Download Visualizing the Venous System: Upper Extremity Thorax

Heather E. Gunter, Ph.D., HMS III
Gillian Lieberman, M.D.
July, 2003
Visualizing the Venous System:
Upper Extremity & Thorax
Heather E. Gunter, Harvard Medical School Year III
Gillian Lieberman, M.D.
Heather E. Gunter, Ph.D., HMS III
Gillian Lieberman, M.D.
Some of the imaging options
Contrast venography
www.brighamrad.harvard.edu
Distinguished by
• Image capabilities
• Cost
• +/- radiation, contrast
ultrasound
magnetic resonance
Butty et al, 2002
Cosgrove, 2002
2
Heather E. Gunter, Ph.D., HMS III
Gillian Lieberman, M.D.
Patient H.V. will guide our discussion
• 52 year old woman with end stage renal failure
• Dialysis access through a catheter placed in the
left internal jugular vein since August, 2002
indication: Confirm catheter location in SVC
study:

Chest X-ray
 Trad. venography
 Ultrasound
 MRI
3
Heather E. Gunter, Ph.D., HMS III
Gillian Lieberman, M.D.
Plain film assessment of central line
I. jugular
E. jugular
• Images are appropriate
ch
bra
i al
ilic
b as
• Inexpensive
• Readily available
• Not operator dependent
SVC
a l ic
ph
ce
ry
illa
• Methods are appropriate
brachiocephalic
subclavian
ax
• Venous anatomy is
implied by catheter path
• Catheter contrasts with
surroundings in thorax
Venous drainage of upper arm
Path of IJ central line
4
Heather E. Gunter, Ph.D., HMS III
Gillian Lieberman, M.D.
Catheter is well placed in R. atrium
PA
Lateral
Images from BIDMC PACS 5
Heather E. Gunter, Ph.D., HMS III
Gillian Lieberman, M.D.
Pt. H.V.’s dialysis access is changed
a l ic A .
ph
l
ce chia
bra
• AV fistula placed in
January, 2003
• AV fistula connects
• End of L cephalic v.
• Side of L brachial a.
AV fistula
Venous drainage of upper arm
6
Heather E. Gunter, Ph.D., HMS III
Gillian Lieberman, M.D.
Pt. H.V. has new onset L upper extremity edema
• DDx local edema
a l ic A .
ph
l
ce chia
bra
• Venous obstruction
• Lymphatic obstruction
• Peripheral/ Central
• Clinical history guidance
• Long term catheter
placement is associated
with stenosis of vessels
• Flow disturbances in AV
fistula predispose to
thrombosis
Venous drainage of upper arm
7
Heather E. Gunter, Ph.D., HMS III
Gillian Lieberman, M.D.
First look for peripheral occlusion
• Turbulence in brachiocephalic AV fistula may have led
to thrombotic occlusion
• Catheter placement may have led to stenosis along its
path (i.e. left internal jugular vein-)
indication: Evaluate for peripheral venous occlusion
study:
 Chest X-ray
 Trad. venography

 Ultrasound
 MRI
8
Heather E. Gunter, Ph.D., HMS III
Gillian Lieberman, M.D.
Ultrasound evaluation of peripheral vessels
• images are appropriate
• methods are appropriate
a l ic A .
ph
l
ce chia
bra
• Fluid contrasts with
surrounding soft tissue
• Flow is represented
• Inexpensive
• Readily available
• No ionizing radiation
• notes
• Operator dependent
Venous drainage of upper arm
Region not evaluated by US
9
Heather E. Gunter, Ph.D., HMS III
Gillian Lieberman, M.D.
Blood is flowing through the fistula
Structural data is
black and white
Flow data is
colored (doppler)
Konner,
2003
Mixed reds and
blues indicates
turbulent flow
10
Heather E. Gunter, Ph.D., HMS III
Gillian Lieberman, M.D.
Fistula flow has decreased in past two months
April, 2003
June, 2003
Images from BIDMC PACS 11
Heather E. Gunter, Ph.D., HMS III
Gillian Lieberman, M.D.
Left upper extremity veins are patent
• Compression with
transducer collapses low
pressure vessels
• Doppler demonstrates
flow in non-occluded
vessels
Images from BIDMC PACS 12
Heather E. Gunter, Ph.D., HMS III
Gillian Lieberman, M.D.
Left jugular is not patent
•
Vein does not compress
• Either high pressure or not
patent
•
Vein does not have flow
• Not patent
Visualization of collaterals (not in these images) points to a chronic process
Images from BIDMC PACS 13
Heather E. Gunter, Ph.D., HMS III
Gillian Lieberman, M.D.
Second, look for central occlusion
• Distal obstruction ruled out with US
• US demonstrated blockage in peripheral path of
catheter, which may continue centrally
indication: Evaluate for central venous occlusion
study:
 Chest X-ray
 Trad. venography
 Ultrasound
 MRI

