The document outlines the techniques and indications for aortography and venography, including the Seldinger technique for catheter insertion. It details the use of contrast media, equipment required, and specific procedures for imaging the aortic and venous systems. Additionally, it addresses potential complications associated with these procedures.
The document outlines the techniques and indications for aortography and venography, including the Seldinger technique for catheter insertion. It details the use of contrast media, equipment required, and specific procedures for imaging the aortic and venous systems. Additionally, it addresses potential complications associated with these procedures.
The document outlines the techniques and indications for aortography and venography, including the Seldinger technique for catheter insertion. It details the use of contrast media, equipment required, and specific procedures for imaging the aortic and venous systems. Additionally, it addresses potential complications associated with these procedures.
The document outlines the techniques and indications for aortography and venography, including the Seldinger technique for catheter insertion. It details the use of contrast media, equipment required, and specific procedures for imaging the aortic and venous systems. Additionally, it addresses potential complications associated with these procedures.
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AORTOGRAPHY
VENOGRAPHY ANATOMY AORTOGRAPHY INDICATIONS
1. Aortic aneurysm or dissection
(echocardiography, CT with intravenous contrast enhancement, and MRI can also be used to demonstrate a dissection). 2. Atheroma at the origin of the major vessels. 3. Aortic regurgitation (echocardiography is more sensitive and less invasive if available). 4. Congenital heart disease - particularly the demonstration of congenital or iatrogenic aorto- pulmonary shunts and coarctation. 5. Aortic trauma. SALDINGER TECHNIQUE
Step 1. Insertion of compound (Seldinger) needle The needle
with an inner cannula is placed in a small incision and advanced so that it punctures both walls of the vessel. Step 2. Placement of needle in lumen of vessel Placement of the needle in the lumen of the vessel is achieved by removing the inner cannula and slowly withdrawing the needle until a steady blood flow returns through the needle. SELDINGER TECHN IQUE Step 3. Insertion of guidewire When the desired blood flow returned through the needle, the flexible end of a guidew inserted through the needle and is advanced about 10 cm the vessel. Step 4. Removal of needle After the guidewire is in positio needle is removed by withdrawing it over the portion of th guidewire that remains outside the patient. Step 5. Threading of catheter to area of interest The cath is threaded over the guidewire and is advanced to the are interest under fluoroscopic control. Step 6. Removal of guidewire When the catheter is locate the desired area, the guidewire is removed from inside th Contrast medium LOCM 370, 0.75 ml/kg (max. 40 ml). Inject at 18-20 ml/s. Equipment 1. Digital fluoroscopy unit with C-arm capable of 20-30 frames s-1. 2. Pump injector 3. Catheter: Technique The catheter is introduced using the Seldinger technique via the femoral artery, and its tip sited 1-3 cm above the aortic valve. The patient is positioned 45° RPO to open out the aortic arch, and to show the aortic valve and the left ventricle to best advantage. A test injection is performed to ensure that: a. the catheter is correctly placed in relation to the aortic valve (which is particularly important in the hyperkinetic heart) b. the catheter tip is not in a coronary artery. FILMS
Films 20-30 frames s-1. Additional films If, on the original run, the right common carotid artery overlies the right innominate artery or an aneurysm is present on the anterior aspect of the ascending aorta, the injection is repeated with the patient positioned LPO. METHODS OF IMAGING THE VENOUS SYSTEM
1. Contrast medium venography.
2. US. 3. CT can show inferior vena cava involvement and renal vein involvement in renal cell carcinoma and Wilms' tumour. 4. MRI will show the presence or absence of flowing blood. The ability of MR to image in the plane of the vessel makes it well suited to assessing the venous system. Flow artefact can cause problems in interpretation but the use of bolus gadolinium enhancement techniques, combined with volume gradient echo imaging (with maximum intensity projection post-processing) can produce excellent visualization of the venous system. In addition, MRI can be used to 'age' thrombus and differentiate acute from chronic clot. 5. Radioisotopes. The patency of blood vessels may be examined using Tc-colloid or Tc-macroaggregated albumin (MAA) injected 99m 99m
into a supplying vessel with fast-frame dynamic imaging. Thrombus
may be imaged with In- or Tc-in vitro-labelled platelets. 111 99m SUPERIOR VENA CAVOGRAPHY
Indications
To demonstrate the site of a venous
obstruction. Congenital abnormality of the venous system, e.g. left-sided superior vena cava. Contrast medium LOCM 370, 60 ml.
