Part 2 Radionuclide Venography

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Part 2 Radionuclide Venography

  1. 1. Siriraj HospitalMahidol University, Thailand Part 2: RNV J SRIPRAPAPORN
  2. 2. VENOUS SYSTEM Part 2: RNV J SRIPRAPAPORN
  3. 3. Deep Vein ThrombosisIncidence: 2.5 million in USComplication: most important= pulmonary embolismDx of DVT Clinical Dx is unreliable Noninvasive tests Invasive tests Part 2: RNV J SRIPRAPAPORN
  4. 4. Diagnosis of DVTClinicals : UnreliableLab tests : D-DimerCompression ultrasonography ***Radionuclide VenographyIn-111 labeled plateletIn-111 labeled antifibrin AbTc-99m labeled peptides (Acutect)Contrast Venography *** [Goldstandard]CTVMRV Part 2: RNV J SRIPRAPAPORN
  5. 5. U/S & D-dimerNormal compression ultrasonographic testand SimpliRED rapid whole-blood bedside D-dimer assay are sufficient to R/O DVT withcumulative incidence of VTE complications of1.3% during the following 3 months.[Kraaijenhagen et al. Arch Intern Med 2002]Normal D-dimer concentration and a non-highpretest clinical probability score is a safestrategy to exclude DVT [Schutgens et alCirculation 2003] Part 2: RNV J SRIPRAPAPORN
  6. 6. Radionuclide VenographyAscending Radionuclide Venography(RNV) Tc-99m phytate/ SC Tc-99m MAA* (+Q scan)Tc-99m labeled RBC RadionuclideVenographyTc-99m labelled peptide venography Part 2: RNV J SRIPRAPAPORN
  7. 7. Indications for RNVTo evaluate Pts with clinically suspected DVTTo evaluate high-risk Ptsfor developing DVTTo detect source & extent of DVT in Ptswith documented DVTTo F/U the efficacy of treatment in Ptswith documented DVT Part 2: RNV J SRIPRAPAPORN
  8. 8. Ascending RNVPrinciple: Direct injection of theradiotracer in to foot veinsMechanism: To evaluate venous flow;venous occlusion or evidence ofcollateral circulationAnatomy: calf veins*, popliteal vein,femoral, ext iliac & common iliac, IVC Part 2: RNV J SRIPRAPAPORN
  9. 9. Ascending RNV: TechniquesRadiopharm: Tc-99m phytate/ sulfur colloid, Tc-99mMAA* (+ Q lung scan)Inject a tracer via (bilateral) foot veinsOn tourniquets above ankles to visualize deepveins and off tourniquets for superficial veins Part 2: RNV J SRIPRAPAPORN
  10. 10. Ascending RNV: InterpretationBilateral comparison, on & off TQNormal: Good flow without signs ofvenous occlusionAbnormal: Obliteration of flow, fillingdefect, asymmetric flow +/-collaterals Part 2: RNV J SRIPRAPAPORN
  11. 11. Positive CriteriaAbrupt termination of the flowPresence of filling defectIrregular or asymmetric flowAbnormal collateralsNonfilling of the deep veins, with +veother signs Part 2: RNV J SRIPRAPAPORN
  12. 12. Normal Asc RNV phytateWhole-body Images Multiple Static Images Part 2: RNV J SRIPRAPAPORN
  13. 13. Normal vs Abnormal RNV Part 2: RNV J SRIPRAPAPORN
  14. 14. DVT WITH PE Part 2: RNV J SRIPRAPAPORN
  15. 15. Accuracy of Asc RNV Authors Year No. Sen Spec Corr Site of (studies) (%) (%) (%) DVTWebber (12) 1974 30 65 92 77 OverallHenkin (13) 1974 25 100 86 96 ProximalVan Kirk (14) 1976 19 100 95 95 OverallVlahos (15) 1976 52 100 100 100 Pelvis 98 89 100 97 Thigh 98 92 97 95 CalfEnnis (16) 1977 154 90 89 95 OverallCordoba (17) 1977 44 100 80 94 OverallRyo (18) 1977 47 89 66 89 OverallGomes (19) 1982 51 88 65 67 OverallMohamadiyeh(20) 1993 32 90 73 89 ProximalMangkharak 1998 72 88 96 90 Overall 55 95 97 96 Pelvic 72 95 100 90 Thigh 72 77 96 83 Calf Mangkharak J, et al. J Med Assoc Thai 1998;81:432-441 Part 2: RNV J SRIPRAPAPORN
