Venography & Lymphography Spring 2009 FINAL. Venous Circulation.
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Transcript of Venography & Lymphography Spring 2009 FINAL. Venous Circulation.
Venography & Lymphography
Spring 2009
FINAL
Venous Circulation
What is Venography?
• Vein study using x-ray and contrast media– Fluoroscopy and still images
• One of the most accurate tests for deep vein thrombosis (DVT)
• Most commonly done in legs for DVT
Thrombosis and Embolism
• Intravascular clot• Commonly in veins
more than arteries
• 3 factors– Where blood is slow– Change in the wall of
vessels– Change in the blood
itself
• Thrombus that becomes detached from the vessel wall
• Can easily flow to heart causing PE
• Severity depends on location of embolism
Pulmonary Embolism
• Occurs when a clot forms or becomes lodged in the pulmonary artery
• Most commonly thrombus originates in the lower limbs and migrates
• Can lead to resp distress, heart failure or cardiogenic shock
• Symptoms are acute:– Sudden coughing– SOB– Chest pain
Pulmonary Emboli (PE)
Indications
• Diagnose deep vein thrombosis – Prevent pulmonary embolism
• Distinguish blood clots from obstructions in the veins
• Evaluate congenital vein problems
• Assess the functioning of deep leg vein valves
• Identify a vein for arterial bypass grafting
Risk Factors and Complications
• Previous thrombosis
• Dilution of the contrast dye in the lower limb
• Difficulty accessing the veins due to: – Obesity– Severe swelling (edema) – Inflammation in the cells ( cellulitis )
Contraindications
• Bleeding disorders
• Allergy to iodine
• CHF
• Severe pulmonary hypertension
Prior to Procedure
• Fast or drink only clear fluids for four hours before the test
• Thorough PT history obtained
• Informed consent
• If you are nervous about the test, your doctor may give you a sedative.
During Procedure
• PT will lie on a tilting x-ray table
• Area of interest will be shaved and cleaned
• Local anesthetic
• Catheter will be inserted.– A small incision may be made in that area as well
Explanation of Procedure: Legs• The catheter is inserted into
PT vein– (usually a vein in the foot)
• Contrast is slowly injected.
• A tight band may be tied around your ankle and upper thigh– or your lower body may be
tilted– Fluoro and/or x-ray images
taken
• The procedure takes about 30 - 45 minutes
Post Procedure
• Rest and avoid strenuous activity
• Increase fluid intake
• Stop bleeding with pressure – Call DR if it won’t stop bleeding
• Observe for signs of infection
• PT will be sore for a few days
• Resume normal activity 24 hours after procedure
Possible Post Procedure Complications
• Infection at the injection site
• Tissue damage
• Phlebitis (inflammation of a vein)
• Allergic reactions to the contrast dye
• Congestive heart failure
• Acute renal insufficiency
• Venous thrombosis in a healthy leg
• Dislodging a clot, perhaps resulting in pulmonary embolus or other complications
Lower Limb Veins
Lower Limb Venograms
• To rule out thrombosis of the deep veins of the leg – Deep vein thrombosis (DVT)
• Contrast media injected in superficial veins of the foot with a needle
Lower Limb Venograms
Deep Vein Thrombosis
• Primarily involves lower limbs
• Major source of fatal PE
• Risks– Restricted mobility– Surgery– Obesity– Pregnant– BC pills– Long trips
• Plane• Car
DVT of Iliac Vein
• On x-ray appears as a constant filling defect
• Largely replaced by duplex color doppler ultrasound– Demonstrates the
velocity of the venous blood flow
Occurrence of DVT in 338 Patients
DVT
Deep Vein Thrombosis
DVT
Phlebitis
• Inflammation of a vein
• Often associated with venous thrombosis
• US usually used to diagnose
• Treated with anticoagulants
Varicose Veins• Dilated, elongated and tortuous vessels
• Most common to superficial veins of leg
• Multiple bluish nodules just under skin
• Development of collateral veins
Varicose Veins
• Valves are unable to prevent backflow• Valves cease to function increasing blood volume is
these veins
Varicose Veins
• Demonstrates patnecy of the deep venous system
• Shows the degree of collateral circulation
Inferior Venacavagram
• Primarily to rule out thrombus or occlusion
• Catheter inserted into femoral vein and positioned inside the common iliac vein or inferior aspect of inferior vena cava
• Contrast injected at 20 ml/sec for total of 40ml
Upper Limb Veins
Upper Limb Venograms• Most often for thrombosis or occlusion
• Contrast injected in a superficial vein in the elbow or wrist– Using a catheter or needle– 40-80ml at a rate of 1-4ml/sec
Superior Venacavagram
• Primarily done to rule out thrombus or occlusion
• Needle or catheter is introduced into antecubital fossa– Catheter is positioned in the axillary or subclavian
