Venography is a radiological procedure for the evaluation of the veins by the help of intravenous radiological contrast media. It is also known as phlebography. Contrast venography is the gold standard for judging diagnostic imaging methods for deep venous thrombosis; although, because of its cost, invasiveness, the increased sensitivity of sonography to demonstrate pathology and other limitations this test is rarely performed.
In medicine, a central venous catheter ("central line", "CVC", "central venous line" or "central venous access catheter") is a catheter placed into a large vein in the neck (internal jugular vein), chest (subclavian vein or axillary vein) or groin (femoral vein)
Angiography is a general term
that describes the radiologic examination
of vascular structures within the body
after the introduction of an iodinated contrast
media or gas.
MI ( blockage of blood flow to heart muscle)
Acute angina (type of chest pain)
Aneurysms
AVM( Arterio-venous Malformations) abnormal connection between artery and vein.
eg. In spine and brain.
AVF (Arterio-venous Fistulas), LCA ,RCA EQUIPMENT
RUKAMANEE YADAV
Anaesthetic considerations for Robotic Surgery, What to expect, how to go ahead. An update and incite on the intricacies of Robotic Surgery and Anaesthetic implications.
An intensive care unit (ICU), also known as an intensive therapy unit or intensive treatment unit (ITU) or critical care unit (CCU), is a special department of a hospital or health care facility that provides intensive treatment medicine.
Similar to Venography/ Phlebography- Avinesh Shrestha (20)
Principle of Radiation Protection- Avinesh ShresthaAvinesh Shrestha
Radiation protection is the science whose aim is to minimize the risks generated by the use of ionizing radiation. Briefly discusses The ICRP System of Radiological Protection, STRUCTURAL SHIELDING OF
IMAGING FACILITIES, APPLICATION OF INDIVIDUAL DOSE LIMTS, RADIATION EXPOSURE IN PREGNANCY, Diagnostic reference level, Personnel Protection in
Medical X-ray Imaging, Dose Optimization in CT, Radiation Protection in Nuclear Medicine.
Brief discussion on the Quality Assurance and Quality Control in Magnetic Resonance Imaging department.
Quality assurance in MRI is a comprehensive concept that comprises all of the management practices developed by the MR imaging team.
Radiation Dose Units and Dose Limits- Avinesh ShresthaAvinesh Shrestha
Describes different units of radiation dose and the dose limits in diagnostic radiology imaging. Discuses different radiation units described by ICRU. Describes different radiation dose limits given by different organizations like ICRP, NCRP, AERB.
The history and fundamental of radiation biology us presented in this presentation. Topics including basic human biology and response to radiation, Law of Bergonie and Tribondeau,
Physical factors that affect radiation response,
Biologic factors that affect radiation response,
Radiation dose-response relationships and 6R's of radiobiology are discussed in this presentation. Topics like Linear energy transfer (LET),
Relative Biologic Effectiveness (RBE),
Protraction and fractionation, age, oxygen enhancement, hormesis, repair, repopulation, re-oxygenation, redistribution, remote (bystander) cellular effects
radio sensitivity etc. are included in concise and comprehensive manner.
Magnetic Resonance Elastography is an advanced imaging technique in MRI. This method is a method of "virtual palpation" of internal organs with the help of MRI.
Echo planar imaging (EPI) is the method of rapid magnetic resonance imaging (MRI), overcoming one of the significant disadvantage of MRI concerning with slow imaging time. However, EPI-MRI imaging comes with it's own unique imaging artifacts.
CT is one of the highest contributor for medical radiation exposure to patients. Some common CT dose descriptors and dose optimizations methods are briefly described in this presentation.
Image Quality, Artifacts and it's Remedies in CT-Avinesh ShresthaAvinesh Shrestha
CT is one of the frequently used diagnostic imaging modalities in Radiology. Knowledge about image quality and artifacts is essential when diagnosing a patient with the help of CT images. Moreover, Radiology Technologist's should be very well aware about the ways to identify and eliminate or minimize the artifacts in CT for better image quality.
Image reconstruction in CT is mostly a mathematical process however, this presentation tries to explain the complicated process of image reconstruction in a visual way, mainly focusing om Filtered back projection, Iterative Reconstruction and AI based image reconstruction.
MDCT Principles and Applications- Avinesh ShresthaAvinesh Shrestha
Multidetector CT (MDCT) is one of the most commonly used imaging modality in the field of Radiology. Development and advancement in MDCT has made it's application as a major component in diagnosis and treatment planning of multitude of disease across the planet. This presentation briefly describes its basic principle and it's wide variety of application in medical imaging.
Application of Perfusion imaging in radiology is increasing with advancement in technology. This presentation briefly describes different perfusion modalities including Computed Tomography, Magnetic Resonance Imaging and Nuclear Medicine. Some of the aspects of perfusion imaging are described in this presentation. This topic was Presented in Radiology department, Institute of Medicine, Maharajgunj.
This presentation discusses briefly about the anatomy of neck and about different protocols used for CT examination of neck. Also, some pathology are shown in the presentation.
The presentation describes basic anatomy of shoulder and focuses on different radiographic projections used for the evaluation of shoulder. Also, it shows some problems that can be identified in the shoulder radiograph.
