1. Venography & Lymphography
Spring 2009
FINAL

2. Venous Circulation

3. 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

4. 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

5. 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

6. Pulmonary Emboli (PE)

7. 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

8. 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 )

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

10. 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

11. 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.

12. 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.

13. 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.

14. 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.

15. Lower Limb Veins

16. 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

17. Lower Limb Venograms

18. Deep Vein Thrombosis Primarily involves lower limbs
Major source of fatal PE
Risks
Restricted mobility
Surgery
Obesity
Pregnant
BC pills
Long trips
Plane
Car

19. 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.

21. Occurrence of DVT in 338 Patients

22. DVT

23. Deep Vein Thrombosis

24. DVT

25. Phlebitis Inflammation of a vein
Often associated with venous thrombosis
US usually used to diagnose
Treated with anticoagulants

26. Varicose Veins Dilated, elongated and tortuous vessels
Most common to superficial veins of leg
Multiple bluish nodules just under skin
Development of collateral veins

27. Varicose Veins Valves are unable to prevent backflow
Valves cease to function increasing blood volume is these veins

28. Varicose Veins Demonstrates patnecy of the deep venous system
Shows the degree of collateral circulation

30. 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

31. Upper Limb Veins

32. 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

33. 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

34. Superior Venacavagram

35. 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.

36. Inferior Venacavagram

37. Inferior Venacavagram

38. Inferior Vena Cava Filters

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

40. Inferior Vena Cava Filter Placement

42. 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

43. Hepatic Venogram

44. Portal Venogram

45. Portal System

46. 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

47. Transjugular Intrahepatic Portosystemic Shunt

48. 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

49. Renal Venogram

50. Lymphatic System: Green-superficial Black- deep

51. RT AND LT LYMPH DRAINAGE

52. LYMPH DRAINAGE

53. 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

54. Pre Procedure Obtain PT history Obtain PT consent
Make sure to have all supplies
Positioning aides and comfort supplies

55. 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

56. 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

57. 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

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

59. Contrast Oil based Water based Iodine More commonly used Ethiodal
Lipodal
Water based Iodine
Less commonly used
Ionic
Non-ionic

60. Iliopelvic-aortic Lymphatic System

61. Iliopelvic Abdominoaortic Lymph Nodes

62. Inguinal Region

63. 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).

64. Upper Limb Lymphography

65. 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

66. 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

67. 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.

68. 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

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

70. 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.

71. Statistics New cases in 2008 : 73,740 5 year survival rate (1996-2004)
NHL 66,120
Hodgkin's 8,220
39,850 males : females
5 year survival rate ( )
NHL 65%
Hodgkin's 86%

72. 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 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

73. 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.

74. 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.

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