medications, contrast dye, or iodine should notify their doctor. Also, patients with kidney failure or other kidney problems should notify their doctor.

Because the procedure involves the blood vessels and blood flow of the lungs and chest, there is a small risk for complications involving these structures. These complications may include, but are not limited to, the following:

• Hemorrhage due to puncture of a blood vessel

• Injury to nerves

• Embolus. A clot in the blood vessel

• Hematoma. An area of swelling caused by a collection of blood

• Infection

There may be other risks depending on your specific medical condition. Be sure to discuss any concerns with your doctor prior to the procedure.

Before the procedure

• Your doctor will explain the procedure to you and offer you the opportunity to ask any questions that you might have about the procedure.

• You will be asked to sign a consent form that gives your permission to do the test. Read the form carefully and ask questions if something is not clear.

• Notify your doctor if you have ever had a reaction to any contrast dye, or if you are allergic to iodine.

• Notify your doctor if you are sensitive to or are allergic to any medications, latex, tape, and anesthetic agents (local and general).

• You will need to fast for a certain period of time prior to the procedure. Your doctor will notify you how long to fast, whether for a few hours or overnight.

• If you are pregnant or suspect that you may be pregnant, you should notify your doctor.

• Notify your doctor of all medications (prescription and over-the-counter) and herbal supplements that you are taking.

• Notify your doctor if you have a history of bleeding disorders, or if you are taking any anticoagulant (blood-thinning) medications, aspirin, or other medications that affect blood clotting. It maybe necessary for you to stop these medications prior to the procedure.

• Your doctor may request a blood test prior to the procedure to determine how long it takes your blood to clot. Other blood tests may be done as well.

• You may receive a sedative prior to the procedure to help you relax. If a sedative is given, you will need someone to drive you home afterwards.

• Depending on the site used for injection of the contrast dye, the recovery period may last up to 12 to 24 hours. You should be prepared to spend the night if necessary.

• The area around the catheter insertion (groin area) may be shaved.

• Based on your medical condition, your doctor may request other specific preparation.

During the procedure

A pulmonary angiogram may be performed on an outpatient basis or as part of your stay in a hospital. Procedures may vary depending on your condition and your doctor's practices.

Generally, a pulmonary angiogram follows this process:

1. You will be asked to remove any clothing, jewelry, or other objects that may interfere with the procedure.

2. If asked to remove clothing, you will be given a gown to wear.

3. You will be asked to empty your bladder prior to the start of the procedure.

4. An intravenous (IV) line will be inserted in your arm or hand.

5. You will be placed in a supine (on your back) position on the X-ray table.

6. You will be connected to an EKG monitor that records the electrical activity of the heart and monitors the heart during the procedure using small, adhesive electrodes. Your vital signs (heart rate, blood pressure, breathing rate, and oxygenation level) will be monitored during the procedure.

7. The radiologist will check your pulses below the injection site for the contrast dye and mark them with a marker so that the circulation to the limb below the site can be checked after the procedure.

8. A special catheter will be inserted either in your arm or in the groin area after the skin is cleansed and a local anesthetic is injected.

9. The catheter will be advanced through the vein to the right side of the heart. A special type of X-ray, called fluoroscopy, (displayed on a television monitor), may be used to assist in advancing the catheter through the chambers of the heart to the pulmonary artery or one of its branches.

10. An injection of contrast dye will be given. You may feel some effects when the dye is injected into the IV line. These effects include a flushing sensation, a salty or metallic taste in the mouth, a brief headache, or nausea and/or vomiting. These effects usually last for a few moments.

11. You should notify the radiologist if you feel any breathing difficulties, sweating, numbness, or heart palpitations.

12. After the contrast dye is injected, a series of rapid sequential X-ray images will be made.

13. Depending on the specific study being done, there may be one or more additional injections of contrast dye.

14. Once sufficient information has been obtained, the IV catheter will be removed and pressure will be applied over the area to keep the blood vessel from bleeding.

15. After the IV site stops bleeding, a dressing will be applied to the site. A small sandbag may be placed over the site for a period of time to prevent further bleeding or the formation of a hematoma at the site.

After the procedure

After the procedure, you will be taken to the recovery room for observation. The circulation and sensation of the limb where the injection catheter was inserted will be monitored. A nurse will monitor your vital signs and the injection site while you are in the recovery room.

You will remain flat in bed in a recovery room for a short time (1 to 2 hours) after the procedure. If the groin or arm site was used, the leg or arm on the side of the injection site will be kept straight while you are in recovery.

You may be given pain medication for pain or discomfort related to the injection site or having to lie flat and still for a prolonged period.

You will be encouraged to drink water and other fluids to help flush the contrast dye from your body.

You may resume your usual diet after the procedure, unless your doctor decides otherwise.

When you have completed the recovery period, you may be returned to your hospital room or discharged to your home. If this procedure was performed on an outpatient basis, you should plan to have another person drive you home.

Once at home, you should monitor the injection site for bleeding, unusual pain, swelling, and abnormal discoloration or temperature change at or near the injection site. A small bruise is normal, as is an occasional drop of blood at the site. If you notice a constant or large amount of blood at the site that cannot be contained with a small dressing, notify your doctor.

If the groin or arm was used, you should monitor the leg or arm for changes in temperature or color, pain, numbness, tingling, or loss of function of the limb.

Drink plenty of fluids to prevent dehydration and to help pass the contrast dye.

You may be advised not to do any strenuous activities or take a hot bath or shower for a period of time after the procedure.

Notify your doctor to report any of the following:

• Fever and/or chills

• Increased pain, redness, swelling, or bleeding or other drainage from the groin injection site

• Coolness, numbness and/or tingling, or other changes in the affected extremity

Your doctor may give you additional or alternate instructions after the procedure, depending on your particular situation.