circulatory and cardiovascular systems spring 2013
TRANSCRIPT
Circulatory and Circulatory and Cardiovascular Cardiovascular
SystemsSystems
Spring 2013Spring 2013
22
Circulatory SystemCirculatory System
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Blood Vascular SystemBlood Vascular System
44
Heart and Great VesselsHeart and Great Vessels
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Cross Section of the HeartCross Section of the Heart
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Arteries of the HeartArteries of the Heart
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Anterior View of Coronary Anterior View of Coronary ArteriesArteries
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Anterior View of Coronary Anterior View of Coronary VeinsVeins
99
Pathologies Pathologies
Congenital Heart Congenital Heart DiseasesDiseases– MurmurMurmur– Patent Ductus ArteriosusPatent Ductus Arteriosus– Arterial Septal DefectsArterial Septal Defects– Ventricular Septal Ventricular Septal
DefectsDefects– Teratology of FallotTeratology of Fallot
Valvular heart diseaseValvular heart disease– Valvular StenosisValvular Stenosis– Congestive Heart FailureCongestive Heart Failure
Degenerative diseasesDegenerative diseases– CADCAD– AtherosclerosisAtherosclerosis
Myocardial infarctionMyocardial infarction Aortic aneurysmAortic aneurysm Pulmonary EmbolismPulmonary Embolism
MurmurMurmur
Murmur- an Murmur- an abnormal heart abnormal heart soundsound– Results from Results from
malformed valvesmalformed valves
Patent Ductus ArteriosusPatent Ductus Arteriosus
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Atrial Septal DefectAtrial Septal Defect
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Ventricular Septal DefectVentricular Septal Defect
Teratology of FallotTeratology of Fallot
Coarctation of the AortaCoarctation of the Aorta
Valvular DiseaseValvular Disease
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Mitral Valvular StenosisMitral Valvular Stenosis
Mitral Valve StenosisMitral Valve Stenosis
Congestive Heart FailureCongestive Heart Failure
CHF RadiographCHF Radiograph
Coronary Artery DiseaseCoronary Artery Disease
Coronary Artery DiseaseCoronary Artery Disease
Myocardial InfarctionMyocardial Infarction
Myocardial Infarction Myocardial Infarction ImagesImages
Aortic AneurysmAortic Aneurysm
Aortic Aneurysm ImagingAortic Aneurysm Imaging
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AortogramAortogram
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AORTOGRAMAORTOGRAM
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Abdominal AortoraphyAbdominal Aortoraphy
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Abdominal AngiographyAbdominal Angiography
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AAA Pre and Post Stent AAA Pre and Post Stent PlacementPlacement
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Abdominal StentAbdominal Stent
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AAAAAA
Pulmonary Pulmonary EmbolismEmbolism
Pulmonary Embolism Pulmonary Embolism ImagingImaging
Angiography Angiography Arteriography and Arteriography and
AortogramsAortograms
SPRING 2013 SPRING 2013
AngiographyAngiography
Is the general term that Is the general term that describes the radiologic describes the radiologic examination of vascular examination of vascular
structures within the body structures within the body after the introduction of an after the introduction of an
iodinated contrast medium or iodinated contrast medium or gasgas
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Types of Angiographic Types of Angiographic ProceduresProcedures
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Angiography TeamAngiography Team
RadiologistRadiologist
CIT (Radiologic Technologist)CIT (Radiologic Technologist)– Sometimes more than oneSometimes more than one
Other specialists (if needed)Other specialists (if needed)
Nurse Nurse
Anesthesiologist (if needed)Anesthesiologist (if needed)
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IndicationsIndications
Verify the presence of Verify the presence of tumorstumors– Blood supply to tumorsBlood supply to tumors
Internal bleedingInternal bleeding– Possible anemiaPossible anemia
StenosisStenosis
– Can be caused form Can be caused form atherosclerosisatherosclerosis
OcclusionsOcclusions– ClotsClots– ThrombusThrombus– EmbolusEmbolus
AneurysmsAneurysms
Heart diseaseHeart disease
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ContraindicationsContraindications
Previous severe reaction to contrast Previous severe reaction to contrast
Impaired renal functionImpaired renal function
Impaired blood clotting factorsImpaired blood clotting factors
Inability to undergo surgical Inability to undergo surgical procedureprocedure
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Contrast MediaContrast Media
Iodinated contrast media is usedIodinated contrast media is used– Can produce nausea & an Can produce nausea & an
uncomfortable burning sensationuncomfortable burning sensation
– Allergic reactionsAllergic reactions Severe: anaphylactic shockSevere: anaphylactic shock
– Shock, rapid shallow breathing, high pulse rate & Shock, rapid shallow breathing, high pulse rate & ALOCALOC
Mild: Hives or slight difficulty breathingMild: Hives or slight difficulty breathing
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What is this?What is this?