Ivu is a radiological investigation for visualization and assessment of the urinary tract.This presentation covers brief anatomy of urinary tract, indication and contraindication,contrast media dose and administration, routine and modified ivu procedure,its complication,ctivu and some abnormalities in the urinary tract.
Intensifying screens are major component of the image receptor used in conventional radiography.Its function is to convert the X-rays into visible light through the process of fluorescence.
Modern medical imaging has been digitized using various technologies which are described here in this presentation.Presented in Department of radiology, ,B.Sc Medical Imaging technology,Institute of Medicine, Nepal.
MANAGEMENT OF ATRIOVENTRICULAR CONDUCTION BLOCK.pdfJim Jacob Roy
Cardiac conduction defects can occur due to various causes.
Atrioventricular conduction blocks ( AV blocks ) are classified into 3 types.
This document describes the acute management of AV block.
Tom Selleck Health: A Comprehensive Look at the Iconic Actor’s Wellness Journeygreendigital
Tom Selleck, an enduring figure in Hollywood. has captivated audiences for decades with his rugged charm, iconic moustache. and memorable roles in television and film. From his breakout role as Thomas Magnum in Magnum P.I. to his current portrayal of Frank Reagan in Blue Bloods. Selleck's career has spanned over 50 years. But beyond his professional achievements. fans have often been curious about Tom Selleck Health. especially as he has aged in the public eye.
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Introduction
Many have been interested in Tom Selleck health. not only because of his enduring presence on screen but also because of the challenges. and lifestyle choices he has faced and made over the years. This article delves into the various aspects of Tom Selleck health. exploring his fitness regimen, diet, mental health. and the challenges he has encountered as he ages. We'll look at how he maintains his well-being. the health issues he has faced, and his approach to ageing .
Early Life and Career
Childhood and Athletic Beginnings
Tom Selleck was born on January 29, 1945, in Detroit, Michigan, and grew up in Sherman Oaks, California. From an early age, he was involved in sports, particularly basketball. which played a significant role in his physical development. His athletic pursuits continued into college. where he attended the University of Southern California (USC) on a basketball scholarship. This early involvement in sports laid a strong foundation for his physical health and disciplined lifestyle.
Transition to Acting
Selleck's transition from an athlete to an actor came with its physical demands. His first significant role in "Magnum P.I." required him to perform various stunts and maintain a fit appearance. This role, which he played from 1980 to 1988. necessitated a rigorous fitness routine to meet the show's demands. setting the stage for his long-term commitment to health and wellness.
Fitness Regimen
Workout Routine
Tom Selleck health and fitness regimen has evolved. adapting to his changing roles and age. During his "Magnum, P.I." days. Selleck's workouts were intense and focused on building and maintaining muscle mass. His routine included weightlifting, cardiovascular exercises. and specific training for the stunts he performed on the show.
Selleck adjusted his fitness routine as he aged to suit his body's needs. Today, his workouts focus on maintaining flexibility, strength, and cardiovascular health. He incorporates low-impact exercises such as swimming, walking, and light weightlifting. This balanced approach helps him stay fit without putting undue strain on his joints and muscles.
Importance of Flexibility and Mobility
In recent years, Selleck has emphasized the importance of flexibility and mobility in his fitness regimen. Understanding the natural decline in muscle mass and joint flexibility with age. he includes stretching and yoga in his routine. These practices help prevent injuries, improve posture, and maintain mobilit
New Directions in Targeted Therapeutic Approaches for Older Adults With Mantl...i3 Health
i3 Health is pleased to make the speaker slides from this activity available for use as a non-accredited self-study or teaching resource.
This slide deck presented by Dr. Kami Maddocks, Professor-Clinical in the Division of Hematology and
Associate Division Director for Ambulatory Operations
The Ohio State University Comprehensive Cancer Center, will provide insight into new directions in targeted therapeutic approaches for older adults with mantle cell lymphoma.
STATEMENT OF NEED
Mantle cell lymphoma (MCL) is a rare, aggressive B-cell non-Hodgkin lymphoma (NHL) accounting for 5% to 7% of all lymphomas. Its prognosis ranges from indolent disease that does not require treatment for years to very aggressive disease, which is associated with poor survival (Silkenstedt et al, 2021). Typically, MCL is diagnosed at advanced stage and in older patients who cannot tolerate intensive therapy (NCCN, 2022). Although recent advances have slightly increased remission rates, recurrence and relapse remain very common, leading to a median overall survival between 3 and 6 years (LLS, 2021). Though there are several effective options, progress is still needed towards establishing an accepted frontline approach for MCL (Castellino et al, 2022). Treatment selection and management of MCL are complicated by the heterogeneity of prognosis, advanced age and comorbidities of patients, and lack of an established standard approach for treatment, making it vital that clinicians be familiar with the latest research and advances in this area. In this activity chaired by Michael Wang, MD, Professor in the Department of Lymphoma & Myeloma at MD Anderson Cancer Center, expert faculty will discuss prognostic factors informing treatment, the promising results of recent trials in new therapeutic approaches, and the implications of treatment resistance in therapeutic selection for MCL.
