1. Angiography Arteriography Aortograms and Venography
SPRING 2011
FINAL

2. Angiography
Is the general term that describes the radiologic examination of vascular structures within the body after the introduction of an iodinated contrast medium or gas

3. Types of Angiographic Procedures

5. Angiography Team Radiologist CIT (Radiologic Technologist)
Sometimes more than one
Other specialists (if needed)
Nurse
Anesthesiologist (if needed)

6. Indications Verify the presence of tumors Internal bleeding Stenosis
Blood supply to tumors
Internal bleeding
Possible anemia
Stenosis
Can be caused form atherosclerosis
Occlusions
Clots
Thrombus
Embolus
Aneurysms
Heart disease

7. Contraindications Previous severe reaction to contrast
Impaired renal function
Impaired blood clotting factors
Inability to undergo surgical procedure

8. Contrast Media Iodinated contrast media is used
Can produce nausea & an uncomfortable burning sensation
Allergic reactions
Severe: anaphylactic shock
Shock, rapid shallow breathing, high pulse rate & ALOC
Mild: Hives or slight difficulty breathing

9. What is this?

11. Angiographic Trays and Sterile Supplies

12. Other Supplies for Angiography

13. Needles Vascular access needles
Size based on external diameter of needle
Allows for appropriate Guidewires matching
So internal diameter must also be known

14. Guidewires Used as a platform over which a catheter is to be advanced
Once positioned guidewire is fixed and catheter is advanced until it meets the tip of the guidwire
Mostly constructed on stainless steel & coated with Teflon

15. Introducer Sheaths
Short catheters used when multiple catheters will be used
Placed in lieu of a catheter

16. Catheters
Angiographic Catheters, PTCA Balloon Catheters, Drug Delivery Catheters, Guide Catheters, Guide Wires, Intravascular Ultrasound Catheters,  Stents, Atherectomy Devices, Valvuloplasty.
 Inflation Devices, Introducers Sheath, Y-Adapters, Manifolds, Stopcocks, Control Syringes, Pressure Monitoring Products, Disposable Transducers, Disposable Domes,  Fluid Delivery System, Contrast Injection Lines.

18. DSA A subtraction mask is taken before contrast injected
Each of digitized image is from the mask
Images acquired form
1 image every 2-3 sec
Up to 30 images per sec

19. Three Dimensional (3-D) Intraarterial Angiography

20. What Method is this?

21. Catherization: Selinger Technique

22. Selinger Technique Catheters and Guidewires

23. Pre-Procedure
PT’s are usually limited to a liquid diet and routine medications
Adequate hydration
An IV line placed
Sedative may be given
History taken and vitals taken
Informed consent

24. Preparing the Patient Room
Must be extensively cleaned
Equipment checked
Room thoroughly stocked
Extra supplies as needed

25. Radiation Protection
PT is protected by no less than 2.5 mm of Aluminum
Beam restriction
Avoidance of repeat exposure
Cardinal rules
Time
Distance
Shielding

26. Post Procedure PTs usually can resume normal activity after 24 hours
Most often can go home after 24 hours
Because internal bleeding can be life threatening
Vitals are monitored
Puncture site is monitored for bleeding

27. Stent Placement

28. Aortogram

30. AORTOGRAM

31. Abdominal Aortoraphy

32. Abdominal Angiography

33. AAA Pre and Post Stent Placement

35. Abdominal Stent

36. AAA
Open repair of abdominal aortic aneurysms is a major operation, and you would need to be in hospital for approx. 7 to 10 days. Under a general anesthetic, an incision (cut) is made in the abdomen. Then the abdominal aorta above and below the aneurysm is controlled and clamped to stop blood flow, which enables the aneurysm to be opened up and a new artificial artery sewn in to replace the dilated segment. The clamps are then removed to restore the blood flow, and the abdomen is sewn up.
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Risks and complications of an 'open' operation with a graft
The major complications of the open operation are the risk of either bleeding or problems with the heart, which is put under some strain when the clamps are placed on the abdominal aorta. There can be problems resulting from a reduction in blood flow to the legs and kidneys during or after the operation. Overall, the incidence of serious complications is 5 to 7%.
What alternatives are there to having an open operation?
A relatively new technique that is being tested in hospitals is to use a 'stent' to help repair abdominal aortic aneurysms (see the diagram below). The aim of this technique is to perform a less major operation, which can be tolerated better by more patients. Depending on the shape and size of the arteries around the aneurysm, the abdominal aortic aneurysm can be repaired from the groin. This operation usually involves making small cuts on each side of the groin under general anesthetic. A graft is then inserted into the abdominal aortic aneurysm through an artery in the groin. Special stents are used to hold the graft in place.

