Lymphography and Venography

2012

Venous Circulation

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

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

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

Pulmonary Emboli (PE)

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

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 )

Contraindications

• Bleeding disorders

• Allergy to iodine

• CHF

• Severe pulmonary hypertension

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.

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

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

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

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

Lower Limb Veins

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

Lower Limb Venograms

DVT

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

Upper Limb Veins

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

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

Superior Venacavagram

Stenosis on a Superior Venacavogram

Inferior Venacavagram

Inferior Venacavagram

Inferior Vena Cava Filters

Inferior Vena Cava Filter Placement

• Designed to trap thrombus before causing an embolization

• When anticoagulants are contraindicated this can be used

Inferior Vena Cava Filter Placement

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

Hepatic Venogram

Portal Venogram

Portal System

http://www.youtube.com/watch?v=4aGNqmWOuEo&feature=related

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=pGA6KUgq7AI

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Transjugular Intrahepatic Portosystemic Shunt

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

Renal Venogram

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Lymphatic System:Green-superficialBlack- deep

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RT AND LT LYMPH DRAINAGE

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LYMPH DRAINAGE

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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

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Pre Procedure

• Obtain PT history

• Obtain PT consent

• Make sure to have all supplies

• Positioning aides and comfort supplies

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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

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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

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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

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Indications• Check for

metastasis

• Edema in limbs– Obstruction

• Infections

• Rule out cancer

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Contrast

• Oil based – More commonly used– Ethiodal– Lipodal

• Water based Iodine– Less commonly used– Ionic– Non-ionic

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Iliopelvic-aortic Lymphatic System

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Iliopelvic Abdominoaortic Lymph Nodes

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Inguinal Region

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Lymphography

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Upper Limb Lymphography