1. Circulatory and Cardiovascular Systems Spring 2013

2. 2 Circulatory System

3. 3 Blood Vascular System

4. 4 Heart and Great Vessels

5. 5 Cross Section of the Heart

6. 6 Arteries of the Heart

7. 7 Anterior View of Coronary Arteries

8. 8 Anterior View of Coronary Veins

9. 9 Pathologies Congenital Heart Diseases Congenital Heart Diseases –Murmur –Patent Ductus Arteriosus –Arterial Septal Defects –Ventricular Septal Defects –Teratology of Fallot Valvular heart disease Valvular heart disease –Valvular Stenosis –Congestive Heart Failure Degenerative diseases Degenerative diseases –CAD –Atherosclerosis Myocardial infarction Myocardial infarction Aortic aneurysm Aortic aneurysm Pulmonary Embolism Pulmonary Embolism

10. Murmur Murmur- an abnormal heart sound Murmur- an abnormal heart sound –Results from malformed valves

11. Patent Ductus Arteriosus 11

12. Atrial Septal Defect 12

13. Ventricular Septal Defect

14. Teratology of Fallot

15. Coarctation of the Aorta

16. Valvular Disease 16

17. Mitral Valvular Stenosis

18. Mitral Valve Stenosis

19. Congestive Heart Failure

20. CHF Radiograph

21. Coronary Artery Disease

23. Myocardial Infarction

24. Myocardial Infarction Images

25. Aortic Aneurysm

26. Aortic Aneurysm Imaging

27. 27 Aortogram

28. 28

29. 29 AORTOGRAM

30. 30 Abdominal Aortoraphy

31. 31 Abdominal Angiography

32. 32 AAA Pre and Post Stent Placement

33. 33

34. 34 Abdominal Stent

35. 35 AAA

36. Pulmonary Embolism

37. Pulmonary Embolism Imaging

38. Angiography Arteriography and Aortograms SPRING 2013

39. 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

40. 40 Types of Angiographic Procedures

41. 41

42. 42 Angiography Team Radiologist Radiologist CIT (Radiologic Technologist) CIT (Radiologic Technologist) –Sometimes more than one Other specialists (if needed) Other specialists (if needed) Nurse Nurse Anesthesiologist (if needed) Anesthesiologist (if needed)

43. 43 Indications Verify the presence of tumors Verify the presence of tumors –Blood supply to tumors Internal bleeding Internal bleeding –Possible anemia Stenosis Stenosis –Can be caused form atherosclerosis Occlusions Occlusions –Clots –Thrombus –Embolus Aneurysms Aneurysms Heart disease Heart disease

44. 44 Contraindications Previous severe reaction to contrast Previous severe reaction to contrast Impaired renal function Impaired renal function Impaired blood clotting factors Impaired blood clotting factors Inability to undergo surgical procedure Inability to undergo surgical procedure

45. 45 Contrast Media Iodinated contrast media is used 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

46. 46 What is this?

47. 47

48. 48 Angiographic Trays and Sterile Supplies

49. 49 Other Supplies for Angiography

50. 50 Needles Vascular access needles Vascular access needles Size based on external diameter of needle Size based on external diameter of needle Allows for appropriate Guidewires matching Allows for appropriate Guidewires matching –So internal diameter must also be known

51. 51 Guidewires Used as a platform over which a catheter is to be advanced 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 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 Mostly constructed on stainless steel & coated with Teflon

52. 52 Introducer Sheaths Short catheters used when multiple catheters will be used Short catheters used when multiple catheters will be used Placed in lieu of a catheter Placed in lieu of a catheter

53. 53 Catheters

54. 54

55. 55 DSA A subtraction mask is taken before contrast injected A subtraction mask is taken before contrast injected Each of digitized image is from the mask Each of digitized image is from the mask Images acquired form Images acquired form –1 image every 2-3 sec –Up to 30 images per sec

56. 56 Three Dimensional (3-D) Intraarterial Angiography

57. 57 What Method is this?

58. 58 Catherization: Selinger Technique

59. 59 Selinger Technique Catheters and Guidewires

60. 60 Radiation Protection PT is protected by no less than 2.5 mm of Aluminum PT is protected by no less than 2.5 mm of Aluminum Beam restriction Beam restriction Avoidance of repeat exposure Avoidance of repeat exposure Cardinal rules Cardinal rules –Time –Distance –Shielding

