Protocols 3

In the correct order, list the six steps of the technique for identified from the question above.

A. Insertion of guidewire

B. Placement of needle into lumen of vessel

C. Removal of guidewire

D. Removal of needle

E. Insertion of compound seldinger needle

F. Threading of catheter to area of interest

E. Insertion of compound seldinger needle

B. Placement of needle into lumen of vessel

A. Insertion of guidewire

D. Removal of needle

F. Threading of catheter to area of interest

C. Removal of guidewire

At what stage of an IVU is the renal parenchyma best seen?a. 5 minutes after injectionb. 10 minutes after injectionc. After the post void projectiond. Within 1 minute after injection

d. Within 1 minute after injection

What is the minimum time requirement for manual compression of an arterial puncture site?a. 5 minutesb. 10 minutesc. 15 minutesd. 20 minutes

d. 20 minutes

Which of the following terms is used to describe the degree of openness of the uterine tube?a. Stenosisb. Patencyc. Atresiad. Gauge

b. Patency

Which of the following procedures might be performed during a postoperative (T-tube) cholangiogram?a. Removal of the gallbladderb. Removal of a liver cystc. Removal of a biliary stoned. Catheterization of the hepatic portal vein

c. Removal of a biliary stone

What CR angle is used for the AP projection taken during cystogram?a. 20-25 degrees caudadb. 5 to 10 degrees cephaladc. 10-15 degrees caudadd. 30-40 degrees caudad

c. 10-15 degrees caudad

Which of the following vessels is preferred for arterial vessel access for the majority of angiographic procedures?a. Femoral arteryb. Brachial arteryc. Axillary arteryd. Common carotid artery

a. Femoral artery

Which of the following is not a common risk or complication of angiography?a. Embolus formationb. Dissection of a vesselc. Hypertensiond. Contrast media reaction

c. Hypertension

What is an advantage of DSA?a. Reduce radiation doseb. Decrease procedure timec. Perform exam without contrastd. Perform exam in operating room

a. Reduce radiation dose
DSA = Digital subtraction angiography (DSA). Test that provides images of the lumen of the blood vessels including the arteries and veins.

Femoral Artery Approach

- palpate pulse 1 cm below inguinal ligament- incision 1-2 cm below intended puncture site- 25-30* angle of needle

What are the steps of the Seldinger Technique?

1. insertion of compound needle2. placement of needle in lumen of vessel3. insertion of guidewire4. removal of needle5. threading of catheter to area of interest6. removal of guide wire

What are some common entry sites for angiography?

Femoral- most common and safe
Brachial- risk of cerebral embolism- L arm for Ab aorta and legs, R arm for As aorta and cerebral vessels
Radial- limits equipment bc small
Aorta- around T12
IVC- via femoral or R internal jugular

What are some clinical indications for cerebral angiography?

- vascular stenosis- aneurysms- trauma- AVM- neoplastic disease

Cerebral Angiography

study of brain blood vessels
Catheter- femoral- advanced to aortic arch and then into vessel of interest
Contrast- 5-10 mL
Imaging- biplane c-arm- arterial, capillary, venous

Common Carotid Arteriography

one of most frequent cerebral angiograms

Internal Carotid Arteriography

Allows visualization of the internal carotid arteries and the bifurcation into the anterior and middle cerebral arteries

What are some indications for thoracic angiography?

- aneurysms- congenital abnormalities- vessel stenosis- embolus- trauma

Thoracic Angiography

Demonstrates the contour and integrity of the thoracic vasculature
Catheter- femoral- advanced to desired location in thoracic aorta
Contrast- 30-50 mL
Imaging- serial images over several seconds- respiration suspended

Pulmonary Angiography

study of pulmonary vessels to look for PE
Catheter- femoral- advanced into veins, IVC, R atrium, R ventricle, Pulm artery
Contrast- 25-35 mL
Imaging- serial images over several seconds- respiration suspended

Thoracic Aortogram

Oblique visualization of the aortic arch, usually performed with the patient in a 45° LAO position
*prevents superimposition*

What are some clinical indication for angiocardiography?