Equipment Rapid serial radiography unit. Patient preparation Nil orally for 5 h prior to the procedure. Preliminary films PA film of upper chest and lower neck. TECHNIQUE
The patient is supine.
18-G butterfly needles are inserted into the median antecubital vein of both arms. Hand injections of contrast medium 30 ml per side, are made simultaneously, as rapidly as possible by two operators. The injection is recorded by rapid serial radiography (see 'Films' below). The film sequence is commenced after about two-thirds of the contrast medium has been injected. Films
Rapid serial radiography is performed:
one film per s for 10 s. Aftercare
None, unless a catheter is used.
INFERIOR VENA CAVOGRAPHY
Indications
To demonstrate the site of a venous
obstruction, displacement or infiltration. Congenital abnormality of the venous system. TECHNIQUE
With the patient supine, the catheter is
inserted into the femoral vein using the Seldinger technique. A Valsalva manoeuvre may facilitate vene-puncture by dilating the veins. An injection of 40 ml of contrast medium is made in 2 s by the pump injector, and recorded by rapid serial radiography. Aftercare
Pressure at venepuncture site.
Routine observations for 2 hours. LOWER LIMB VENOGRAPHY
Indications Deep venous thrombosis To demonstrate incompetent perforating veins Oedema of unknown cause Congenital abnormality of the venous system (rare). Contraindications Local sepsis. Contrast medium LOCM 240.
Equipment Fluoroscopy unit with spot film device Tilting radiography table.
Patient preparation Elevated leg overnight if oedema is severe. TECHNIQUE
The patient is supine and tilted 40° head up, to delay the transit time of the contrast medium. A tourniquet is applied tightly just above the ankle to occlude the superficial venous system. It is important to remember that this may also occlude the anterior tibial vein, and so its absence should not automatically be interpreted as due to a venous thrombosis. A 19-G butterfly needle (smaller if necessary) is inserted into a distal vein on the dorsum of the foot. If the needle is too proximal, the contrast medium may bypass the deep veins and so give the impression of a deep venous occlusion. 4. 40 ml of contrast medium is injected by hand. The first series of spot films is then taken. TECHNIQUE CONT A further 20 ml of contrast are injected quickly whilst the patient performs a Valsalva manoeuvre to delay the transit of contrast medium into the proximal and pelvic veins. The patient is tilted quickly into a slightly head down position and the Valsalva manoeuvre is relaxed. Alternatively, if the patient is unable to Valsalva, direct manual pressure over the femoral vein whilst the table is being tilted into the head-down position will delay transit of contrast medium proximally. Films are taken 2-3 s after releasing pressure.
At the end of the procedure the needle should be
flushed with 0.9% saline to avoid the risk of phlebitis due to stasis of contrast medium. FILMS AP of calf Both obliques of calf (foot internally and externally rotated) AP of popliteal, common femoral and iliac veins.
Aftercare The limb should be exercised. Complications Due to the contrast medium
As for the general complications of intravascular contrast media
Thrombophlebitis. Tissue necrosis due to extravasation of contrast medium. This is rare, but may occur in patients with peripheral ischaemia. Cardiac arrhythmia - more likely if the patient has pulmonary hypertension.
Due to the technique
Haematoma Pulmonary embolus - due to dislodged clot or air. UPPER LIMB
Methods :Intravenous venography.
Indications
Oedema To demonstrate the site of a venous obstruction SVC obstruction - Contrast medium LOCM 300.
Equipment
Fluoroscopy unit with spot film device.
Patient preparation None. Preliminary film PA shoulder. Technique For intravenous venography
The patient is supine.
An 18-G butterfly needle is inserted into the medium 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. HANK YOU FOR YOUR TIM
