Arteriograms and Lower Limb Venograms Numbers next to items refer to plates in Netter’s Atlas of Atlas of Human Anatomy Numbers in parenthesis are from the 3 rd edition. Numbers not in parenthesis are frrom the 4 th edition.

1. Abdominal Aorta 2. 4th lt lumbar artery (256) Stent in the rt common iliac artery 4. Lt common iliac artery 5. Lt internal iliac artery (383) Posterior division of the lt iliac artery (382) Lt external iliac artery 8 Anterior division of the lt iliac artery Iliacs #1 Inflated balloon in the right common iliac artery, deploying a stent.

This is the raw image seen in the previous slide (#1) before it was subtracted. This process, known as digital subtraction angiography (DSA) attempts to remove all densities except those in the range of the iodine contrast in the arteries. Notice the bones of the pelvis and spine seen on this image are not seen on image 1. Bowel gas is seen due to motion. The success of this process is dependant on there being no motion between an image taken before contrast injection, (the mask image) and the contrast film. Several seconds may pass between them, and areas of motion create subtraction artifacts. Radiographs vs. DSA

#2 #2a These images are identical. Image 2 is the original, 2a is subtracted and the densities have been reversed. 1. Rt renal artery 1. Rt. common iliac artery 2. Pigtail catheter in the abdominal aorta 2. Perirenal branch of rt renal artery 3. 1st through 4th lumbar arteries 3. Rt low accessory renal artery (324) 333 Abdominal arteriogram

#3 1. Superior messenteric artery (328) Middle suprarenal arteries 332 * 3. Abdominal aorta * Compare the origin of this vessel, from the abdominal aorta, to the variation labeled “B” on plate (324) 333 This injection of the abdominal aorta is unusual. Typically the aorta fills instantly, and the renals and SMA fill momentarily, or sometimes not well at all (notice the lack of filling of the SMA on image 2). In this case the position of the catheter and the sideholes were such that everything but a small portion of the aorta were filled at the moment the image was made. Bilateral renal arteriogram

1. Catheter* 2. Rt renal artery** 3. Segmental arteries (323) Interlobar arteries 5. Rt ureter 1. Tip of the angioplasty catheter 2. Opaque markers*** 3. Capsular branches of the renal artery (323) 335 * The tip is in a proximal subdivision of the renal artery, which is a variation of the typical appearance ** Just beyond the arrow is a stenosed segment of the vessel. This is the major area of atherosclerotic disease that is being treated in image 3a. *** Between the markers is where the angioplasty balloon will deploy Selected renal arteriogram and angioplasty #3 #3a

1. Common hepatic artery 2. Gastroduodenal artery 3. Hepatic artery proper 4. Rt hepatic artery 5. Lt hepatic artery On this injection the catheter tip was advanced to the common hepatic artery. On Netter’s plate (293) 303, the catheter tip is in the celiac trunk. Notice the filling of the splenic and Lt gastric artery as well. Due to its small size and position at the proximal part of the trunk the Lt gastric does not always fill on a celiac injection. Selective Hepatic Plates ( )

1. Catheter* 2. Middle colic artery** 3. Rt colic artery 4. Ileocolic artery 5. Jejunal & ileal (intestinal) arteries 6. Anastomotic loops (arcades) * In the abdominal aorta. The tip is in the proximal SMA. ** Due to the numerous normal variants of the SMA (note a few of the more common presentations on plate 298) 308 the exact identification of items 2-4 are difficult. These will not be included on the test. #5 Selected SMA Plates ( )

1. Descending aorta* 2. Rt. common carotic artery** 3. Rt subclavian artery 4. Rt vertebral artery 5. Lt common carotid artery 6. Lt vertebral artery 7. Lt subclavian artery 8. Lt thyrocervical artery * Note the end of the pigtail catheter in the ascending aorta, just beyond the aortic valve. ** This arch is anomalous. There is no brachiocephalic trunk. The Rt CCA and subclavian originate from the arch. To lay the arch out in profile the patient is in an RPO position. (Supine, rolled to the right side at approximately 30 degrees.) #6 Arch of the Aorta Plate (131) 138

1. Rt subclavian artery * The subclavian becomes the axillary 2. Rt axillary artery* on passing under the clavicle. #2 is 3. Rt internal thoracic (mammary) artery** close to the boundary of the 1st & 4. Rt thyrocervical trunk*** 2nd segment of the axillary artery 5. Rt dorsal scapular artery ** Sometimes used in coronary bypass *** The trunk is lower than the arrow indicates (prior to the bifurcation) #7 Subclavian arteriogram Plate (420) 427 Head of the humerus Glenoid process Clavicle Lung