Target Audience
Hematology/oncology fellows, attending faculty, and other health care professionals involved in the treatment of patients with mantle cell lymphoma (MCL).
Learning Objectives
1.) Identify clinical and biological prognostic factors that can guide treatment decision making for older adults with MCL
2.) Evaluate emerging data on targeted therapeutic approaches for treatment-naive and relapsed/refractory MCL and their applicability to older adults
3.) Assess mechanisms of resistance to targeted therapies for MCL and their implications for treatment selection
Ozempic: Preoperative Management of Patients on GLP-1 Receptor Agonists Saeid Safari
Preoperative Management of Patients on GLP-1 Receptor Agonists like Ozempic and Semiglutide
ASA GUIDELINE
NYSORA Guideline
2 Case Reports of Gastric Ultrasound
Anti ulcer drugs and their Advance pharmacology ||
Anti-ulcer drugs are medications used to prevent and treat ulcers in the stomach and upper part of the small intestine (duodenal ulcers). These ulcers are often caused by an imbalance between stomach acid and the mucosal lining, which protects the stomach lining.
||Scope: Overview of various classes of anti-ulcer drugs, their mechanisms of action, indications, side effects, and clinical considerations.
These lecture slides, by Dr Sidra Arshad, offer a quick overview of physiological basis of a normal electrocardiogram.
Learning objectives:
1. Define an electrocardiogram (ECG) and electrocardiography
2. Describe how dipoles generated by the heart produce the waveforms of the ECG
3. Describe the components of a normal electrocardiogram of a typical bipolar leads (limb II)
4. Differentiate between intervals and segments
5. Enlist some common indications for obtaining an ECG
Study Resources:
1. Chapter 11, Guyton and Hall Textbook of Medical Physiology, 14th edition
2. Chapter 9, Human Physiology - From Cells to Systems, Lauralee Sherwood, 9th edition
3. Chapter 29, Ganong’s Review of Medical Physiology, 26th edition
4. Electrocardiogram, StatPearls - https://www.ncbi.nlm.nih.gov/books/NBK549803/
5. ECG in Medical Practice by ABM Abdullah, 4th edition
6. ECG Basics, http://www.nataliescasebook.com/tag/e-c-g-basics
Report Back from SGO 2024: What’s the Latest in Cervical Cancer?bkling
Are you curious about what’s new in cervical cancer research or unsure what the findings mean? Join Dr. Emily Ko, a gynecologic oncologist at Penn Medicine, to learn about the latest updates from the Society of Gynecologic Oncology (SGO) 2024 Annual Meeting on Women’s Cancer. Dr. Ko will discuss what the research presented at the conference means for you and answer your questions about the new developments.
- Video recording of this lecture in English language: https://youtu.be/lK81BzxMqdo
- Video recording of this lecture in Arabic language: https://youtu.be/Ve4P0COk9OI
- Link to download the book free: https://nephrotube.blogspot.com/p/nephrotube-nephrology-books.html
- Link to NephroTube website: www.NephroTube.com
- Link to NephroTube social media accounts: https://nephrotube.blogspot.com/p/join-nephrotube-on-social-media.html
Pulmonary Thromboembolism - etilogy, types, medical- Surgical and nursing man...VarunMahajani
Disruption of blood supply to lung alveoli due to blockage of one or more pulmonary blood vessels is called as Pulmonary thromboembolism. In this presentation we will discuss its causes, types and its management in depth.
Pulmonary Thromboembolism - etilogy, types, medical- Surgical and nursing man...
Venography/ Phlebography- Avinesh Shrestha
1.
2. OVERVIEW
Angiography refers to radiologic imaging of blood vessels after injection of
contrast media. Highly specialized imaging equipment is required for these
procedures.
Angiography can be more specifically described as follows:
Arteriography
Venography
Angiocardiography
3. ANGIOGRAPHY TEAM
Angiography is performed by a team of health professionals, including
1. a radiologist (or other qualified angiographer),
2. a “scrub/OR” nurse or technologist who assists with sterile and catheterization
procedures, and
3. a radiologic technologist.
Depending on the departmental protocol and the specific situation, an
additional physician, nurse, technologist, or hemodynamic technologist
may be available to assist with the procedure.
4. ANGIOGRAPHIC REQUIREMENTS
ANGIOGRAPHIC ROOM
The procedure room should be specifically designed to accommodate the
sophisticated and accessory equipment as well as angiographic team and other staffs.
An angiographic room is equipped for all types of angiographic and interventional
procedures and has a wide variety of needles, catheters, and guide wires close at
hand.
It is larger than conventional radiographic rooms and includes a sink and scrub area
and a patient holding area. The room must have outlets for oxygen and suction as
well as emergency medical equipment must be nearby.
5.
6. ANGIOGRAPHIC IMAGING EQUIPMENT
EQUIPMENT REQUIREMENTS
A table that provides access to the patient from all sides; it should have four-way floating
capability, adjustable height, and a tilting mechanism.
An fluoroscopy imaging system with intensifier or the newer flat detector digital fluoroscopy
acquisition type; both of these systems are available in C-arm.
