Circulatory and Circulatory and Cardiovascular Cardiovascular

SystemsSystemsSpring 2013Spring 2013

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Circulatory SystemCirculatory System

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Blood Vascular SystemBlood Vascular System

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Heart and Great VesselsHeart and Great Vessels

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Cross Section of the HeartCross Section of the Heart

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Arteries of the HeartArteries of the Heart

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Anterior View of Coronary Anterior View of Coronary ArteriesArteries

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Anterior View of Coronary Anterior View of Coronary VeinsVeins

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Pathologies Pathologies Congenital Heart Congenital Heart

DiseasesDiseases– MurmurMurmur– Patent Ductus ArteriosusPatent Ductus Arteriosus– Arterial Septal DefectsArterial Septal Defects– Ventricular Septal Ventricular Septal

DefectsDefects– Teratology of FallotTeratology of Fallot

Valvular heart diseaseValvular heart disease– Valvular StenosisValvular Stenosis– Congestive Heart FailureCongestive Heart Failure

Degenerative diseasesDegenerative diseases– CADCAD– AtherosclerosisAtherosclerosis

Myocardial infarctionMyocardial infarction Aortic aneurysmAortic aneurysm Pulmonary EmbolismPulmonary Embolism

MurmurMurmur Murmur- an Murmur- an

abnormal heart abnormal heart soundsound– Results from Results from

malformed valvesmalformed valves

Patent Ductus ArteriosusPatent Ductus Arteriosus

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Atrial Septal DefectAtrial Septal Defect

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Ventricular Septal DefectVentricular Septal Defect

Teratology of FallotTeratology of Fallot

Coarctation of the AortaCoarctation of the Aorta

Valvular DiseaseValvular Disease

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Mitral Valvular StenosisMitral Valvular Stenosis

Mitral Valve StenosisMitral Valve Stenosis

Congestive Heart FailureCongestive Heart Failure

CHF RadiographCHF Radiograph

Coronary Artery DiseaseCoronary Artery Disease

Coronary Artery DiseaseCoronary Artery Disease

Myocardial InfarctionMyocardial Infarction

Myocardial Infarction Myocardial Infarction ImagesImages

Aortic AneurysmAortic Aneurysm

Aortic Aneurysm ImagingAortic Aneurysm Imaging

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AortogramAortogram

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AORTOGRAMAORTOGRAM

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Abdominal AortoraphyAbdominal Aortoraphy

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Abdominal AngiographyAbdominal Angiography

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AAA Pre and Post Stent AAA Pre and Post Stent PlacementPlacement

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Abdominal StentAbdominal Stent

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AAAAAA

Pulmonary Pulmonary EmbolismEmbolism

Pulmonary Embolism Pulmonary Embolism ImagingImaging

Angiography Angiography Arteriography and Arteriography and

AortogramsAortogramsSPRING 2013 SPRING 2013

AngiographyAngiography

Is the general term that Is the general term that describes the radiologic describes the radiologic examination of vascular examination of vascular

structures within the body structures within the body after the introduction of an after the introduction of an

iodinated contrast medium or iodinated contrast medium or gasgas

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Types of Angiographic Types of Angiographic ProceduresProcedures

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Angiography TeamAngiography Team RadiologistRadiologist

CIT (Radiologic Technologist)CIT (Radiologic Technologist)– Sometimes more than oneSometimes more than one

Other specialists (if needed)Other specialists (if needed)

Nurse Nurse

Anesthesiologist (if needed)Anesthesiologist (if needed)

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IndicationsIndications Verify the presence of Verify the presence of

tumorstumors– Blood supply to tumorsBlood supply to tumors

Internal bleedingInternal bleeding– Possible anemiaPossible anemia

StenosisStenosis

– Can be caused form Can be caused form atherosclerosisatherosclerosis

OcclusionsOcclusions– ClotsClots– ThrombusThrombus– EmbolusEmbolus

AneurysmsAneurysms

Heart diseaseHeart disease

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ContraindicationsContraindications Previous severe reaction to contrast Previous severe reaction to contrast

