Angiography Arteriography Aortograms and Venography SPRING 2011 FINAL

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

Types of Angiographic Procedures

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

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

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

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

What is this?

Angiographic Trays and Sterile Supplies

Other Supplies for Angiography

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

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

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

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.

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

Three Dimensional (3-D) Intraarterial Angiography

What Method is this?

Catherization: Selinger Technique

Selinger Technique Catheters and Guidewires

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

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

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

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

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

Aortogram

AORTOGRAM

Abdominal Aortoraphy

Abdominal Angiography

AAA Pre and Post Stent Placement

Abdominal Stent

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. Back to top 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.

Pulmonary Circulation

Pulmonary Arteriogram

Celiac Ateriogram

Hepatic Arteriogram

Splenic Arteriorgram

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)

renal

                                         

Lower Limb Arteries

Leg Atherosclerosis

Atherosclerosis Left Leg

Upper Limb Arteries

Upper Extremity Anatomy

Brachial and Axillary Arteriogram

Axillary Arteriogram

Hand Arteriogram

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.

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     

Balloon Angioplasty

Balloon Angioplasty Procedure

Femoral Artery Angioplasty

Placing a Stent after Angioplasty with Balloon

Intravascular Stents

Let’s Review

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

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

What is the name of this pathology?

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

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

What is this method callled?

A C B Arch of aorta Descending aorta Asending aorta

Venography

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 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

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. 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

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.

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 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.

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.

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.

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

DVT

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 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.

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 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