Other Imaging Modalities: CT, MR, Venography, Lymphangiography, Lymphoscintigraphy, Transillumination

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Giles Garrett
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1 Other Imaging Modalities: CT, MR, Venography, Lymphangiography, Lymphoscintigraphy, Transillumination Sanjeeva P. Kalva MD, FSIR Chief, Interventional Radiology UT Southwestern Medical Center, Dallas, TX ACP Review Course

2 Objective To discuss the role and technique of CT Venography, MR Venography, Lymphangiography, Lymphoscintigraphy and Transillumination To review the imaging findings of common venous diseases on these imaging modalities To review the limitations of these imaging modalities

3 CT Venography

4 Direct CT Venography l and scan the area as the contrast travels up along the veins Phlebology. Sep2012, Vol. 27 Issue 6, p

5 Indirect CT Venography nd scan the desired area during the equilibrium phase of cont Korean J Radiol May-Jun;12(3):

6 Why CT? Not operator dependent (unlike US) Better visualization of deep veins of abdomen, pelvis and chest (no problem with bowel gas or obesity) Can be combined with CT pulmonary angiography during PE evaluation Can detect other pathologies responsible for patient s symptoms

7 Limitations Needs IV Contrast material (Nephrotoxicity, Allergic reactions) Quality is dependent on phase of scanning Radiation

8 CTV vs. US for DVT of legs Patel S, Kazeeroni E. AJR 2005

9 Why combine CTV during CTPA for PE Evaluation

10 Acute DVT on CTV Direct Evidence: Complete or partial intraluminal filling defect Associated Findings: Enlarged vein Peri-venous edema Dense rim around the vein Presence of collateral veins

12 Chronic DVT on CTV Calcification in the vein Eccentric, juxtra-mural filling defect with irregular margin Intra-luminal strands due to partial recanalization Retracted small cord-like vein Multiple collateral veins

14 Acute on Chronic DVT Signs of acute DVT in combination with signs of chronic DVT

15 Unusual Sites of DVT on CTV

18 CTV Can differentiate tumor thrombus from bland thrombus

19 Alternative Diagnosis

20 CTV Pitfalls beam hardening artifacts

21 beam hardening artifacts

22 CTV Pitfalls Incomplete venous opacification

23 Radiation Dose during CTV Depends on the technical parameters and extent chosen. Can vary from 7 to 10mSv. Gonadal dose may range from 3 to 4mSv. Methods to decrease radiation dose should always be adopted

24 CTV - Summary Highly useful for detection of DVT in the abdomen, pelvis and chest Sensitivity and specificity approach those of US for lower extremity DVT Radiation dose and need for IV contrast are drawbacks

25 MR Venography

26 MRV Accepted Indications Suspected lower extremity DVT--first line if pelvic DVT Suspected upper extremity DVT--may be first line in central thorax Suspected neurologic venous sinus thrombosis (infection, dehydration)

27 MR Venography Physics (made ridiculously simple) + + = Magnetic field RF Pulse Receiver coil MR Image

29 Blood vessel

30 Blood vessel Black Blood MRA

31 White Blood MRA Blood vessel ECG gating optional

32 Blood vessel Time of Flight MRA

33 Time of Flight MRV Artery Vein

34 Direct Contrast MRV M. Prince, MD

35 Time-resolved Contrast MRV Cornfeld, AJR, 2009.

36 Blood Pool contrast agents: MRV (+ MRA) Leiner T,

37 Contraindications for MRV MRI: Pacemaker / AICD Stimulators / devices Some surgical implants and clips Gadolinium contrast: Allergic reaction Pregnancy Renal failure/nsf

38 Acute DVT AHA 2013; AOS Noncoronary Vascular Imaging

39 Chest. 2001;120(5): Krinsky, G., Applied Radiology, Glockner JF. Applied Radiology 2010

40 Differentiate Tumor Thrombus Glockner JF. Applied Radiology 2010

41 Dynamic Assessment Popliteal venous entrapment

42 MRV Without IV Contrast

43 Assessment during entire cardiac cycle

44 MRV - Summary Indications similar to CTV - Deep veins of chest, abdomen and pelvis Differentiating tumor thrombus from bland thrombus No radiation Dynamic imaging With or without IV contrast material

45 Lymphangiography

46 Lymphangiography To assess lymphatics for leaks (chylous thorax, chylous effusion, lymphocele, lymphatic fistula which usually occur following surgery) To assess lymph nodal involvement by tumors (no more an indication now) To assess lymphedema for aplasia, hypoplasia and hyperplasia of lymphatics

47 Lymphangiography - Technique Journal of Medical Imaging and Radiation Oncology 54 (2010) 43 46

48 Journal of Medical Imaging and Radiation Oncology 54 (2010) 43 46

49 Journal of Medical Imaging and Radiation Oncology 54 (2010) 43 46

50 Intra-nodal Lymphangiography

51 Lymphocele following left nephrectomy

52 Lympho-calyceal fistula: Chyluria

53 Chylous Thorax

54 Lymph Node Metastases Can Med Assoc J November 18; 97(21):

55 Lymphangioma

56 Lymphangiography - Summary Currently used to assess lymphatic leaks in the work up chylous effusions and during thoracic duct embolization Traditional pedal lymphangiography is replaced by intranodal lymphangiography

57 Lymphoscintigraphy

58 Lymphoscintigraphy Radioactive Technetium (Tc-99m) sulphur colloid particles or radioactive iodinated albumin are injected in to the web spaces of foot using a fine needle. These particles are taken up by lymphatics Imaging is done by using a Gamma Camera

59 Lymphoscintigraphy Radioactivity at inguinal nodes is measured at minutes. Normal uptake is %. If it is less than 0.3% in 30 minutes it is diagnostic of lymphedema. If it is >2% at 30 minutes, it suggests venous edema. In 3 hours, it reaches para-aortic lymph nodes and liver. Later, thoracic duct is visualized.

60 Normal lymphoscinitigraphy with radioactive albumin Ann Rehabil Med December; 35(6):

61 Lymphocele Following nephrectomy

62 Chylothorax Indian J Nucl Med Jul-Sep; 27(3):

63 Assessment of lymphatic drainage of a tumor J Anat June; 218(6):

64 Lymphoscintigraphy Technically easier compared to lymphangiography Commonly used to detect sentinal node in breast cancer Helpful to detect lymph leak

65 Transillumination

66 Transillumination Passage of light through body tissues or cavities for examination of internal structures Diaphanoscopy; Diaphanography

67 Surface Transillumination

69 Transillumination Powered Phlebectomy Transilluminator/irrigator Resector The Vein Book edited by John J. Bergan, Nisha Bunke

70 Resection Tumescent injection The Vein Book edited by John J. Bergan, Nisha Bunke

71 Transillumination - Summary Red or orange light to see subcutaneous veins To achieve better visualization of surface veins for sclerotherapy and phlebectomy

72 Thank You

Information for you Treatment of venous thrombosis in pregnancy and after birth. What are the symptoms of a DVT during pregnancy?

Information for you Treatment of venous thrombosis in pregnancy and after birth Published in September 2011 What is venous thrombosis? Thrombosis is a blood clot in a blood vessel (a vein or an artery).