Impaired renal functionImpaired renal function

Impaired blood clotting factorsImpaired blood clotting factors

Inability to undergo surgical procedureInability to undergo surgical procedure

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Contrast MediaContrast Media Iodinated contrast media is usedIodinated contrast media is used

– Can produce nausea & an Can produce nausea & an uncomfortable burning sensationuncomfortable burning sensation

– Allergic reactionsAllergic reactions Severe: anaphylactic shockSevere: anaphylactic shock

– Shock, rapid shallow breathing, high pulse rate & Shock, rapid shallow breathing, high pulse rate & ALOCALOC

Mild: Hives or slight difficulty breathingMild: Hives or slight difficulty breathing

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What is this?What is this?

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Angiographic Trays Angiographic Trays and Sterile Suppliesand Sterile Supplies

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Other Supplies for Other Supplies for AngiographyAngiography

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NeedlesNeedles Vascular access Vascular access

needlesneedles Size based on Size based on

external diameter of external diameter of needleneedle

Allows for Allows for appropriate appropriate Guidewires matchingGuidewires matching– So internal diameter So internal diameter

must also be knownmust also be known

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GuidewiresGuidewires Used as a platform Used as a platform

over which a catheter over which a catheter is to be advancedis to be advanced

Once positioned Once positioned guidewire is fixed and guidewire is fixed and catheter is advanced catheter is advanced until it meets the tip until it meets the tip of the guidwireof the guidwire

Mostly constructed on Mostly constructed on stainless steel & stainless steel & coated with Tefloncoated with Teflon

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Introducer SheathsIntroducer Sheaths Short catheters Short catheters

used when multiple used when multiple catheters will be catheters will be usedused

Placed in lieu of a Placed in lieu of a cathetercatheter

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CathetersCatheters

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DSA DSA A subtraction mask is A subtraction mask is

taken before contrast taken before contrast injectedinjected

Each of digitized Each of digitized image is from the image is from the maskmask

Images acquired Images acquired formform– 1 image every 2-3 sec1 image every 2-3 sec– Up to 30 images per Up to 30 images per

secsec

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Three Dimensional (3-D) Three Dimensional (3-D) Intraarterial AngiographyIntraarterial Angiography

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What Method is this?What Method is this?

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Catherization: Selinger Catherization: Selinger TechniqueTechnique

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Selinger Technique Catheters Selinger Technique Catheters and Guidewiresand Guidewires

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Radiation ProtectionRadiation Protection PT is protected by no less than 2.5 PT is protected by no less than 2.5

mm of Aluminummm of Aluminum Beam restrictionBeam restriction Avoidance of repeat exposureAvoidance of repeat exposure Cardinal rulesCardinal rules

– Time Time – DistanceDistance– ShieldingShielding

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Stent PlacementStent Placement http://images.google.com/imgres?http://images.google.com/imgres?

imgurl=http://www.nhlbi.nih.gov/health/dci/imgurl=http://www.nhlbi.nih.gov/health/dci/images/stent_restenosis.gif&imgrefurl=http://images/stent_restenosis.gif&imgrefurl=http://www.nhlbi.nih.gov/health/dci/Diseases/stents/www.nhlbi.nih.gov/health/dci/Diseases/stents/stents_all.html&usg=__xDlbsaX9JhuYbpVojLcz1stents_all.html&usg=__xDlbsaX9JhuYbpVojLcz19apr-9apr-I=&h=513&w=450&sz=59&hl=en&start=20&tI=&h=513&w=450&sz=59&hl=en&start=20&tbnid=vWwqaG-RNW7M-bnid=vWwqaG-RNW7M-M:&tbnh=131&tbnw=115&prev=/images%3FqM:&tbnh=131&tbnw=115&prev=/images%3Fq%3Dabdominal%2Bstents%26gbv%3D2%26hl%3Dabdominal%2Bstents%26gbv%3D2%26hl%3Den%3Den

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Pulmonary CirculationPulmonary Circulation

http://www.youtube.com/watch?v=D3ZDJgFDdk0

http://www.youtube.com/watch?v=0jznS5psypI

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Pulmonary ArteriogramPulmonary Arteriogram

