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
• Thrombus that
becomes detached
from the vessel wall
• 3 factors
• Can easily flow to
heart causing PE
– Where blood is slow
– Change in the wall of
vessels
– Change in the blood
itself
• 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
• Dilated, elongated
and tortuous vessels
• Most common to
superficial veins of leg
• Multiple bluish
nodules just under
skin
• Development of
collateral veins
Varicose 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-superficial
Black- 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
• CT exams show
enlarged
retroperitoneal nodes
• Symptoms
– Painless lymph node
swelling in cervical area
– Fever
– Fatigeu
– Anemia & weight loss
– Coughing
– breathlessness
Case study:
Hodgkin’s Disease
Hodgkin’s Disease
Treatment includes RAD therapy
And 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