vein and contrast is injected– 30-50ml at 10-15ml/sec
• X-rays should include:– Brachicephalic vein– Subclavian vein– Superior vena cava– RT Atrium
Superior Venacavagram
Stenosis on a Superior Venacavogram
Inferior Venacavagram
Inferior Venacavagram
Inferior Vena Cava Filters
Inferior Vena Cava Filter Placement
• Designed to trap thrombus before causing an embolization
• When anticoagulants are contraindicated this can be used
Inferior Vena Cava Filter Placement
Hepatic Venogram
• Performed to rule out stenosis or thrombus of the hepatic veins
• Obtain pressure measurements of the veins inside the liver
• Usually catheter i=enters jugular vein or upper limb veins
Hepatic Venogram
Portal Venogram
Portal System
Transjugular Intrahepatic Portosystemic Shunt
• Intervention for creating an artificial low-pressure pathway– Between portal & hepatic
veins
• Hepatic venogram usually preformed b before placement
• US also useful
Transjugular Intrahepatic Portosystemic Shunt
Renal Venogram
• Rule out thrombosis of renal vein
• Renal vein catheterized to take blood– Measure the production of renin– Catheter insertion site: femoral vein
• Contrast injected 8ml/sec for 16ml total– 2 images per second for 4 seconds
Renal Venogram
Lymphatic System:Green-superficialBlack- deep
RT AND LT LYMPH DRAINAGE
LYMPH DRAINAGE
Lymphography
• General term applied to the radiologic examination of:– Lymph nodes – Lymph Vessels
• Usually done to demonstrate pelvis and abdomen– Injected in foot
• For axillary, clavicular area and upper limbs– Injected in hand
• Checks drainage of lymph nodes
Pre Procedure
• Obtain PT history
• Obtain PT consent
• Make sure to have all supplies
• Positioning aides and comfort supplies
Procedure
• Inject blue dye under skin in between toes
• Inject small amount of contrast into the lymph vessels– Show blue tint
• Nodes in pelvis and abdomen are demonstrated with foot injection
Procedure
• X-rays are usually taken 1 HR after injection– 24 hrs– 48 hrs (if needed)– 72hrs (if needed)
• First hour– Contrast in lymph ducts
• 24 hours – If lymph nodes
• After 24 hours it is indicative of cancer
Post Procedure
1. Watch for signs of infection Swelling red and warm to touch Accompanied by a fever Contact DR right away
2. Drink lots of water
3. Major swelling in one limb Especially limb injected
Indications
• Check for metastasis
• Edema in limbs– Obstruction
• Infections
• Rule out cancer
Contrast
• Oil based – More commonly used– Ethiodal– Lipodal
• Water based Iodine– Less commonly used– Ionic– Non-ionic
Iliopelvic-aortic Lymphatic System
Iliopelvic Abdominoaortic Lymph Nodes
Inguinal Region
Lymphography
Upper Limb Lymphography
Lymphoma• Malignancy of lymphatic system
– Either Hodgkin's or Non-Hodgkin's
• Non-Hodgkin's– Originate in parenchymal organs– 60 years of age (median)
• Hodgkin's– 90% start in lymph nodes– 15-40 years– 2nd peak: mid to late 50’s
• Can be imaged using x-ray, CT, MRI, PET, US and NM.– Modality of choice depends on location.– VERY rarely is lymphangiograms used to diagnosis this disease
anymore
Non-Hodgkin’s Lymphoma
• CT of abdomen & pelvis is used to stage disease
• Treatment consists of chemo and/or Rad therapy
• Symptoms vary– Lymphadenopathy– anemia – Hepatomegaly– Splenomegaly– Fever and weakness
Non-Hodgkin’s Lymphoma
Case study:Hodgkin’s Disease
• CT exams show enlarged retroperitoneal nodes
• Symptoms– Painless lymph node
swelling in cervical area– Fever– Fatigeu– Anemia & weight loss– Coughing – breathlessness
Hodgkin’s Disease
Treatment includes RAD therapyAnd chemotherapy
Symptoms include malaise, fever,Anorexia, enlarged lymph nodes
Staging of Lymphomas• Stage I:
– One lymph node group – Only one part of a tissue – One organ
• Stage II: – Two lymph node groups on the same side – one part of a tissue or an organ and the lymph nodes near that organ– In other lymph node groups on the same side of the diaphragm
• Stage III: – In lymph nodes above and below the diaphragm.– In one part of a tissue or an organ near these lymph node groups– It may also be found in the spleen
• Stage IV:– In several parts of one or more organs or tissues– In an organ and in distant lymph nodes
Statistics
• New cases in 2008 : 73,740– NHL 66,120– Hodgkin's 8,220– 39,850 males : 34.490 females
• 5 year survival rate (1996-2004) – NHL 65%– Hodgkin's 86%
www.lls.org
Increased Incidences of Lymphoma
• Certain viruses– Epstein-Barr virus (EBV) – human immunodeficiency virus (HIV)
• Weakened immune system: – weakened immune system
• inherited condition • certain drugs used after an organ transplant)
• Age: – 15 to 35 years and – adults aged 55 years and older
• Family history
CT: Lymphoma
PET Lymphoma
DMS Lymphoma