Celiac AteriogramCeliac Ateriogram

Celian artery carries Celian artery carries blood from stomach to blood from stomach to duodenum, liver, duodenum, liver, spleen and pancreasspleen and pancreas

Approx at level T12Approx at level T12

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Hepatic ArteriogramHepatic Arteriogram

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Splenic Splenic ArteriorgramArteriorgram

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Renal ArteriogramRenal Arteriogram

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renalrenal

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Lower Limb ArteriesLower Limb Arteries

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Leg AtherosclerosisLeg Atherosclerosis

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Atherosclerosis Left LegAtherosclerosis Left Leg

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Upper Limb ArteriesUpper Limb Arteries

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Upper Extremity AnatomyUpper Extremity Anatomy

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Brachial and Axillary Brachial and Axillary ArteriogramArteriogram

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Hand ArteriogramHand Arteriogram

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Hand Arteriogram with Hand Arteriogram with OcclusionOcclusion

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Balloon AngioplastyBalloon Angioplasty

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Balloon Angioplasty Balloon Angioplasty ProcedureProcedure

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Femoral Artery AngioplastyFemoral Artery Angioplasty

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Placing a Stent after Placing a Stent after Angioplasty with BalloonAngioplasty with Balloon

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Intravascular StentsIntravascular Stents

Cerebral Angiography Cerebral Angiography IndicationsIndications

• AneurysmsAneurysms

• Arteriovenous MalformationsArteriovenous Malformations

• TumorsTumors

• Athersclerotic LesionsAthersclerotic Lesions

• Stenotic lesionsStenotic lesions

Circle of WillisCircle of Willis

Circulation Time Circulation Time Cerebral circulationCerebral circulation

Carotid artery to jugular vein (3 seconds)Carotid artery to jugular vein (3 seconds) With contrastWith contrast

– 4.13 seconds4.13 seconds Certain pathologies shorten or delay Certain pathologies shorten or delay

timetime– AVM’s shorten timeAVM’s shorten time– Arterial vasospasm delays timeArterial vasospasm delays time

EquipmentEquipment Bi-plane imagingBi-plane imaging

– FilmFilm– DSADSA

Automatic InjectorAutomatic Injector

Carotid AngiogramCarotid Angiogram

Internal Carotid AngiogramsInternal Carotid Angiograms

Internal Carotid AngiogramInternal Carotid Angiogram

Vertebral Arteries Vertebral Arteries AngiogramAngiogram

Vertebral Artery AngiogramVertebral Artery Angiogram

Let’s ReviewLet’s Review

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What is the name of this What is the name of this Procedure?Procedure?

What is it done for?What is it done for?

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What is the name of this What is the name of this pathology?pathology?

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What part of the body is being What part of the body is being imaged?imaged?

What is the pathology is this What is the pathology is this image?image?

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What is this method callled?What is this method callled?

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A

B

C

Venography Venography 20132013

Venous Venous CirculationCirculation

What is Venography?What is Venography?

Vein study using x-ray and contrast Vein study using x-ray and contrast mediamedia– Fluoroscopy and still imagesFluoroscopy and still images

One of the most accurate tests for One of the most accurate tests for deep vein thrombosis (DVT)deep vein thrombosis (DVT)

Most commonly done in legs for DVTMost commonly done in legs for DVT

Thrombosis and EmbolismThrombosis and Embolism Intravascular clotIntravascular clot Commonly in veins Commonly in veins

more than arteriesmore than arteries

3 factors3 factors– Where blood is slowWhere blood is slow– Change in the wall Change in the wall

of vesselsof vessels– Change in the blood Change in the blood

itselfitself

Thrombus that Thrombus that becomes detached becomes detached from the vessel wallfrom the vessel wall

Can easily flow to Can easily flow to heart causing PEheart causing PE

Severity depends on Severity depends on location of embolismlocation of embolism

Pulmonary EmbolismPulmonary Embolism Occurs when a clot forms or becomes lodged in Occurs when a clot forms or becomes lodged in

the pulmonary arterythe pulmonary artery

Most commonly thrombus originates in the lower Most commonly thrombus originates in the lower limbs and migrateslimbs and migrates