37. Pulmonary Circulation

38. Pulmonary Arteriogram

39. Celiac Ateriogram

40. Hepatic Arteriogram

41. Splenic Arteriorgram

42. Renal Arteriogram
A) Large eccentric noncalcified stenosis of the proximal renal artery (arrowhead). (B) Angiography shows the absence of flow in the renal artery and in distal runoff arteries after initial predilation with a 2.5-mm balloon catheter. (C) Obstruction of the main renal artery after stent implantation; the delivery catheter is still in place (arrowhead). (D) The angiogram shows the guiding catheter deep inside the artery (arrowhead). (E) Angiogram after thrombolysis shows no modification in the clot. (F) Angiography after successful recanalization: the renal parenchyma is well contrasted apart from a small area of the lower pole (arrowhead)

43. renal

47. Lower Limb Arteries

49. Leg Atherosclerosis

50. Atherosclerosis Left Leg

51. Upper Limb Arteries

52. Upper Extremity Anatomy

53. Brachial and Axillary Arteriogram

54. Axillary Arteriogram

55. Hand Arteriogram

56. Hand Arteriogram with Occlusion
Right upper extremity angiogram shows abrupt occlusion of the superficial palmar arch (arrow). The deep palmar arch remains patent (arrowheads). There is no visible filling of the proper palmar digital arteries of the fourth and fifth digits.

57. A, Guidewire advanced through stenosis
A, Guidewire advanced through stenosis. B, Small catheter advanced through stenosis. C, Large catheter advanced through stenosis. D, Postangioplasty stenotic area. View JPG     View PDF     

58. Balloon Angioplasty

60. Balloon Angioplasty Procedure

61. Femoral Artery Angioplasty

62. Placing a Stent after Angioplasty with Balloon

63. Intravascular Stents

64. Let’s Review

65. B C A: RT subclavian B: Lt internal carotid C. Lt subclavina
D: brachicephalic
Aortic bulb
Ascending aorta
Aortic Arch
Descending Aorta

66. What is the name of this Procedure? What is it done for?

67. What is the name of this pathology?

68. What part of the body is being imaged
What part of the body is being imaged? What is the pathology is this image?

69. A Right common carotid
B. RT external carotid
C. RT internal carotid

70. What is this method callled?

71. A C B
Arch of aorta
Descending aorta
Asending aorta

72. Venography

73. Venous Circulation

74. 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

75. 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

76. 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

77. Pulmonary Emboli (PE)

78. 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
Diagnose deep vein thrombosis , a blood clot deep within the leg that may lead to an obstruction of a blood vessel in the lungs ( 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

79. 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 )

80. Contraindications Bleeding disorders Allergy to iodine CHF
Severe pulmonary hypertension

81. 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.
You may be asked to fast or drink only clear fluids for four hours before the test. Tell your doctor if you have a history of allergies, hay fever, or bad reactions to an injected contrast dye. If you are nervous about the test, your doctor may give you a sedative

82. 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
You will lie on a tilting x-ray table.
If necessary, you will be shaved in the area where the catheter (small tube used to inject the dye) will be inserted. A small incision may be made in that area as well.
Anesthesia 
You may be given a local anesthetic to numb the area where the catheter will be inserted.

83. 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 minutes
The catheter is inserted into your vein (usually a vein in the foot) and a special dye is slowly injected. A tight band may be tied around your ankle, or your lower body may be tilted, which helps to fill the deep venous system with dye. You will be asked to remain still as a clinician uses a fluoroscope to view the movement of the dye through your veins. A series of x-rays will be taken during this time.
How Long Will It Take? 
The procedure takes about 30 minutes for an uncomplicated venography. This time may increase, depending on the specifics of the procedure. Furthermore, you will need to keep your leg straight for six hours after the procedure has been completed.

84. 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
When you get home from the test, take it easy for the rest of the day and try to avoid going up and down flights of stairs, or any strenuous activity.
Drink large amounts of fluid for the next 24 hours, to help flush the remaining dye from your body.
If any bleeding or swelling occurs at the injection or puncture site, put pressure on the site for at least 10 minutes. If this fails to stop the bleeding, go to the emergency room of a local hospital or call your physician for advice.
You may remove the bandage the day after your test.
Observe the injection site for any swelling, heat, redness, pain, or drainage. The injection area will be sore for a few days.
Most people are able to resume normal activities the day after the procedure.

85. 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
People with kidney problems or diabetes , especially those taking metformin (Glucophage), may have a higher risk for complications resulting from venography.

86. Lower Limb Veins

87. 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

88. Lower Limb Venograms

89. DVT

90. 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

91. Upper Limb Veins

92. 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

93. 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

94. Superior Venacavagram

95. Stenosis on a Superior Venacavogram
72-year-old man with non—small cell lung carcinoma and progressive superior vena cava syndrome due to severe stenosis. Superior venacavagram before endovascular treatment shows severe stenosis of vena cava and confluence of right innominate vein. Note collateral venous network from thoracic, neck, and azygos veins.

96. Inferior Venacavagram

97. Inferior Venacavagram

98. Inferior Vena Cava Filters

99. Inferior Vena Cava Filter Placement
Designed to trap thrombus before causing an embolization
When anticoagulants are contraindicated this can be used

100. Inferior Vena Cava Filter Placement

102. Hepatic Venogram
Performed to rule out stenosis or thrombus of the hepatic veins
Obtain pressure measurements of the veins inside the liver
Usually catheter enters jugular vein or upper limb veins

103. Hepatic Venogram

104. Portal Venogram

105. Portal System

106. 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

107. Transjugular Intrahepatic Portosystemic Shunt

108. 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

109. Renal Venogram