1. Lymphography and Venography 2012

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

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.

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

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 30 - 45 minutes

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

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

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. DVT

19. 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

20. Upper Limb Veins

21. 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

22. 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

23. Superior Venacavagram

24. Stenosis on a Superior Venacavogram

25. Inferior Venacavagram

27. Inferior Vena Cava Filters

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

29. Inferior Vena Cava Filter Placement

31. 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

32. Hepatic Venogram

33. Portal Venogram

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

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

36. 36

37. Transjugular Intrahepatic Portosystemic Shunt

38. 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

39. Renal Venogram

40. 40 Lymphatic System: Green-superficial Black- deep

41. 41 RT AND LT LYMPH DRAINAGE

42. 42 LYMPH DRAINAGE

43. 43 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

44. 44 Pre Procedure Obtain PT history Obtain PT consent Make sure to have all supplies Positioning aides and comfort supplies

45. 45 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

46. 46 Procedure X-rays are usually taken 1 HR after injection – 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

47. 47 Post Procedure 1.Watch for signs of infection Swelling red and warm to touch Accompanied by a fever Contact DR right away 2.Drink lots of water 3.Major swelling in one limb Especially limb injected

48. 48 Indications Check for metastasis Edema in limbs – Obstruction Infections Rule out cancer

49. 49 Contrast Oil based – More commonly used – Ethiodal – Lipodal Water based Iodine – Less commonly used – Ionic – Non-ionic

50. 50 Iliopelvic-aortic Lymphatic System

51. 51 Iliopelvic Abdominoaortic Lymph Nodes

52. 52 Inguinal Region

53. 53 Lymphography

54. 54 Upper Limb Lymphography