  16. 16. RNV-Upper Extremities NormalAbnormal Part 2: RNV J SRIPRAPAPORN
  17. 17. Advantages & DisadvantagesContrast Venography Radionuclide VenographyMost reliable for Dx (gold Reliable results esp.std.) proximal vNeed skilled team SimplerGood anatomic visualization Poorer anatomic details(calf iliac veins & IVC) (Good for proximal v.)More Invasive Less invasivePotential risks SafeNot suitable for frequent More suitable for frequentF/U F/UNot provide information Provide information aboutabout associated PE associated PE (Tc-99m MAA) Part 2: RNV J SRIPRAPAPORN
  18. 18. Tc-99m labeled RBC Radionuclide VenographyOr blood-pool radionuclide venography equilibrium stageInject the radiotracer via any veinNeed high-resolution collimatorImage quality depends on labelingefficiency Part 2: RNV J SRIPRAPAPORN
  19. 19. Tc-99m RBC RNV Whole-body vs multiple overlapping static images Part 2: RNV J SRIPRAPAPORN
  20. 20. Tc-99m RBC RNV Part 2: RNV J SRIPRAPAPORN
  21. 21. Tc-99m Labeled RBC vs Ascending RNVADVANTAGES DISADVANTAGES Do not need foot Image quality depends on vein access, labeling efficiency easier Not direct evaluation of venous Possible less flow painful Less anatomical details Concomitant Q lung scan is impossible. Both cannot DDx acute vs chronic DVT ! Part 2: RNV J SRIPRAPAPORN
  22. 22. Tc-99m Apcitide Scintigraphy FDA approved in Sept 1998 Tc-99m apcitide is a radiolabeled peptide that binds with high affinity and specificity to the glycoprotein IIb/IIIa receptors expressed on activated platelets being involved in acute thrombosis. Therefore, 99mTc-apcitide scintigraphy should be negative with residual abnormalities caused by old, inactive thrombi and positive with new, active thrombi. Part 2: RNV J SRIPRAPAPORN
  23. 23. Tc-99m Apcitide Scintigraphy Tc-99m apcitide is a radiolabeled peptide that binds with high affinity and specificity to the glycoprotein IIb/IIIa receptors expressed on activated platelets being involved in acute thrombosis. [FDA approved in Sept 1998] Therefore, 99mTc-apcitide scintigraphy should be negative with residual abnormalities caused by old, inactive thrombi and positive with new, active thrombi. If 20% prevalence of DVT, sen of 99mTc-apcitide scintigraphy is about 90% and spec of 85%-90% --> a scan with normal results would have a NPV of about 98%.(similar to that of ascending venography & serial compression US) Part 2: RNV J SRIPRAPAPORN
  24. 24. Tc-99m Apcitide Scintigraphy Method: Planar scintigraphic images at 10, 60,120-180 min pi. Results: New onset DVT < 3 D: sen 90.6%, spec 83.9%, agreement 87.3 % [Taillefer R JNM 00] With & wo previousConclusion: VTE: sen 92% spec The combination of at least two sets of 90% [Bates et al. images provided the highest accuracy in detecting ADVT. Arch Intern Med. Taillefer R et al. J Nucl Med 2003;163:452-456] 2000;41(7):1214-1223 Part 2: RNV J SRIPRAPAPORN
  25. 25. SummaryDiagnosis of DVT needs clinical anddiagnostic tests eg. venous US, radionuclidevenography, etc.Nuclear Medicine has an important role inevaluation of patients with suspected PE &/orDVT as a single test.V/Q lung scan is helpful in an appropriatesetting eg. normal CXR, reproductive women,pregnant women, C/I for CTAIt can be used not only for diagnosis but alsofor follow-up after treatment. Part 2: RNV J SRIPRAPAPORN

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