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 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

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 Doppler is 95% accurate and is the preferred initial imaging modality. Demonstrates lack of compressibility of the vein and this indicates the presence of a thrombus.

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 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 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-superficial Black- 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 First hour 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 Watch for signs of infection Drink lots of water Swelling red and warm to touch Accompanied by a fever Contact DR right away Drink lots of water Major swelling in one limb Especially limb injected

Indications Check for metastasis Edema in limbs Infections Obstruction Infections Rule out cancer

Contrast Oil based Water based Iodine 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 Lipiodol lymphography: Left image: After the injection of contrast material (lymphangiographic phase) the normal lymphatic vessels of the minor pelvis are visualized. Right image: 24 hours after the injection normal inguinal, pelvic and paralumbar lymph nodes are demonstrated (nodal phase).

Upper Limb Lymphography

Lymphoma Malignancy of lymphatic system Non-Hodgkin's Hodgkin's 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 XRAY- shows enlarged lymph nodes along mediastinum. CT, MRI and PET can demonstrate lymphoma in almost any organ. US is used for retroperitoneal adenopathy. NM: gallium has an increased intake in affected nodes.

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 59-year-old man with adenovirus infection after hematopoietic stem cell transplantation for Hodgkin's disease. Transverse thin-section (1-mm collimation, lung window) CT scan at level of suprahepatic inferior vena cava shows bilateral multifocal small nodules (arrowhead), branching multiple ill-defined bilateral nodules (black arrow), and thickening of small bronchial walls (white

Hodgkin’s Disease Treatment includes RAD therapy And chemotherapy Symptoms include malaise, fever, Anorexia, enlarged lymph nodes

Staging of Lymphomas Stage I: Stage II: Stage III: Stage IV: 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 Stage I: The lymphoma cells are in one lymph node group (such as in the neck or underarm). Or, if the lymphoma cells are not in the lymph nodes, they are in only one part of a tissue or an organ (such as the lung). Stage II: The lymphoma cells are in at least two lymph node groups on the same side of (either above or below) the diaphragm. Or, the lymphoma cells are in one part of a tissue or an organ and the lymph nodes near that organ (on the same side of the diaphragm). There may be lymphoma cells in other lymph node groups on the same side of the diaphragm. Stage III: The lymphoma cells are in lymph nodes above and below the diaphragm. Lymphoma also may be found in one part of a tissue or an organ (such as the liver, lung, or bone) near these lymph node groups. It may also be found in the spleen. Stage IV: Lymphoma cells are found in several parts of one or more organs or tissues. Or, the lymphoma is in an organ (such as the liver, lung, or bone) and in distant lymph nodes.

Statistics New cases in 2008 : 73,740 5 year survival rate (1996-2004) 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 Certain viruses: Having an infection with the Epstein-Barr virus (EBV) or the human immunodeficiency virus (HIV) may increase the risk of developing Hodgkin lymphoma. However, lymphoma is not contagious. You can't catch lymphoma from another person. Weakened immune system: The risk of developing Hodgkin lymphoma may be increased by having a weakened immune system (such as from an inherited condition or certain drugs used after an organ transplant). Age: Hodgkin lymphoma is most common among teens and adults aged 15 to 35 years and adults aged 55 years and older. (For information about this disease in children, call the NCI's Cancer Information Service at 1-800-4-CANCER.) Family history: Family members, especially brothers and sisters, of a person with Hodgkin lymphoma or other lymphomas may have an increased chance of developing this disease. Family History of Hodgkin's Disease:  Having a brother or sister with Hodgkin's Disease indicates that you may be at higher risk because of genetic factors. Viruses:  People who have had an infection from the Epstein-Barr virus or who have had infectious mononucleosis ("mono") are at a higher risk. Compromised Immune System:  AIDS, immune system suppressing drugs, and various immunodeficiency syndromes have been associated with an increased risk

CT: Lymphoma This is a CT image from an abdomen scan. Compare the left kidney to the mass on the right. The "L" marks the lymphomatous mass that has completely overtaken the right kidney. The "M" marks another very enlarged lymph node. This is image evidence of lymphoma.

PET Lymphoma This is a PET image of lymphoma. All of the areas of increased uptake (darker) are evidence of active disease in the lymphatic tissues.

DMS Lymphoma This DMS image shows calipers and numbers marking enlarged lymph nodes due to lymphoma. The nodes were found around the pancreas.