61. 61 Stent Placement http://images.google.com/imgres?imgurl=http:// www.nhlbi.nih.gov/health/dci/images/stent_rest enosis.gif&imgrefurl=http://www.nhlbi.nih.gov/h ealth/dci/Diseases/stents/stents_all.html&usg=_ _xDlbsaX9JhuYbpVojLcz19apr- I=&h=513&w=450&sz=59&hl=en&start=20&tb nid=vWwqaG-RNW7M- M:&tbnh=131&tbnw=115&prev=/images%3Fq %3Dabdominal%2Bstents%26gbv%3D2%26hl %3Den http://images.google.com/imgres?imgurl=http:// www.nhlbi.nih.gov/health/dci/images/stent_rest enosis.gif&imgrefurl=http://www.nhlbi.nih.gov/h ealth/dci/Diseases/stents/stents_all.html&usg=_ _xDlbsaX9JhuYbpVojLcz19apr- I=&h=513&w=450&sz=59&hl=en&start=20&tb nid=vWwqaG-RNW7M- M:&tbnh=131&tbnw=115&prev=/images%3Fq %3Dabdominal%2Bstents%26gbv%3D2%26hl %3Den http://images.google.com/imgres?imgurl=http:// www.nhlbi.nih.gov/health/dci/images/stent_rest enosis.gif&imgrefurl=http://www.nhlbi.nih.gov/h ealth/dci/Diseases/stents/stents_all.html&usg=_ _xDlbsaX9JhuYbpVojLcz19apr- I=&h=513&w=450&sz=59&hl=en&start=20&tb nid=vWwqaG-RNW7M- M:&tbnh=131&tbnw=115&prev=/images%3Fq %3Dabdominal%2Bstents%26gbv%3D2%26hl %3Den http://images.google.com/imgres?imgurl=http:// www.nhlbi.nih.gov/health/dci/images/stent_rest enosis.gif&imgrefurl=http://www.nhlbi.nih.gov/h ealth/dci/Diseases/stents/stents_all.html&usg=_ _xDlbsaX9JhuYbpVojLcz19apr- I=&h=513&w=450&sz=59&hl=en&start=20&tb nid=vWwqaG-RNW7M- M:&tbnh=131&tbnw=115&prev=/images%3Fq %3Dabdominal%2Bstents%26gbv%3D2%26hl %3Den

62. 62 Pulmonary Circulation http://www.youtube.com/watch?v=D3ZDJ gFDdk0 http://www.youtube.com/w atch?v=0jznS5psypI

63. 63 Pulmonary Arteriogram

64. Celiac Ateriogram Celian artery carries blood from stomach to duodenum, liver, spleen and pancreas Celian artery carries blood from stomach to duodenum, liver, spleen and pancreas Approx at level T12 Approx at level T12 64

65. Hepatic Arteriogram 65

66. Splenic Arteriorgram 66

67. 67 Renal Arteriogram

68. 68 renal

69. 69

70. 70

71. 71

72. 72 Lower Limb Arteries

73. 73

74. 74 Leg Atherosclerosis

75. 75 Atherosclerosis Left Leg

76. 76 Upper Limb Arteries

77. 77 Upper Extremity Anatomy

78. 78 Brachial and Axillary Arteriogram

79. 79 Hand Arteriogram

80. 80 Hand Arteriogram with Occlusion

81. 81

82. 82 Balloon Angioplasty

83. 83

84. 84 Balloon Angioplasty Procedure

85. 85 Femoral Artery Angioplasty

86. 86 Placing a Stent after Angioplasty with Balloon

87. 87 Intravascular Stents

88. Cerebral Angiography Indications Aneurysms Aneurysms Arteriovenous Malformations Arteriovenous Malformations Tumors Tumors Athersclerotic Lesions Athersclerotic Lesions Stenotic lesions Stenotic lesions

89. Circle of Willis

90. Circulation Time Cerebral circulation Cerebral circulation Carotid artery to jugular vein (3 seconds) With contrast With contrast –4.13 seconds Certain pathologies shorten or delay time Certain pathologies shorten or delay time –AVM’s shorten time –Arterial vasospasm delays time

91. Equipment Bi-plane imaging Bi-plane imaging –Film –DSA Automatic Injector Automatic Injector

92. Carotid Angiogram

93. Internal Carotid Angiograms

94. Internal Carotid Angiogram

95. Vertebral Arteries Angiogram

96. Vertebral Artery Angiogram

97. Let’s Review

98. 98 What is the name of this Procedure? What is it done for?

99. 99 What is the name of this pathology?

100. 100 What part of the body is being imaged? What is the pathology is this image?

101. 101

102. 102 What is this method callled?

103. 103 A B C

104. Venography 2013

105. Venous Circulation

106. What is Venography? Vein study using x-ray and contrast media Vein study using x-ray and contrast media –Fluoroscopy and still images One of the most accurate tests for deep vein thrombosis (DVT) One of the most accurate tests for deep vein thrombosis (DVT) Most commonly done in legs for DVT Most commonly done in legs for DVT

107. Thrombosis and Embolism Intravascular clot Intravascular clot Commonly in veins more than arteries Commonly in veins more than arteries 3 factors 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 Thrombus that becomes detached from the vessel wall Can easily flow to heart causing PE Can easily flow to heart causing PE Severity depends on location of embolism Severity depends on location of embolism