-CAD- MI- valvular disease- atypical chest pain- congenital heart anomaly- other heart pathology

Cardiac Catheterization

Placing a catheter into one of the chambers of the heart
obtain blood samples (O2 sat, pressures, gradients)
Catheter- femoral- pigtail b/c large volume of contrast
Contrast- ventriculogram = 30-40 mL
Imaging- rapid, 15-30 fps- biplane (RAO & LAO) or single plane (30* RAO)- ejection fraction (stroke volume) calculated

Coronary Arteriography

visualize coronary arteries
Catheter- after injection, catheter removed immediately to prevent occlusion
Contrast- 7-10 mL
Imaging- rapid, 15-30 fps- biplane (RAO & LAO) or single plane (30* RAO)- 6 views of L and 2 views of R

cardiac catheterization (CC)

R Heart Cath (venous)- measurement of blood pushed out of heart- measure R heart O2- assess high pressure in lungs- assess electrical problems in heart
L Heart Cath (arterial)- pumping function- heart pressure- leaky or tight valve- heart blockage

What are some indications for abdominal angiography?

- aneurysm- congenital abnormality- GI bleed- stenosis- trauma

Abdominal Angiography

Demonstrates the contour and integrity of abdominal vasculature
Catheter- aortogram: pigtail via femoral artery- venocavography: femoral vein
Contrast- 30-40 mL
Imaging- supine- serial images over several seconds

What are some common selective studies of abdominal angiography?

- celiac- renal- super mesenteric- inferior mesenteric

Peripheral Angiography

Catheter- lower limbs: femoral artery, catheter advanced to aortic bifurcation- upper limb: catheter advanced along aorta
Contrast- upper limbs less than lower limbs
Imaging - Lower- time of circulation important- programmed by computer- uni or bilateral
Imaging - Upper- timing important- only unilateral

If unilateral acess is used for peripheral angiographal, which side is used?

side opposite of side of interest

Biopsies

- removal of tissue to examine it for disease- guided by US, CT, or MRI

Vertebroplasty

treatment of vertebral compression fractures (commonly caused by osteoporosis)
image guidance used to inject cement fixture into the fractured bone

Kyphoplasty

treatment of vertebral compression fractures (commonly caused by osteoporosis)
balloon is inserted into the fractured bone to create cavity, then cement is injected

What is the purpose of a transcatheter embolization?

1. stop active bleeding2. control blood flow from malformed vessels3. stop/reduce blood flow to area before surgery

Uterine Fibroid Embolization (UFE)

blockage of arteries of uterine fibroid (causes shrinkage)
only done to women who no longer want to become pregnant

Transcatheter Hepatic Arterial Chemoembolization

treatment for liver tumours
access through groin
chemo and embolic material directed to tumor

Percutaneous Abscess Drainage

needle is placed into fluid under imaging guidance
drainage tube left in place

Nerve Block

injection of anesthetic or anti-inflammatory toward nerve
image guidance used to place the needle in right location

Radiofrequency Ablation of Liver Tumors

minimally invasive treatment for cancer
needle electrode guided into cancerous tumors and heats/destroys abnormal cells

IVC Filter

traps large clots and prevents them from enters the heart and lungs
imaged guided placement

What are some risks of IVC Filter?

- DVT- filter migration- filter embolization- filter fracture- IVC occlusion- vena cava stenosis- PE- guide wire entrapment

Transjugular Intrahepatic Portosystemic Shunt (TIPS)

shunt created in liver via x-ray guidance to connect 2 veins in liver (portal vein & hepatic vein)
patients usually have portal hypertension (caused backflow of blood into speen, stomach and esophagus)

What are some indications for a TIPS?