Electromechanical injector for delivery of contrast media.
Physiologic monitoring equipment that allows monitoring of the patient’s venous and
arterial pressures, oxygen levels, and electrocardiogram.
Image archiving method linked to a PACS and laser printer
7. ANGIOGRAPHIC IMAGING EQUIPMENT
1. Hemostats
2. Preparation sponges & antiseptic solution
3. Scalpel blade
4. Syringe and needle for local anesthetic
5. Basins and medicine cup
6. Sterile drapes and towels
7. Band-Aids(Fixing Tapes)
8. Sterile image intensifier cover
9. Needle(Butterfly, IV cannula) for vessel(vein) puncture, if catheterization is not done.
ANGIOGRAPHIC TRAY
A sterile tray contains the basic equipment necessary for a catheterization. Basic sterile items include
the following:
8.
9.
10. INTRODUCTION
Venography/phlebography is a procedure in which x-ray of the veins, is taken after a
special dye is injected into the veins. The dye has to be injected constantly via a
catheter, making it an invasive procedure.
Contrast venography is the gold standard for judging diagnostic imaging methods
for deep venous thrombosis; although, because of its cost, invasiveness, the increased
sensitivity of sonography to demonstrate pathology and other limitations this test is
rarely performed
Venography can also be used to distinguish blood clots from obstructions in the veins,
to evaluate congenital vein problems, to see how the deep leg vein valves are
working, or to identify a vein for arterial bypass grafting.
11. SPECIFIC VENOGRAPHIC PROCEDURES
Venography can be divided into following sections:
Peripheral Venography
L o w e r l i m b v e n o g r a p h y
U p p e r l i m b V e n o g r a p h y
P e r i p h e r a l V a r i c o g r a p h y
Central Venography
I n f e r i o r V e n a C a v o g r a p h y
S u p e r i o r V e n a C a v o g r a p h y
Selective visceral Venography
R e n a l v e n o g r a p h y
H e p a t i c V e n o g r a p h y
P o r t a l v e n o g r a p h y
12. PATIENT PREPARATION
• Some common procedure for patient preparation are:
• NPO for 4-6hrs prior to examination
• Check recent serum creatinine(M:60-130;F:40-110µmol/L) and urea(1.6-7µmol/L)
level.
• Taking proper medical history so that appropriate premedication can be used.
• Changing patient to an appropriate gown.
• Signing Informed consent
*These may not be discussed in the specific sections of venography as these are common points to all the venographic procedures.
13. CONTRAINDICATIONS(RELATIVE)
Common Contraindications for venography include
• contrast media allergy,
• impaired renal function
• blood-clotting disorders
• Anticoagulant medication
• unstable cardiopulmonary or neurologic status.
• non-consent by patient to procedure
*These may not be discussed in the specific sections of venography as these are common points to all the venographic procedures.
14. PERIPHERAL VENOGRAPHY
It is the study of the veins of the extremities. It is still considered the gold standard
for diagnosis of deep venous thrombosis, but is now only very rarely performed
It can be studied under:
Upper limb venography
Lower limb venography
Peripheral Varicography
15. LOWER LIMB VENOGRAPHY
It is the study of the veins of the lower limb by the introduction of
contrast medium.
16. ANATOMY:
The veins of the lower limb can be divided into a superficial
and a deep venous system.
1. Superficial veins:
Great saphenous vein
Small saphenous vein and their tributaries(originates in the foot and
extends posteriorly along the leg, terminating at the knee, where it empties
into the popliteal vein. )
Superficial veins of the foot.
LOWER LIMB VENOGRAPHY
17. ANATOMY:
2. Deep veins:
Posterior tibial
Anterior tibial (The posterior tibial and anterior tibial veins joins
distally with the dorsal venous arch to drain the foot and lower leg and join
proximally to become the popliteal vein at the level of the knee. )
Popliteal(The popliteal vein continues upward to become the femoral
vein before becoming the external iliac vein)
Femoral.
LOWER LIMB VENOGRAPHY
18.
19. INDICATION
Deep vein thrombosis of lower limb
To demonstrate incompetent perforating veins
Suspected venous obstruction(by tumor or extrinsic pressure)
Investigation of varicose ulcers in the post thrombotic syndrome
Secondary or recurrent varicose veins
Patient with swollen legs
Outlining venous malformation
Edema of unknown cause
Congenital abnormality of the venous system.
20. CONTRAINDICATION
Local sepsis
Acute deep vein thrombosis
Conventional/advanced Fluoroscopy unit with spot film device and tilting
radiography table
Butterfly needle
EQUIPMENT
21. CONTRAST MEDIA
Low/Iso osmolar contrast media 240mgI/ml
Volume about 50-150 ml
PATIENT PREPARATION
Elevate the leg overnight if edema is severe.
22. PROCEDURE
• Patient is placed supine on the x-ray table with all elastic wrappings removed
from the leg
• Preliminary radiograph of leg and thigh is taken in order to ascertain optimum
exposure
23. TECHNIQUE
Ascending phlebography :
Tourniquets applied just above the ankle and below the knee in order to occlude the
superficial system and direct flow into the deep veins.
