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Angiography Arteriography Aortograms and Venography SPRING 2011 FINAL Angiography Is the general term that describes the radiologic examination of vascular structures within the body after the introduction of an iodinated contrast medium or gas Types of Angiographic Procedures 3 4 Angiography Team Radiologist CIT (Radiologic Technologist) – Sometimes more than one Other specialists (if needed) Nurse Anesthesiologist (if needed) 5 Indications Verify the presence of tumors – Clots – Thrombus – Embolus – Blood supply to tumors Internal bleeding – Possible anemia Occlusions Aneurysms Heart disease Stenosis – Can be caused form atherosclerosis 6 Contraindications Previous severe reaction to contrast Impaired renal function Impaired blood clotting factors Inability to undergo surgical procedure 7 Contrast Media Iodinated contrast media is used – Can produce nausea & an uncomfortable burning sensation – Allergic reactions Severe: anaphylactic shock – Shock, rapid shallow breathing, high pulse rate & ALOC Mild: Hives or slight difficulty breathing 8 What is this? 9 10 Angiographic Trays and Sterile Supplies 11 Other Supplies for Angiography 12 Needles Vascular access needles Size based on external diameter of needle Allows for appropriate Guidewires matching – So internal diameter must also be known 13 Guidewires Used as a platform over which a catheter is to be advanced Once positioned guidewire is fixed and catheter is advanced until it meets the tip of the guidwire Mostly constructed on stainless steel & coated with Teflon 14 Introducer Sheaths Short catheters used when multiple catheters will be used Placed in lieu of a catheter 15 Catheters 16 17 DSA A subtraction mask is taken before contrast injected Each of digitized image is from the mask Images acquired form – 1 image every 2-3 sec – Up to 30 images per sec 18 Three Dimensional (3-D) Intraarterial Angiography 19 What Method is this? 20 Catherization: Selinger Technique 21 Selinger Technique Catheters and Guidewires 22 Pre-Procedure PT’s are usually limited to a liquid diet and routine medications Adequate hydration An IV line placed – Sedative may be given History taken and vitals taken Informed consent 23 Preparing the Patient Room Must be extensively cleaned Equipment checked Room thoroughly stocked Extra supplies as needed 24 Radiation Protection PT is protected by no less than 2.5 mm of Aluminum Beam restriction Avoidance of repeat exposure Cardinal rules – Time – Distance – Shielding 25 Post Procedure PTs usually can resume normal activity after 24 hours Most often can go home after 24 hours – Because internal bleeding can be life threatening Vitals are monitored Puncture site is monitored for bleeding 26 Stent Placement http://images.google.com/imgres?imgurl=http:// www.nhlbi.nih.gov/health/dci/images/stent_rest enosis.gif&imgrefurl=http://www.nhlbi.nih.gov/h ealth/dci/Diseases/stents/stents_all.html&usg=_ _xDlbsaX9JhuYbpVojLcz19aprI=&h=513&w=450&sz=59&hl=en&start=20&tb nid=vWwqaG-RNW7MM:&tbnh=131&tbnw=115&prev=/images%3Fq %3Dabdominal%2Bstents%26gbv%3D2%26hl %3Den 27 Aortogram 28 29 AORTOGRAM 30 Abdominal Aortoraphy 31 Abdominal Angiography 32 AAA Pre and Post Stent Placement 33 34 Abdominal Stent 35 AAA 36 Pulmonary Circulation 37 Pulmonary Arteriogram 38 Celiac Ateriogram 39 Hepatic Arteriogram 40 Splenic Arteriorgram 41 Renal Arteriogram 42 renal 43 44 45 46 Lower Limb Arteries 47 48 Leg Atherosclerosis 49 Atherosclerosis Left Leg 50 Upper Limb Arteries 51 Upper Extremity Anatomy 52 Brachial and Axillary Arteriogram 53 Axillary Arteriogram 54 Hand Arteriogram 55 Hand Arteriogram with Occlusion 56 57 Balloon Angioplasty 58 59 Balloon Angioplasty Procedure 60 Femoral Artery Angioplasty 61 Placing a Stent after Angioplasty with Balloon 62 Intravascular Stents 63 Let’s Review B C 65 What is the name of this Procedure? What is it done for? 66 What is the name of this pathology? 67 What part of the body is being imaged? What is the pathology is this image? 68 69 What is this method callled? 70 A C B 71 Venography 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 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