1. Lt axillary artery 2. Lt brachial artery 3. Anterior & Posterior circumflex arteries 4. Lt circumflex subscapular artery 5. Lt thoracoacromial artery 6. Lt subscapular artery 7. Head of the lt humerus #8 Axillary arteriogram Projection is anterior to posterior with the arm raised Plate (417) 434

1. Rt internal carotid artery 2. Rt external carotid artery 3. Rt common carotid artery 4. Tip of catheter 5. Swallowing artifact* Digital subtraction angiography (DSA) requires the patient to be still or motion artifacts appear. A swallowing artifact is common to a carotid study. #9 Carotid injection Plate (130) 136

1. Rt internal carotid artery 2. Rt external carotid artery 3. Rt middle cerebral artery 4. Rt anterior cerebral artery 5. Anterior communicating artery 6. Rt anterior cerebral artery #10 Cerebral arteriogram Plates ( )

1. Rt superior sagittal sinus 2. Rt cerebral veins 3. Rt transverse sinus 4. Confluence of sinuses* 5. Rt sigmoid sinus 6. Rt internal jugular vein * The confluence of sinuses appears to be shifted to the right. This is due to the patient’s head being slightly rotated to the left. #11 Cerebral arteriogram, venous phase Plates (96- 98)

1. Rt middle cerebral artery 2. Lt anterior cerebral artery 3. Anterior cerebral artery 4. Rt posterior cerebral artery 5. Basilar artery 6. Internal carotid artery There is a trace of the right posterior communicating artery, but the left is not seen. #12 MRA:axial Magnetic Resonance Angiography Plate (133) 140 #12 This magnetic resonance angiography (MRA) image is a 3D reconstruction of the circle of willis, view in the axial plane. The two triangular shapes on the top are the superior surface of the orbital part of the frontal bone (roof of orbit).

1. Rt internal carotid artery 2. Rt internal carotid artery in the carotid canal (130) 3. Rt middle cerebral artery 4. Rt anterior cerebral artery 5. Anterior communicating artery #13 MRA: Coronal Orientation marker indicates right, superior, and anterior This 3D reconstruction is the result of extracting the vasculature in the volume of the MR scan, and displaying a selected portion in the coronal plane. #13

1. Radial artery 2. Ulnar artery 3. Common palmar digital arteries 4. Proper palmar digital arteries 5. Superficial palmar arch Hand arteriorgram #14 Plate (449) 466

1. Joint space of Rt knee 2. Lt popliteal artery 3a. Lt tibioperoneal trunk* 3b. Lt posterior tibial artery 4. Lt anterior tibial artery 5. Lt peroneal (fibular) artery 6. Adipose tissue** * Netter labels 3a and 3b only as the posterior tibial artery. Identifying 3a as the tibioperoneal trunk helps differentiate that section of the vessel. This area (3-5) is also known as a trifurcation. ** When doing a bilateral study of the femoral arteries the legs must be close together, causing an overlap of soft tissue. #15 Femoral arteriogram Plate (494) 512 a. b.

1. Inferior vena cava 2. Rt common iliac vein 3. Lt common iliac vein 4. Rt external iliac vein 5. Rt internal iliac vein 6. Posterior branch of Rt internal iliac vein #16 Rt leg venogram Plates (257, 283) 265, 403 Iliac crest Lumbar spine

1. Rt ilium of the pelvis 2. Rt common iliac vein 3. Rt femoral vein 4. Rt great saphenous vein 5. Pubic symphysis 6. Rt external iliac vein 7. Rt internal iliac vein #17 Rt leg venogram Plates (257, 283) 265, 403 Femoral head

1. Rt femoral vein 2. Rt deep (femoral) vein (487) Rt femoral vein* 4. Rt obturator foramen * The inverted V shape is a valve. Another is seen in the deep vein. The previous image showed the veins as black. This is the typical fluoroscopic presentation. The gray scale can be reversed electronically, but in this case was filmed in the fluoroscopic mode. When contrast filled vessels are white, that is the radiographic presentation. #18 Rt leg venogram Femoral head

1. Rt femoral vein 2. Rt popliteal vein The proliferation of veins below the head of the fibula are superficial. They disappear so dramatically due to a tourniquet at that level. Prior to vascular ultrasound venograms were the “gold standard” for visualizing deep vein thrombosis (DVT). The injection was made through a superficial vein in the dorsum of the foot, and tourniquets at the ankle, below the knee, and on the distal thigh helped drive the iodine contrast into the deep system. Finding a vein in edematous tissue was a challenge, and filling the deep venous system was a tricky and exacting process, and most uncomfortable for the patient. There are undoubtedly few, if any, radiologic technologists who are not thankful that vascular ultrasound has supplanted there need to perform this exam. #19 Rt leg venogram Plates (498, ) 502,

1. Rt. Popliteal vein 2. Rt short saphenous vein (498) 3. Rt great saphenous vein #20 Rt leg venogram Plates (498, 526–528) 502,