Venography & Lymphography

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. 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 Thrombosis and 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. 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 Possible Post Procedure 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. 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

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

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-superficialBlack- deep