Venography & Lymphography

Spring 2009

FINAL

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

Deep Vein Thrombosis

• Primarily involves lower limbs

• Major source of fatal PE

• Risks– Restricted mobility– Surgery– Obesity– Pregnant– BC pills– Long trips

• Plane• Car

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

Occurrence of DVT in 338 Patients

DVT

Deep Vein Thrombosis

DVT

Phlebitis

• Inflammation of a vein

• Often associated with venous thrombosis

• US usually used to diagnose

• Treated with anticoagulants

Varicose Veins• Dilated, elongated and tortuous vessels

• Most common to superficial veins of leg

• Multiple bluish nodules just under skin

• Development of collateral veins

Varicose Veins

• Valves are unable to prevent backflow• Valves cease to function increasing blood volume is

these veins

Varicose Veins

• Demonstrates patnecy of the deep venous system

• Shows the degree of collateral circulation

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 i=enters jugular vein or upper limb veins

Hepatic Venogram

Portal Venogram

Portal System

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

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

Lymphatic System:Green-superficialBlack- deep

RT AND LT LYMPH DRAINAGE

LYMPH DRAINAGE

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

Pre Procedure

• Obtain PT history

• Obtain PT consent

• Make sure to have all supplies

• Positioning aides and comfort supplies

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

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

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

Indications

• Check for metastasis

• Edema in limbs– Obstruction

• Infections

• Rule out cancer

Contrast

• Oil based – More commonly used– Ethiodal– Lipodal

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

Iliopelvic-aortic Lymphatic System

Iliopelvic Abdominoaortic Lymph Nodes

Inguinal Region

Lymphography

Upper Limb Lymphography

Lymphoma• Malignancy of lymphatic system

– 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

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

Non-Hodgkin’s Lymphoma

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

Hodgkin’s Disease

Treatment includes RAD therapyAnd chemotherapy

Symptoms include malaise, fever,Anorexia, enlarged lymph nodes

Staging of Lymphomas• Stage I:

– 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

Statistics

• New cases in 2008 : 73,740– NHL 66,120– Hodgkin's 8,220– 39,850 males : 34.490 females

• 5 year survival rate (1996-2004) – NHL 65%– Hodgkin's 86%

www.lls.org

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

CT: Lymphoma

PET Lymphoma

DMS Lymphoma