14
Heather E. Gunter, Ph.D., HMS III
Gillian Lieberman, M.D.
MRI evaluation of venous flow
L. Brachiocephalic V
SVC V
L. I. Jugular V
L. Subclavian V
• Images are appropriate
• Vessels in thorax visible
• Flow is represented
• Soft tissue anatomy
visible
• Volumetric images
• Methods are appropriate
• No ionizing radiation
• Gadolinium contrast (non
iodinated)
• Note
• Lengthy study, expensive
Image from BIDMC PACS
15
Heather E. Gunter, Ph.D., HMS III
Gillian Lieberman, M.D.
MRV confirms filling defect of LIJV
Image from BIDMC PACS 16
Heather E. Gunter, Ph.D., HMS III
Gillian Lieberman, M.D.
L. brachiocephalic is occluded (reaction to catheter)
•
Proximal left brachiocephalic
artery is not visualized with
intervenous contrast
Images from BIDMC PACS 17
Heather E. Gunter, Ph.D., HMS III
Gillian Lieberman, M.D.
SVC stenosis (reaction to catheter)
a.
15.5mm
a rc
h
8.5mm
•
SVC
a. arch
•
a.
ao
rt
a
Filling defect in SVC is
quantified with transverse
slices
Appearance is consistent with
stenosis due to fibrous sheath
Images from BIDMC PACS 18
Heather E. Gunter, Ph.D., HMS III
Gillian Lieberman, M.D.
Recanalization of LBCV to improve circulation
Fibrous reaction to previous catheter placement
has resulted in a L. brachiocephalic occlusion
and SVC stenosis.
indication: Recanalize the obstructed vein
study:
 Chest X-ray

Trad. venography
 Ultrasound
 MRI
19
Heather E. Gunter, Ph.D., HMS III
Gillian Lieberman, M.D.
Contrast venography for stenosis dilation
• Images are appropriate
a l ic A .
ph
l
ce chia
bra
• Real time display
• Vessels visualized
• Interventions visualized
• Methods are appropriate
• Compatible with
intervention
• Notes
femoral veins
venous catheter placement
•
•
•
•
Iodinated contrast
Ionizing radiation
Operator dependent
Expensive
20
Heather E. Gunter, Ph.D., HMS III
Gillian Lieberman, M.D.
Angio demonstrates obstuction and collaterals
Contrast injection
Raw image
catheters
Digital subtraction
• Digital subtraction enhances contrast, but minimizes
appearance of anatomical landmarks
• Dye injected into upper extremity venous access does
not pass through left brachiocephalic vein
Images from BIDMC PACS 21
Heather E. Gunter, Ph.D., HMS III
Gillian Lieberman, M.D.
SVC is dilated in order to access obstruction
Contast
demonstrates
stenosis in SVC
Ballon inflation
dilates SVC
Stented vessel
permits instrument
passage
Images from BIDMC PACS 22
Heather E. Gunter, Ph.D., HMS III
Gillian Lieberman, M.D.
Brachiocephalic V. flow is restored
1. Sharp recanalization
3. Stent placement
•
•
2. Balloon angioplasty
Prior to treatment contrast
does not pass through BC
obstruction and fills collateral
vessels
Following treatment contrast
passed through patent BC
and does not fill collateral
vessels
Images from BIDMC PACS 23
Heather E. Gunter, Ph.D., HMS III
Gillian Lieberman, M.D.
Patient H.V. follow up
• L upper extremity edema resolved following
recanalization procedure
24
Heather E. Gunter, Ph.D., HMS III
Gillian Lieberman, M.D.
Menu of tests and their distinguishing features
US
MRI
venography
$
$$
$$
yes
yes
yes
some
extensive
some
Real time
yes
no
yes
Anatomic restrictions
yes
no
no
Ionizing radiation
none
none
yes
Contrast
no
yes (gad)
yes (I)
Operator dependent
yes
no
yes
Cost
Flow imaging
Tissue imaging
25
Heather E. Gunter, Ph.D., HMS III
Gillian Lieberman, M.D.
Additional approaches (not in wide spread use)
CT venography
Radionuclide venography
Krishnan, 2002
Lawler, 2003
Nuclear studies of
thrombosis
• radiolabelled fibrinogen
• radiolabelled apcitide
26
Heather E. Gunter, Ph.D., HMS III
Gillian Lieberman, M.D.
References
•
•
•
•
•
•
•
(1999). The diagnostic approach to acute venous thromboembolism.
Clinical practice guideline. Am J Respir Crit Care Med 160:1043
Butty, S. et al. (2002). Body MR venography. Rad Clin N Am. 40 (4) 899919.
Konner, K. (2003). The arteriovenous fistula. J Am Soc Nephrol. 14(6):
1669-80.
Krishnan, P. (2002). Venous dilatation seen on routine mammography: a
clue to superior vena cava obstruction. Chest 121(4): 1361-3.
Lang, E. et al. (2003). Sharp racanalization for chronic central venous
occlusions. In From Bench to Bedside: Emergency Revascularization.
Lawler, L.P. (2003). Thoracic venous anatomy: multidetector row CT
evaluation. Radiol Clin North Am. 41(3): 545-60.
Meire, H., & Cosgrove D., (2001). Vascular Ultrasound. in Cosgrove in
Grainger & Allison’s Diagnostic Radiology: A Textbook of Medical
Imaging, 4th Ed. pp. 59-80.
27
Heather E. Gunter, Ph.D., HMS III
Gillian Lieberman, M.D.
Acknowledgements
•
•
•
•
Phoebe Lewit Olhava, M.D.
Elvira Lang, M.D.
Pamela Lepkowski
Larry Barbaras
28