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Angiographic Trays Angiographic Trays and Sterile Suppliesand Sterile Supplies
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Other Supplies for Other Supplies for AngiographyAngiography
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NeedlesNeedles
Vascular access Vascular access needlesneedles
Size based on Size based on external diameter of external diameter of needleneedle
Allows for Allows for appropriate appropriate Guidewires Guidewires matchingmatching– So internal diameter So internal diameter
must also be knownmust also be known
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GuidewiresGuidewires Used as a platform Used as a platform
over which a catheter over which a catheter is to be advancedis to be advanced
Once positioned Once positioned guidewire is fixed and guidewire is fixed and catheter is advanced catheter is advanced until it meets the tip until it meets the tip of the guidwireof the guidwire
Mostly constructed on Mostly constructed on stainless steel & stainless steel & coated with Tefloncoated with Teflon
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Introducer SheathsIntroducer Sheaths
Short catheters Short catheters used when multiple used when multiple catheters will be catheters will be usedused
Placed in lieu of a Placed in lieu of a cathetercatheter
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CathetersCatheters
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DSA DSA
A subtraction mask is A subtraction mask is taken before contrast taken before contrast injectedinjected
Each of digitized Each of digitized image is from the image is from the maskmask
Images acquired Images acquired formform– 1 image every 2-3 sec1 image every 2-3 sec– Up to 30 images per Up to 30 images per
secsec
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Three Dimensional (3-D) Three Dimensional (3-D) Intraarterial AngiographyIntraarterial Angiography
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What Method is this?What Method is this?
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Catherization: Selinger Catherization: Selinger TechniqueTechnique
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Selinger Technique Catheters Selinger Technique Catheters and Guidewiresand Guidewires
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Radiation ProtectionRadiation Protection
PT is protected by no less than 2.5 PT is protected by no less than 2.5 mm of Aluminummm of Aluminum
Beam restrictionBeam restriction Avoidance of repeat exposureAvoidance of repeat exposure Cardinal rulesCardinal rules
– Time Time – DistanceDistance– ShieldingShielding
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Stent PlacementStent Placement
http://images.google.com/imgres?http://images.google.com/imgres?imgurl=http://www.nhlbi.nih.gov/health/dci/imgurl=http://www.nhlbi.nih.gov/health/dci/images/stent_restenosis.gif&imgrefurl=http://images/stent_restenosis.gif&imgrefurl=http://www.nhlbi.nih.gov/health/dci/Diseases/stents/www.nhlbi.nih.gov/health/dci/Diseases/stents/stents_all.html&usg=__xDlbsaX9JhuYbpVojLcz19stents_all.html&usg=__xDlbsaX9JhuYbpVojLcz19apr-apr-I=&h=513&w=450&sz=59&hl=en&start=20&tbI=&h=513&w=450&sz=59&hl=en&start=20&tbnid=vWwqaG-RNW7M-nid=vWwqaG-RNW7M-M:&tbnh=131&tbnw=115&prev=/images%3FqM:&tbnh=131&tbnw=115&prev=/images%3Fq%3Dabdominal%2Bstents%26gbv%3D2%26hl%3Dabdominal%2Bstents%26gbv%3D2%26hl%3Den%3Den
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Pulmonary CirculationPulmonary Circulation
http://www.youtube.com/watch?v=D3ZDJgFDdk0
http://www.youtube.com/watch?v=0jznS5psypI
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Pulmonary ArteriogramPulmonary Arteriogram