Table tilted 65 degree from the horizontal feet down position in order to prevent layering
of contrast medium
Leg should be internally rotated in order to separate the tibia and fibula and the deep veins
of the calf
Weight should not be borne by the foot being injected so that the calf muscle remain
relaxed and the vein can be filled with the contrast
23G butterfly needle is inserted into peripheral vein on the dorsum of the foot
24. CONTD..
40cc contrast medium is injected into the extremity either by hand or pressure injector
First exposure is made about 2 minute after the beginning of injection focusing the legs
If stereoscopic views are required , exposure of legs taken in second or stereo position
3rd film is taken exposing the thigh
The table is lowered again and another film is taken of the legs to determine the degree of stasis present
Lastly, a separate exposure of the pelvis done by tilting the table back to the horizontal position as this
position favors the filling of the pelvic veins with the contrast medium
At the end of the procedure , needle should be flushed with 0.9% saline to avoid the risk of phlebitis
25. CONTD..
Descending Phlebography:
Less frequently done procedure
Patient supine with feet against foot rest
Femoral vein is puncture at the groin and with the needle insitu, patient is put in erect or
near erect position and contrast injected
If the patient performs valsalva maneuver contrast will reflux down an incompetent
femoral vein into the popliteal vein
26. IMAGES
1. Anterior-posterior(AP)of calf.
2. Both Oblique of calf(Internal and External)
3. AP of popliteal, femoral and iliac veins.
AFTERCARE
The limb should be exercised.
27.
28. UPPER LIMB VENOGRAPHY
It is the study of the veins of the upper limb by the introduction of contrast medium.
29. UPPER LIMB VENOGRAPHY
ANATOMY:
The venous system of the upper limb may be divided into two
sets: deep and superficial veins.
Superficial veins:
Cephalic vein
Basilic vein
Median cubital vein(it is anterior to the elbow joint ;the
vein most commonly used to draw blood, which connects
the superficial drainage systems of the forearm)
30. UPPER LIMB VENOGRAPHY
ANATOMY:
Deep veins:
Brachial vein
Radial vein
Ulnar vein
Palmer arch
The deep brachial veins join the superficial basilic vein to
form the axillary vein, which empties into the subclavian and
finally into the superior vena cava.
31.
32. INDICATION
Oedema
To demonstrate the site of venous obstruction
SVC obstruction
Congenital abnormality of the venous system
CONTRAST MEDIUM
Low/Iso osmolar contrast medium of 300mgI/ml
EQUIPMENT
Conventional/advanced Fluoroscopy unit with spot film device
and Tilting x-ray table
33. TECHNIQUE
The patient is supine
An 18G butterfly needle is inserted into the median cubital vein at the elbow. The
cephalic vein is not used, as this bypasses the axillary vein.
Spot films are taken of the region of interest during a hand injection of 30 ml of
contrast medium. Alternatively a digital subtraction angiographic run can be
performed at 1 frame sec−1.
34. PERIPHERAL VARICOGRAPHY
INDICATIONS
• To demonstrate distribution of varicose veins.
• To demonstrate sites of communication with deep venous system.
• Assessment of recurrent varicosity.
CONTRAINDICATIONS
• Local sepsis.
CONTRAST MEDIUM
• LOCM/IOCM 240mgI/ml. Volume depends on extent and volume of varicosities.
35. TECHNIQUE
The patient lies supine and tilted 40° head up to delay washout of contrast.
A 19-G butterfly needle is inserted into a suitable varix below the knee.
40-50 ml of contrast are injected by hand under fluoroscopic control.
A series of spot films is taken:
AP calf and 2 obliques
lateral knee - to assess the short sapheno-popliteal junction.
If contrast filling above the knee is adequate, then further views of the thigh can be taken
to demonstrate the extent of long saphenous varicosity.
Due to the large volume of varicose veins, it may be necessary to re-site the needle in a
suitable varix above the knee to obtain adequate contrast filling of the entire system.
CONTD..
36. CONTD..
Contd..
A further 40 ml of contrast are then injected and spot films taken.
AP thigh and oblique - particular attention should be given to the potential sites of communication, e.g.
mid-thigh perforator
AP and oblique of groin - views to demonstrate the sapheno-femoral junction arc particularly necessary
in assessing recurrent varicosity even if there has been previous sapheno-femoral ligation, as
recurrence at this site is common.
After injection and imaging is complete the veins should be flushed with saline to prevent
contrast stasis and the risk of phlebitis.
The needles are removed and pressure applied to ensure hemostasis.