108. Pulmonary Embolism Occurs when a clot forms or becomes lodged in the pulmonary artery Occurs when a clot forms or becomes lodged in the pulmonary artery Most commonly thrombus originates in the lower limbs and migrates Most commonly thrombus originates in the lower limbs and migrates Can lead to resp distress, heart failure or cardiogenic shock Can lead to resp distress, heart failure or cardiogenic shock Symptoms are acute: Symptoms are acute: –Sudden coughing –SOB –Chest pain

109. Pulmonary Emboli (PE)

110. Indications Diagnose deep vein thrombosis Diagnose deep vein thrombosis – Prevent pulmonary embolism Distinguish blood clots from obstructions in the veins Distinguish blood clots from obstructions in the veins Evaluate congenital vein problems Evaluate congenital vein problems Assess the functioning of deep leg vein valves Assess the functioning of deep leg vein valves Identify a vein for arterial bypass grafting Identify a vein for arterial bypass grafting

111. Risk Factors and Complications Previous thrombosis Previous thrombosis Dilution of the contrast dye in the lower limb Dilution of the contrast dye in the lower limb Difficulty accessing the veins due to: Difficulty accessing the veins due to: –Obesity –Severe swelling (edema) –Inflammation in the cells ( cellulitis )

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

113. Prior to Procedure Fast or drink only clear fluids for four hours before the test Fast or drink only clear fluids for four hours before the test Thorough PT history obtained Thorough PT history obtained Informed consent Informed consent If you are nervous about the test, your doctor may give you a sedative. If you are nervous about the test, your doctor may give you a sedative.

114. During Procedure PT will lie on a tilting x-ray table PT will lie on a tilting x-ray table Area of interest will be Area of interest will be shaved and cleaned shaved and cleaned Local anesthetic Local anesthetic Catheter will be inserted. Catheter will be inserted. – A small incision may be made in that area as well made in that area as well

115. Explanation of Procedure: Legs The catheter is inserted into PT vein The catheter is inserted into PT vein – (usually a vein in the foot) Contrast is slowly injected. Contrast is slowly injected. A tight band may be tied around your ankle and upper thigh 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 procedure takes about 30 - 45 minutes

116. Post Procedure Rest and avoid strenuous activity Rest and avoid strenuous activity Increase fluid intake Increase fluid intake Stop bleeding with pressure Stop bleeding with pressure –Call DR if it won’t stop bleeding Observe for signs of infection Observe for signs of infection PT will be sore for a few days PT will be sore for a few days Resume normal activity 24 hours after procedure Resume normal activity 24 hours after procedure

117. Possible Post Procedure Complications Infection at the injection site Infection at the injection site Tissue damage Tissue damage Phlebitis (inflammation of a vein) Phlebitis (inflammation of a vein) Allergic reactions to the contrast dye Allergic reactions to the contrast dye Congestive heart failure Congestive heart failure Acute renal insufficiency Acute renal insufficiency Venous thrombosis in a healthy leg Venous thrombosis in a healthy leg Dislodging a clot, perhaps resulting in pulmonary embolus or other complications Dislodging a clot, perhaps resulting in pulmonary embolus or other complications

118. Lower Limb Veins

119. Lower Limb Venograms To rule out thrombosis of the deep veins of the leg 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 Contrast media injected in superficial veins of the foot with a needle

120. Lower Limb Venograms

121. DVT

122. Inferior Venacavagram Primarily to rule out thrombus or occlusion 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 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 Contrast injected at 20 ml/sec for total of 40ml

123. Upper Limb Veins

124. Upper Limb Venograms Most often for thrombosis or occlusion Most often for thrombosis or occlusion Contrast injected in a superficial vein in the elbow or wrist 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

125. Superior Venacavagram Primarily done to rule out thrombus or occlusion Primarily done to rule out thrombus or occlusion Needle or catheter is introduced into antecubital fossa 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: X-rays should include: – Brachicephalic vein –Subclavian vein –Superior vena cava –RT Atrium

126. Superior Venacavagram

127. Stenosis on a Superior Venacavogram

128. Inferior Venacavagram

130. Inferior Vena Cava Filters

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

132. Inferior Vena Cava Filter Placement

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

135. Hepatic Venogram

136. Portal Venogram

137. Portal System http://www.youtube.com/watch? v=4aGNqmWOuEo&feature=relat ed

138. Transjugular Intrahepatic Portosystemic Shunt Intervention for creating an artificial low-pressure pathway Intervention for creating an artificial low-pressure pathway –Between portal & hepatic veins Hepatic venogram usually preformed before placement Hepatic venogram usually preformed before placement US also useful US also useful http://www.youtube.com/watch?v=pGA6KUgq 7AI

139. 139

140. Transjugular Intrahepatic Portosystemic Shunt

141. Renal Venogram Rule out thrombosis of renal vein Rule out thrombosis of renal vein Renal vein catheterized to take blood Renal vein catheterized to take blood –Measure the production of renin –Catheter insertion site: femoral vein Contrast injected 8ml/sec for 16ml total Contrast injected 8ml/sec for 16ml total –2 images per second for 4 seconds

142. Renal Venogram