Celiac AteriogramCeliac Ateriogram
Celian artery carries Celian artery carries blood from stomach to blood from stomach to duodenum, liver, duodenum, liver, spleen and pancreasspleen and pancreas
Approx at level T12Approx at level T12
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Hepatic ArteriogramHepatic Arteriogram
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Splenic Splenic ArteriorgramArteriorgram
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Renal ArteriogramRenal Arteriogram
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renalrenal
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Lower Limb ArteriesLower Limb Arteries
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Leg AtherosclerosisLeg Atherosclerosis
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Atherosclerosis Left LegAtherosclerosis Left Leg
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Upper Limb ArteriesUpper Limb Arteries
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Upper Extremity AnatomyUpper Extremity Anatomy
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Brachial and Axillary Brachial and Axillary ArteriogramArteriogram
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Hand ArteriogramHand Arteriogram
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Hand Arteriogram with Hand Arteriogram with OcclusionOcclusion
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Balloon AngioplastyBalloon Angioplasty
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Balloon Angioplasty Balloon Angioplasty ProcedureProcedure
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Femoral Artery AngioplastyFemoral Artery Angioplasty
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Placing a Stent after Placing a Stent after Angioplasty with BalloonAngioplasty with Balloon
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Intravascular StentsIntravascular Stents
Cerebral Angiography Cerebral Angiography IndicationsIndications
• AneurysmsAneurysms
• Arteriovenous MalformationsArteriovenous Malformations
• TumorsTumors
• Athersclerotic LesionsAthersclerotic Lesions
• Stenotic lesionsStenotic lesions
Circle of WillisCircle of Willis
Circulation Time Circulation Time
Cerebral circulationCerebral circulationCarotid artery to jugular vein (3 seconds)Carotid artery to jugular vein (3 seconds)
With contrastWith contrast– 4.13 seconds4.13 seconds
Certain pathologies shorten or delay Certain pathologies shorten or delay timetime– AVM’s shorten timeAVM’s shorten time– Arterial vasospasm delays timeArterial vasospasm delays time
EquipmentEquipment
Bi-plane imagingBi-plane imaging– FilmFilm– DSADSA
Automatic InjectorAutomatic Injector
Carotid AngiogramCarotid Angiogram
Internal Carotid AngiogramsInternal Carotid Angiograms
Internal Carotid AngiogramInternal Carotid Angiogram
Vertebral Arteries Vertebral Arteries AngiogramAngiogram
Vertebral Artery AngiogramVertebral Artery Angiogram
Let’s ReviewLet’s Review
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What is the name of this What is the name of this Procedure?Procedure?
What is it done for?What is it done for?
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What is the name of this What is the name of this pathology?pathology?
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What part of the body is being What part of the body is being imaged?imaged?
What is the pathology is this What is the pathology is this image?image?
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What is this method callled?What is this method callled?
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A
B
C
Venography Venography
20132013
Venous Venous CirculationCirculation
What is Venography?What is Venography?