37. AFTERCARE
The limb should be exercised gently to washout any remaining contrast
40. INFERIOR VENA-CAVOGRAPHY
It is the Venography of the IVC
It is performed primarily to rule out the existence of thrombus or the occlusion of the IVC
The contrast medium is injected through a multiple side hole catheter inserted through the femoral
vein and positioned in the common iliac vein or the inferior aspect of the IVC
Radiographs may need to include the opacified vasculature from the catheter tip to the right atrium
Representative injection and imaging programs are 20ml/sec for a 40 ml total volume of contrast
medium and two image per second for 4-8 second in both planes
Imaging begins at the end of suspended respiration
41. INDICATION
• To demonstrate the site of venous obstruction, displacement or infiltration
• As a preliminary examination in trans-venous interventional techniques
• To detect caval and renal anomalies
• To evaluate the status of the cava and its collaterals before ligation of the inferior vena cava
CONTRAINDICATIONS
• Active spreading thrombophlebitis
• Severe concurrent hepatic and renal dysfunction
42. CONTRAST MEDIA
• LOCM/IOCM 370mgI/ml, 40 ml
EQUIPMENT
• Conventional/advanced fluoroscopy unit
• Catheter 5F with side holes
• Injector
43. TECHNIQUE
With the patient supine, the catheter is inserted into the femoral vein using the seldinger
technique
An injection of 40 ml of contrast medium is made in 2 seconds by the pump injector and recorded
Better and more prolonged filling seen if patient perform valsalva maneuver
44. FILMS
Rapid serial radiography is performed(Two film/frames per second for 5 seconds
and one film per second for 5-10 second in AP and lateral positions) or as a digital
subtraction run at 2 frames/s
AFTERCARE
Pressure at the venipuncture site Monitoring the patient
45.
46. SUPERIOR VENA-CAVOGRAPHY
• Venography of the superior venacava is performed primarily to rule out the
existence of thrombus or the occlusion of the superior venacava
• The contrast medium may be injected through a needle or an angiographic
catheter introduced into a vein in an antecubital fossa , although superior
opacification result from injection through the catheter positioned in the axillary
or subclavian vein
• Radiographs should include the opacified subclavian vein, brachiocephalic vein,
the SVC and the right atrium
47. SUPERIOR VENA-CAVOGRAPHY
• The injection program depends mostly on whether a needle , an angiographic
catheter or a regular catheter is used
• A representative program for a catheter injection is 10 to 15 ml/sec for a 30 to 50
ml total volume of contrast medium
• Image are produced in both planes, if desired, at a rate of one or two image per
second for 5-10 seconds and are made at the end of the suspended inspiration
48. INDICATION
Thrombus or occlusion or stenosis of superior venacava
To demonstrate the site of venous obstruction
Congenital abnormality of the venous system e.g. left sided superior venacava
As a preliminary examination in trans-venous interventional techniques
49. TECHNIQUE
The patient is supine
PA view of upper chest and lower neck is taken as the preliminary film
18G butterfly needles are inserted into the medial antecubital vein of both arms
Hand injection of contrast media 30 ml from each side, are made simultaneously, as rapidly as
possible by two operators.
The film sequence is started after two third of the contrast medium is injected.
52. SELECTIVE VISCERAL VENOGRAPHY
The visceral veins are often visualized by extending the imaging program
of the corresponding visceral artery injection.
For example the veins that drain the small bowel are normally visualized
by extending the imaging program of a superior mesenteric arteriogram.
53. RENAL VENOGRAPHY
It is usually performed to rule out thrombosis of the renal vein . It is also catheterized for
blood sampling , usually to measure the production of renin, an enzyme produced by kidney
when it lacks adequate blood supply.
The renal vein is most usually catheterized from a femoral vein approach.
16 ml volume of contrast is given at 8 ml/sec.
2 images per second are taken for 4 seconds.
54.
55. HEPATIC VENOGRAPHY
• Performed to rule out stenosis or thrombus of the hepatic veins
• Also done to Obtain pressure measurements of the veins inside the liver
• Usually catheter enters jugular vein or upper limb veins but a
• femoral vein approach may also be used.
Can be done by following method:
• The patient is placed in the supine position that include the liver tissue and the extreme
upper inferior vena cava
• 30 ml volume of contrast is given at 10 ml/sec
• 1 image per second is taken for 8 seconds
• Exposures made at the end of suspended expiration.
56.
57. PORTAL VENOGRAPHY
To demonstrate prior to operation the anatomy of the portal system in patients with
portal hypertension.
To check the patency of a Porto-systemic anastomosis.
LOCM 370, 50 ml is used.
It can be performed by injecting the portal vein directly from a percutaneous approach
but is usually accomplished by late phase imaging of splenic artery or a superior
mesenteric arteriogram.
Images are taken in Rapid serial radiography or digital subtraction runs: at one image
s−1 for 10 s.
58.
59. CEREBRAL VENOGRAPHY
Cerebral veins are usually visualized during the procedure of cerebral
angiography because the transit time from cerebral arteries two veins is very
less(about 2-4 sec)
Abnormalities at the base of the skull can be visualized by Jugular vein approach.
Improper technique can results in a lack of intracranial Dural sinus filling which
may disguise as venous occlusion. This problem is avoided by adequate neck
compression along with proper volume and rate of delivery of contrast.
Internal carotid artery injection venous phase
60.
61. CAPNOCAVOGRAPHY
Visualization of inferior vena cava by injection of CO2 into the vein
It is ideal in patients who are allergic to iodinated contrast media and
compromised renal function.
The buoyancy of CO2 makes it necessary for the procedure to be done in the left
lateral position for optimal visualization of the IVC
The main limitation of the technique is the possibility of neurotoxicity
62. Use of carbon dioxide (CO2) as a contrast
medium is demonstrated (appearing white along
the right of the spine) on a frail 75 year old man.