Can lead to resp distress, heart failure or Can lead to resp distress, heart failure or cardiogenic shockcardiogenic shock

Symptoms are acute:Symptoms are acute:– Sudden coughingSudden coughing– SOBSOB– Chest painChest pain

Pulmonary Emboli (PE)Pulmonary Emboli (PE)

IndicationsIndications Diagnose deep vein Diagnose deep vein

thrombosis thrombosis – Prevent pulmonary Prevent pulmonary

embolismembolism

Distinguish blood clots from Distinguish blood clots from obstructions in the veins obstructions in the veins

Evaluate congenital vein Evaluate congenital vein problems problems

Assess the functioning of Assess the functioning of deep leg vein valves deep leg vein valves

Identify a vein for arterial Identify a vein for arterial bypass graftingbypass grafting

Risk Factors and Risk Factors and ComplicationsComplications

Previous thrombosis Previous thrombosis

Dilution of the contrast dye in the Dilution of the contrast dye in the lower limb lower limb

Difficulty accessing the veins due to: Difficulty accessing the veins due to: – ObesityObesity– Severe swelling (edema) Severe swelling (edema) – Inflammation in the cells ( cellulitis ) Inflammation in the cells ( cellulitis )

ContraindicationsContraindications Bleeding disordersBleeding disorders

Allergy to iodineAllergy to iodine

CHFCHF

Severe pulmonary hypertensionSevere pulmonary hypertension

Prior to ProcedurePrior to Procedure Fast or drink only clear fluids for four Fast or drink only clear fluids for four

hours before the testhours before the test

Thorough PT history obtainedThorough PT history obtained

Informed consentInformed consent

If you are nervous about the test, your If you are nervous about the test, your doctor may give you a sedative.doctor may give you a sedative.

During ProcedureDuring Procedure

PT will lie on a tilting x-ray tablePT will lie on a tilting x-ray table

Area of interest will be Area of interest will be shaved and cleaned shaved and cleaned

Local anestheticLocal anesthetic

Catheter will be inserted.Catheter will be inserted.– A small incision may be A small incision may be made in that area as wellmade in that area as well

Explanation of Procedure: Explanation of Procedure: LegsLegs The catheter is inserted The catheter is inserted

into PT veininto PT vein– (usually a vein in the foot) (usually a vein in the foot)

Contrast is slowly injected. Contrast is slowly injected.

A tight band may be tied A tight band may be tied around your ankle and around your ankle and upper thighupper thigh– or your lower body may be or your lower body may be

tiltedtilted– Fluoro and/or x-ray images Fluoro and/or x-ray images

takentaken

The procedure takes about The procedure takes about 30 - 45 minutes 30 - 45 minutes

Post ProcedurePost Procedure Rest and avoid strenuous activityRest and avoid strenuous activity

Increase fluid intakeIncrease fluid intake

Stop bleeding with pressure Stop bleeding with pressure – Call DR if it won’t stop bleedingCall DR if it won’t stop bleeding

Observe for signs of infectionObserve for signs of infection

PT will be sore for a few daysPT will be sore for a few days

Resume normal activity 24 hours after procedureResume normal activity 24 hours after procedure

Possible Post Procedure Possible Post Procedure ComplicationsComplications

Infection at the Infection at the injection site injection site

Tissue damage Tissue damage

Phlebitis Phlebitis (inflammation of a (inflammation of a vein) vein)

Allergic reactions to Allergic reactions to the contrast dye the contrast dye

Congestive heart failure Congestive heart failure

Acute renal insufficiency Acute renal insufficiency

Venous thrombosis in a Venous thrombosis in a healthy leg healthy leg

Dislodging a clot, Dislodging a clot, perhaps resulting in perhaps resulting in pulmonary embolus or pulmonary embolus or other complicationsother complications

Lower Limb VeinsLower Limb Veins

Lower Limb VenogramsLower Limb Venograms To rule out thrombosis of the deep To rule out thrombosis of the deep

veins of the leg veins of the leg – Deep vein thrombosis (DVT)Deep vein thrombosis (DVT)