Vein study using x-ray and contrast Vein study using x-ray and contrast mediamedia– Fluoroscopy and still imagesFluoroscopy and still images
One of the most accurate tests for One of the most accurate tests for deep vein thrombosis (DVT)deep vein thrombosis (DVT)
Most commonly done in legs for DVTMost commonly done in legs for DVT
Thrombosis and EmbolismThrombosis and Embolism
Intravascular clotIntravascular clot Commonly in veins Commonly in veins
more than arteriesmore than arteries
3 factors3 factors– Where blood is slowWhere blood is slow– Change in the wall Change in the wall
of vesselsof vessels– Change in the blood Change in the blood
itselfitself
Thrombus that Thrombus that becomes detached becomes detached from the vessel wallfrom the vessel wall
Can easily flow to Can easily flow to heart causing PEheart causing PE
Severity depends Severity depends on location of on location of embolismembolism
Pulmonary EmbolismPulmonary Embolism Occurs when a clot forms or becomes lodged in Occurs when a clot forms or becomes lodged in
the pulmonary arterythe pulmonary artery
Most commonly thrombus originates in the lower Most commonly thrombus originates in the lower limbs and migrateslimbs and migrates
Can lead to resp distress, heart failure or Can lead to resp distress, heart failure or cardiogenic shockcardiogenic shock
Symptoms are acute:Symptoms are acute:– Sudden coughingSudden coughing– SOBSOB– Chest painChest pain
Pulmonary Emboli (PE)Pulmonary Emboli (PE)
IndicationsIndications Diagnose deep vein Diagnose deep vein
thrombosis thrombosis – Prevent pulmonary Prevent pulmonary
embolismembolism
Distinguish blood clots from Distinguish blood clots from obstructions in the veins obstructions in the veins
Evaluate congenital vein Evaluate congenital vein problems problems
Assess the functioning of Assess the functioning of deep leg vein valves deep leg vein valves
Identify a vein for arterial Identify a vein for arterial bypass graftingbypass grafting
Risk Factors and Risk Factors and ComplicationsComplications
Previous thrombosis Previous thrombosis
Dilution of the contrast dye in the Dilution of the contrast dye in the lower limb lower limb
Difficulty accessing the veins due to: Difficulty accessing the veins due to: – ObesityObesity– Severe swelling (edema) Severe swelling (edema) – Inflammation in the cells ( cellulitis ) Inflammation in the cells ( cellulitis )
ContraindicationsContraindications
Bleeding disordersBleeding disorders
Allergy to iodineAllergy to iodine
CHFCHF
Severe pulmonary hypertensionSevere pulmonary hypertension
Prior to ProcedurePrior to Procedure
Fast or drink only clear fluids for four Fast or drink only clear fluids for four hours before the testhours before the test
Thorough PT history obtainedThorough PT history obtained
Informed consentInformed consent
If you are nervous about the test, your If you are nervous about the test, your doctor may give you a sedative.doctor may give you a sedative.
During ProcedureDuring Procedure
PT will lie on a tilting x-ray tablePT 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 anestheticLocal anesthetic
Catheter will be inserted.Catheter will be inserted.– A small incision may be A small incision may be made in that area as wellmade in that area as well
Explanation of Procedure: Explanation of Procedure: LegsLegs The catheter is inserted The catheter is inserted
into PT veininto PT vein– (usually a vein in the foot) (usually a vein in the foot)
Contrast is slowly injected. Contrast is slowly injected.
A tight band may be tied A tight band may be tied around your ankle and around your ankle and upper thighupper thigh– or your lower body may be or your lower body may be
tiltedtilted– Fluoro and/or x-ray images Fluoro and/or x-ray images
takentaken
The procedure takes about The procedure takes about 30 - 45 minutes 30 - 45 minutes
Post ProcedurePost Procedure
Rest and avoid strenuous activityRest and avoid strenuous activity
Increase fluid intakeIncrease fluid intake
Stop bleeding with pressure Stop bleeding with pressure – Call DR if it won’t stop bleedingCall DR if it won’t stop bleeding
Observe for signs of infectionObserve for signs of infection
PT will be sore for a few daysPT will be sore for a few days
Resume normal activity 24 hours after procedureResume normal activity 24 hours after procedure
Possible Post Procedure Possible Post Procedure ComplicationsComplications
Infection at the Infection at the injection site injection site
Tissue damage Tissue damage
Phlebitis Phlebitis (inflammation of a (inflammation of a vein) vein)