63. RISKS AND COMPLICATIONS
Angiographic, therefore venography procedures always involve some level of risk for the
patient. Common risks and complications include the following:
A. Due to technique:
1. Bleeding at the puncture site
2. Thrombus formation
3. Embolus formation
*These points may not be discussed in the specific sections of venography as these are common points to all the venographic procedures.
4. Hematoma
5. Dissection of a vessel
6. Infection of puncture site
7. Tissue necrosis due to extravasation
64. CONTD..
B. Due to contrast media:
1. Contrast media reaction
2. Thrombophlebitis
3. Cardiac arrhythmia
*These points may not be discussed in the specific sections of venography as these are common points to all the
venographic procedures.
65. RADIATION PROTECTION
A potential risk exists for increased radiation dose to the members of the angiography team because of
their proximity to the patient and equipment during the procedure. So, Careful use of radiation
protection devices, such as lead aprons, thyroid shields, and lead glasses, is required.
Ensuring that fluoroscopy time is absolutely minimized can also help in reducing dose.
The use of pulsed fluoroscopy can also reduce radiation dose to the patient during angiography.
Precise collimation is important for reducing the dose to the patient and the angiography team.
Glass Lead shields may be suspended from the ceiling as an additional means of protecting the
angiographer’s face and eyes.
66. OTHER MODALITIES
ULTRASOUND
Ultrasound is the most widely used imaging method for the venous system
The advantages are that it is low cost and readily available
It is now the modality of choice because veins can be systematically examined using a combination of
continuous wave, duplex and color Doppler systems ( demonstrates changes in the velocity of venous blood
flow with 95% accuracy)
It can be used to assess the following:
Lower limb veins
Upper limb veins
Abdominal veins including renal veins, hepatic and portal veins, and inferior vena cava
Venous anatomy to assist in central venous line placement, e.g. for the internal jugular or subclavian vein.
67. OTHER MODALITIES
COMPUTED TOMOGRAPHY
Multidetector CT (MDCT) with standard IV contrast and scan delay protocols for the chest
or abdomen/pelvis is very effective for detection of compression or thrombosis of major
veins including the superior and inferior vena cavae, iliac and renal veins.
Although it would be possible to perform direct lower-limb CT venography after infusion
of contrast via a foot vein, this technique has found little application and is not used in
clinical practice.
68. OTHER MODALITIES
MAGNETIC RESONANCE IMAGING(MRI)
MRI is well suited to imaging the venous system, but because of cost and limited availability it is
used infrequently
Peripheral MR venography (MRV) is currently used in selected cases of:
venous thrombosis in pregnant subjects and
where fractured limbs are immobilized in casts.
It is useful in evaluation of congenital abnormalities of peripheral venous anatomy and venous
malformations.
This is the best and most versatile imaging modality for the brain,
70. CONCLUSION
Conventional Venography is nearly 100% sensitive and specific in making the diagnosis of
DVT.
Accuracy is crucial since deep vein thrombosis can lead to pulmonary embolism, a condition
that can be fatal.
But, due to the development of newer modalities such as ultrasound, CT and MRI; these
procedures are almost obsolete.
Venography takes between 30-45 minutes .It is an invasive procedure requiring intravenous
injection of contrast medium, and is painful and expensive. Failure to cannulate veins occurs
with swollen limbs. False negative results do occur.
It is especially useful when there is a strong suspicion of deep vein thrombosis, but non-
invasive tests (ultrasound) have failed to identify the disease.
71. REFERENCES
A guide to radiological procedure ;Stephen Chapman, 4th and 6th edition
Clark’s special procedure in radiography
Radiological procedures a guideline ; Dr. Bhushan N. Lakhkar.
Merrill’s atlas of radiological procedures ; Vol3
Principle of anatomy and physiology ; Tortora and Derrickson
Text book of Radiographic anatomy and related anatomy; Kenneth L. Bontrager, MA John P.
Lampignano, MEd, RT(R)(CT)
72.
73.
74. ???
1. What is Venography/Phlebography?
2. Common Patient preparation?
3. Indications of Lower limb venography?
4. Images for Lower limb venography?
5. Contraindications for venography?
6. Risks and Complications?
Editor's Notes
An angiography unit generally requires the following:
Physiologic monitoring equipment that allows monitoring of the patient’s venous and arterial pressures, oxygen levels, and electrocardiogram (especially important for angioplasty and cardiac catheterization)
Specialized x-ray tube with high heat load capacity and rapid
cooling to meet the need for high mA, high frame rates, and
multiple acquisition series
An angiography unit generally requires the following:
Physiologic monitoring equipment that allows monitoring of the patient’s venous and arterial pressures, oxygen levels, and electrocardiogram (especially important for angioplasty and cardiac catheterization)
The great saphenous vein is the longest vein in the body;
It extends from the foot, along the medial aspect of the leg, to the thigh, where it opens into the femoral vein.
The great saphenous vein is the longest vein in the body;
It extends from the foot, along the medial aspect of the leg, to the thigh, where it opens into the femoral vein.