Contrast media injected in superficial Contrast media injected in superficial veins of the foot with a needleveins of the foot with a needle

Lower Limb Lower Limb VenogramsVenograms

DVTDVT

Inferior VenacavagramInferior Venacavagram Primarily to rule out thrombus or Primarily to rule out thrombus or

occlusionocclusion

Catheter inserted into femoral vein and Catheter inserted into femoral vein and positioned inside the common iliac vein positioned inside the common iliac vein or inferior aspect of inferior vena cavaor inferior aspect of inferior vena cava

Contrast injected at 20 ml/sec for total of Contrast injected at 20 ml/sec for total of 40ml40ml

Upper Limb VeinsUpper Limb Veins

Upper Limb VenogramsUpper Limb Venograms Most often for thrombosis or Most often for thrombosis or

occlusionocclusion Contrast injected in a superficial vein Contrast injected in a superficial vein

in the elbow or wristin the elbow or wrist– Using a catheter or needleUsing a catheter or needle– 40-80ml at a rate of 1-4ml/sec40-80ml at a rate of 1-4ml/sec

Superior VenacavagramSuperior Venacavagram Primarily done to rule out thrombus or Primarily done to rule out thrombus or

occlusionocclusion

Needle or catheter is introduced into Needle or catheter is introduced into antecubital fossaantecubital fossa– Catheter is positioned in the axillary or Catheter is positioned in the axillary or

subclavian vein and contrast is injectedsubclavian vein and contrast is injected– 30-50ml at 10-15ml/sec30-50ml at 10-15ml/sec

X-rays should include:X-rays should include:– Brachicephalic veinBrachicephalic vein– Subclavian veinSubclavian vein– Superior vena cavaSuperior vena cava– RT AtriumRT Atrium

Superior VenacavagramSuperior Venacavagram

Stenosis on a Superior Stenosis on a Superior VenacavogramVenacavogram

Inferior VenacavagramInferior Venacavagram

Inferior VenacavagramInferior Venacavagram

Inferior Vena Cava FiltersInferior Vena Cava Filters

Inferior Vena Cava Filter Inferior Vena Cava Filter PlacementPlacement

Designed to trap Designed to trap thrombus before thrombus before causing an causing an embolizationembolization

When When anticoagulants are anticoagulants are contraindicated contraindicated this can be usedthis can be used

Inferior Vena Cava Filter Inferior Vena Cava Filter PlacementPlacement

Hepatic VenogramHepatic Venogram Performed to rule out stenosis or Performed to rule out stenosis or

thrombus of the hepatic veinsthrombus of the hepatic veins

Obtain pressure measurements of Obtain pressure measurements of the veins inside the liverthe veins inside the liver

Usually catheter enters jugular vein Usually catheter enters jugular vein or upper limb veinsor upper limb veins

Hepatic VenogramHepatic Venogram

Portal VenogramPortal Venogram

Portal SystemPortal System

http://www.youtube.com/watch?v=4aGNqmWOuEo&feature=related

Transjugular Intrahepatic Transjugular Intrahepatic Portosystemic ShuntPortosystemic Shunt

Intervention for Intervention for creating an artificial creating an artificial low-pressure pathwaylow-pressure pathway– Between portal & Between portal &

hepatic veinshepatic veins

Hepatic venogram Hepatic venogram usually preformed usually preformed before placementbefore placement

US also usefulUS also useful http://www.youtube.com/watch?v=pGA6KUgq7AI

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Transjugular Intrahepatic Transjugular Intrahepatic Portosystemic ShuntPortosystemic Shunt

Renal VenogramRenal Venogram Rule out thrombosis of renal veinRule out thrombosis of renal vein

Renal vein catheterized to take bloodRenal vein catheterized to take blood– Measure the production of reninMeasure the production of renin– Catheter insertion site: femoral veinCatheter insertion site: femoral vein

Contrast injected 8ml/sec for 16ml totalContrast injected 8ml/sec for 16ml total– 2 images per second for 4 seconds2 images per second for 4 seconds

Renal VenogramRenal Venogram