when is contrast venography useful?
DESCRIPTION
By: Mark J. Garcia MD, MS, FSIR Visit VeinGlobal at http://www.veinglobal.com/ for more presentations and videos on this topic, or for more information on venous disease news, education and research.TRANSCRIPT
Mark J. Garcia MD, MS, FSIR
Chief Interventional Radiology
Medical Director Center for Comprehensive Venous Health
Medical Director, Center for Heart & Vascular Peripheral Labs
Christiana Care Health Services
Newark, DE
Speaker Honoraria:Bayer Medrad, BTG/EKOS, Cook, BSX
Steering Cmt:Bayer/Medrad-PEARL, BTG/EKOS-ACCESS PTS
Consultant:Merit Medical, BSX, Gore, Fusion Medical
Stock Ownership:ELGX, Fusion Medical, Tack It
Research: NIH-ATTRACT, BTG/EKOS-ACCESS PTS, Cook-VIVO, Medtronic-In Pact II, BSX-HTN IV
Modalities:
Doppler US
CTV
MRV
IVUS
Venography
Cost Analysis
Indications
Pros/Cons
Appropriateness/Guidelines
Technique Pearls
Cost Analysis: (Global)
DUS
LE IVC
CTV
Abd/pelvis
MRV
Abd/pelvis
IVUS Venogram
LE IVC
CMS 118
201
Total = 319
807 878 132 95
117
Total = 212
BC/BS 124
135
Total = 259
803 1032 316 95
192
Total = 287
Doppler US:
Indications – Diagnostic tool:
Peripheral > central eval (dec sensitivity peripherally)
r/o DVT
Insuff exam
f/u post intervention
eval peripheral vasc mass
Pros: cheap, quick, easy, no rads, flow physiology
Limitations: tech dependent, false +, early false –,
body habitus, central imaging
CTV:Indications – Diagnostic tool:
Central anatomy:
IVC – thrombosis, atresia, absence
Iliacs – compression, thrombosis
Renals – Nutcracker, PCS
f/u post intervention
Extravascular anatomy (esp compression, masses)
Non-diagnostic US
Pros: Big picture view, quick, easy
Limitations: Rads, contrast, $$, streak artifacts, +/- flow physiology
MRV:Indications – Diagnostic tool:
Central anatomy:
IVC – thrombosis, atresia, absence
Iliacs – compression, thrombosis
Renals – Nutcracker, PCS
f/u post intervention
Extravascular anatomy (compression, masses)
Non-diagnostic US
Pros: Big picture view, no-rads,
Limitations: contrast, $$, motion, metallic voids, technique challenges, time, +/- flow physiology
IVUS:
Indications – Diagnostic tool:
Central anatomy:
IVC – compression
Iliacs – compression ** May-Thurner
Renals – Nutcracker
Intra-op: compression, sizing, localizing, stent apposition
f/u post intervention – lumen size
Pros: Intra-luminal view, non-rads, easy, quick
Limitations: Invasive, additional $, flow physiology
Venography:Indications – Diagnostic tool: Venous Intervention:
identify clot burden,
compression, reflux,
flow physiology
IVC – Atresia, absence, fliter eval
Iliacs – M-T
Renals – Nutcracker, PCS
Pros: Anatomic & Luminal eval, flow physiology (wash-out info, collateral filling)
Limitations: Invasive, rads, $, technique challenges, contrast ARF
Venography:
Renal Issues/Allergies:
Prep – hydration
Limit contrast w/ IVUS, CO2
CO2
Venography:
Indications – If there is any consideration for
intervention…..MUST do.
As a diagnostic tool,
it should be second in line, after non-invasive
diagnotic tool(s) have been utilized.
To maximize flow physiology:
Image thru “wash-out” phase
From leading edge to trailing end of contrast
For “compression” evaluation:
Obtain minimum 2 views
21 yo F with 6 mos onset of swollen Lt leg
No trauma, travel, hx of DVT
DUS – No DVT – abn CFV waveform
CTV – M-T compression
38 yo M with hx of Rt leg DVT since 1999 with
significant, asymmetric swelling (10 cm thigh
differential), mild venous ectasia
DUS – Chronic venous changes Rt fem-pop
Venography 9/13 – Fem strictures w/ very
sluggish flow into profunda collaterals
PTA, EKOS – patent but to & fro though improved
flow
“Rethrombosis of fem-pop veins”
• Patent Fem-pop
• No change in leg size
• Some mild venous ectasia
• No varicosities
65 yo F with longstanding, severe cellulitis &
ulcer Lt leg, persists despite Abx, ECS x > 1 yr
DUS – “No DVT”
VS – felt reflux not sole etiology of issues
CT – Prominent parametrial vessels ? PCS
Venography:
As a diagnostic tool, venography should be second
in line, after non-invasive diagnotic tool(s) have been
utilized.
If non-invasive studies are inconclusive or there is
any consideration for intervention …..MUST do.
Consider alternative agents (CO2), tools (IVUS) in
appropriate setting