The venous drainage of the upper limb is composed of superfi cial and
deep groups of vessels.
The superfi cial group starts as an irregular dorsal arch on the back
of the hand. The cephalic vein begins at the radial extremity of the
arch, ascends along the lateral aspect of the arm within the superfi cial
fascia and then pierces the deep fascia to enter the axillary vein just
distal to the clavicle (Fig. 45.5). The basilic vein drains the ulnar end
of the arch, passes along the medial aspect of the forearm, pierces
the deep fascia at the elbow and joins the venae comitantes of the
brachial artery to form the axillary vein. In front of the elbow, the
prominent median cubital vein links the cephalic and basilic veins.
It receives a number of tributaries from the front of the forearm andgives off the deep median vein which pierces the fascial roof of the
antecubital fossa to join the venae comitantes of the brachial
artery.
The deep group of veins accompany the arteries, usually as
venae comitantes, and ultimately become the axillary and then the
subclavian vein. They drain the tissues beneath the deep fascia of the
upper limb and are connected to the superfi cial system by perforating
veins. all carpal aspects. Dorsal vessels, after running proximally in parallel,
curve successively round the borders of the limb to join the ventral
vessels. Anterior carpal vessels run through the forearm parallel with
the median vein of the forearm to the cubital region, then follow the
medial border of biceps brachii before piercing the deep fascia at
the anterior axillary fold to end in the lateral axillary lymph nodes
(Fig. 45.6).
Lymph vessels that lie laterally in the forearm receive vessels that
curve round the lateral border from the dorsal aspect of the limb. They
follow the cephalic vein to the level of the deltoid tendon, where most
incline medially to reach the lateral axillary nodes; a few continue with
the vein and drain into the infraclavicular nodes. Vessels lying medially
in the forearm are joined by vessels that curve round the medial border
of the limb. They follow the basilic vein. Proximal to the elbow some
end in supratrochlear lymph nodes whose efferents, together with the
medial vessels that have bypassed them, pierce the deep fascia with the
basilic vein and end in the lateral axillary nodes or deep lymphatic
vessels.
Collecting vessels from the deltoid region pass round the anterior
and posterior axillary folds to end in the axillary nodes. The scapular
skin drains either to subscapular axillary nodes or by channels that
follow the transverse cervical vessels to the inferior deep cervical
nodes.
The veins of the lower limb can be subdivided, like those of the upper
limb, into superfi cial and deep groups (Figs 79.8, 79.9). The superfi cial
veins are subcutaneous and lie in the superfi cial fascia; the deep veins
(beneath the deep fascia) accompany the major arteries. Valves are
present in both groups, but are more numerous in the deep veins.
(Valves are more numerous in the veins of the lower limb than in the
veins of the upper limb.) Venous plexuses occur within and between
some of the lower limb muscles. The principal named superfi cial veins
are the long and short saphenous veins; their numerous tributaries are
mostly unnamed. For details and variations consult Kosinski (1926).
Deep veins of the lower limbs accompany the arteries and their
branches. Plantar digital veins arise from plexuses in the plantar regions
of the toes, connect with dorsal digital veins and unite to form four
plantar metatarsal veins. These run in the intermetatarsal spaces and
connect with dorsal veins by means of perforating veins. They then
connect with each other to constitute a deep plantar venous arch
adjacent to the plantar arterial arch. From this arch, medial and lateralplantar veins run near the corresponding arteries: they communicate
with the long and short saphenous veins before forming the posterior
tibial veins behind the medial malleolus. The posterior tibial veins
accompany the posterior tibial artery. They receive veins from the calf
muscles, especially the venous plexus in soleus, and connect with superfi
cial veins and with the fi bular veins. The latter, running with their
artery, receive tributaries from soleus and from superfi cial veins.
The anterior tibial veins are continuations of the venae comitantes
of the dorsalis pedis artery. They leave the extensor region between the
tibia and fi bula, pass through the proximal end of the interosseous
membrane, and unite with the posterior tibial veins, at the distal border
of popliteus, to form the popliteal vein.
The cephalic and basilic veins are the primary tributaries of the superficial venous system. Both veins originate in the arch of the hand.. The upper basilic vein empties into the large axillary vein, which flows into the subclavian and eventually the superior vena cava
The cephalic and basilic veins are the primary tributaries of the superficial venous system. Both veins originate in the arch of the hand.. The upper basilic vein empties into the large axillary vein, which flows into the subclavian and eventually the superior vena cava
Inspiration ma ivc collapses
Patients who exhibit a history of severe reaction to iodinated contrast or with compromised renal function may undergo procedures in which CO2 is used as a contrast agent.
CO2 is less radiopaque than blood and appears as a negative or void in angiographic imaging. CO2 is only approved for use below the diaphragm because the possibility of emboli is too great near the brain.
Bleeding usually can be controlled by applying compression.
A blood clot may form in a vessel and disrupt the flow.
A piece of plaque(or rarely, a portion of the guide-wire or catheter)may be dislodged from a vessel wall by the catheter. A stroke or other vessel occlusion may result.
collection of blood outside of blood vessels
An IVC Filter is a “wire basket” that is used to trap emboli