Allergic reactions to Allergic reactions to the contrast dye the contrast dye
Congestive heart Congestive heart failure failure
Acute renal Acute renal insufficiency insufficiency
Venous thrombosis in a Venous thrombosis in a healthy leg healthy leg
Dislodging a clot, Dislodging a clot, perhaps resulting in perhaps resulting in pulmonary embolus or pulmonary embolus or other complicationsother complications
Lower Limb VeinsLower Limb Veins
Lower Limb VenogramsLower Limb Venograms
To rule out thrombosis of the deep To rule out thrombosis of the deep veins of the leg veins of the leg – Deep vein thrombosis (DVT)Deep vein thrombosis (DVT)
Contrast media injected in superficial Contrast media injected in superficial veins of the foot with a needleveins of the foot with a needle
Lower Limb Lower Limb VenogramsVenograms
DVTDVT
Inferior VenacavagramInferior Venacavagram
Primarily to rule out thrombus or Primarily to rule out thrombus or occlusionocclusion
Catheter inserted into femoral vein and Catheter inserted into femoral vein and positioned inside the common iliac vein positioned inside the common iliac vein or inferior aspect of inferior vena cavaor inferior aspect of inferior vena cava
Contrast injected at 20 ml/sec for total of Contrast injected at 20 ml/sec for total of 40ml40ml
Upper Limb VeinsUpper Limb Veins
Upper Limb VenogramsUpper Limb Venograms Most often for thrombosis or Most often for thrombosis or
occlusionocclusion Contrast injected in a superficial vein Contrast injected in a superficial vein
in the elbow or wristin the elbow or wrist– Using a catheter or needleUsing a catheter or needle– 40-80ml at a rate of 1-4ml/sec40-80ml at a rate of 1-4ml/sec
Superior VenacavagramSuperior Venacavagram Primarily done to rule out thrombus or Primarily done to rule out thrombus or
occlusionocclusion
Needle or catheter is introduced into Needle or catheter is introduced into antecubital fossaantecubital fossa– Catheter is positioned in the axillary or Catheter is positioned in the axillary or
subclavian vein and contrast is injectedsubclavian vein and contrast is injected– 30-50ml at 10-15ml/sec30-50ml at 10-15ml/sec
X-rays should include:X-rays should include:– Brachicephalic veinBrachicephalic vein– Subclavian veinSubclavian vein– Superior vena cavaSuperior vena cava– RT AtriumRT Atrium
Superior VenacavagramSuperior Venacavagram
Stenosis on a Superior Stenosis on a Superior VenacavogramVenacavogram
Inferior VenacavagramInferior Venacavagram
Inferior VenacavagramInferior Venacavagram
Inferior Vena Cava FiltersInferior Vena Cava Filters
Inferior Vena Cava Filter Inferior Vena Cava Filter PlacementPlacement
Designed to trap Designed to trap thrombus before thrombus before causing an causing an embolizationembolization
When When anticoagulants are anticoagulants are contraindicated contraindicated this can be usedthis can be used
Inferior Vena Cava Filter Inferior Vena Cava Filter PlacementPlacement
Hepatic VenogramHepatic Venogram
Performed to rule out stenosis or Performed to rule out stenosis or thrombus of the hepatic veinsthrombus of the hepatic veins
Obtain pressure measurements of Obtain pressure measurements of the veins inside the liverthe veins inside the liver
Usually catheter enters jugular vein Usually catheter enters jugular vein or upper limb veinsor upper limb veins
Hepatic VenogramHepatic Venogram
Portal VenogramPortal Venogram
Portal SystemPortal System
http://www.youtube.com/watch?v=4aGNqmWOuEo&feature=related
Transjugular Intrahepatic Transjugular Intrahepatic Portosystemic ShuntPortosystemic Shunt
Intervention for Intervention for creating an artificial creating an artificial low-pressure pathwaylow-pressure pathway– Between portal & Between portal &
hepatic veinshepatic veins
Hepatic venogram Hepatic venogram usually preformed usually preformed before placementbefore placement
US also usefulUS also useful http://www.youtube.com/watch?v=pGA6KUgq7AI
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Transjugular Intrahepatic Transjugular Intrahepatic Portosystemic ShuntPortosystemic Shunt
Renal VenogramRenal Venogram
Rule out thrombosis of renal veinRule out thrombosis of renal vein
Renal vein catheterized to take bloodRenal vein catheterized to take blood– Measure the production of reninMeasure the production of renin– Catheter insertion site: femoral veinCatheter insertion site: femoral vein
Contrast injected 8ml/sec for 16ml Contrast injected 8ml/sec for 16ml totaltotal– 2 images per second for 4 seconds2 images per second for 4 seconds
Renal VenogramRenal Venogram