- variceal bleeding- refractory ascites- advanced cirrhosis- end-stage liver disease

Dialysis & Fistula/Graft Declotting

improve blood flow in fistula and grafts in dialysis patients
catheter directed thrombolysis to dissolve clot in fistual
vascular stenting

Lumbar Puncture

imaged guided test that involves removal of CSF or injection of medication into lumbar region of spinal cord

Ureteral stenting

image guidance to place stents in the ureter to restore flow of urine (from obstruction)
if not possible, a nephrostomy performed

Nephrostomy

tube placed through skin on patients back into kidney
tube connected to external drainage bag from kidney to bladder

Stent Placement Steps

1. atherosclerotic artery with compromised lumen2. guidewire passed through blockage3. balloon catheter advanced4. balloon inflated5. deflated balloon withdrawn6. new balloon w/ stent advanced over guidewire7. expands stent compressing it again vessel wall8. balloon is deflated and stent remains

Thombolysis

interventional procedure to dissolve a blood clot

Liver

Hepatic Arteryoxygenated blood from abdominal aorta
Portal Veinblood from digestive system to be filtered by liver
Primary Functionproduce bile

Biliary System

common bile duct and pancreatic duct join and enter duodenum at ampulla of Vater
ampulla controlled by sphincter of Oddi

Gallbladder

visceral surface of R liver lobe
stores and concentrate bile

What are the responsibilties of the MRT during specialized radiological procedures?

1. prepare fluro suite2. set up exam tray3. select & prepare contrast4. take scouts5. provide lead aprons6. monitor patient7. change fluor cassettes8. take conventional x-rays

Percutaneous Transhepatic Cholangiography (PTC)

performed on patients w/ jaundice when ductal system is dilated on CT or US

PTC procedure

1. obstructed biliary tract2. catheter needle insertion3. needle removed, guidewire inserted4. sheath removed and dilation catheter inserted5. dilation catheter replaced by drainage catheter w/ curved tip

Post-Op Cholangiography (T-tube) purpose

delayed cholangiography
T-shaped tube left in common hepatic and common bile duct of post-op drainage
Demonstrates:- patency of ducts- status of sphincter- presence of residual stones

Post-Op Cholangiography Procedure

- NPO 8 hr prior- tube clamped day before- contrast media injected into t-tube
Position- RPO- center to R upper quadrant

Post-Op Removal of Biliary Calculus

1. t-tube cholangiogram to determine location of stone2. guidewire inserted through t-tube and t-tube removed3. catheter inserted and positioned close to catheter4. stone basket advanced to tip of catheter5-6. get stone in basket, several techniques can be used7. catheter and stone basket removed

endoscopic retrograde cholangiopancreatography (ERCP)

endoscopic inspection, cannulation and injection of biliary ducts
Indications- patency of biliary/pancreatic duct- undetected choleliths- small lesions

ERCP Procedure

- NPO 8 hrs- throat sprayed w/ anesthetic- endoscope enter duodenum- hepatopancreatic ampulla cannulated- contrast injected into common bile duct- spot/conventional images taken

Where are the 3 points of constriction of urinary system?

1. ureteropelvic junction2. pelvic brim3. ureterovesical junction

What is the purpose of intravenous urography (IVU)?

1. visualize collecting portion of urinary system2. assess function ability of kidneys3. evaluate urinary system to pathology

Indications for IVU?
Contraindications of IVU?

Indications:- masses- urolithiasis- pylonephritis- UTI- hydronephrosis- trauma- pre-op eval- renal HTN- renal failure- hematuria- flank pain
Contraindications:- poor kidney function- pregnancy (only perform if absolutely necessary)

AP Intravenous Urography

SID: 100 cmkVp: 80-85CR: perp to midway between xiphoid & iliac crest
compression paddles are placed at level of iliac crest

Patient Prep for IVU

1. light evening meal2. bowel cleansing laxative3. NPO after midnight4. enema on morning of exam

IVU Equipment

- syringe/contrast- sterile needles/tubing- venipuncture supplied- emesis basin- lead numbers/markers- emergency cart- uretic compression device- cold/warm towels

IVU Procedure

Contrast- 30-100 mL contrast
Images1. nephrogram immediately after injection2. 5 min KUB3. 10-15 min KUB4. 20 min RPO & LPO5. post void

Why is a post-void radiograph taken during IVU?Nephrogram IVU Protocol?

check for tumor mass or enlarged prostate
Protocol:SID: 100cmkVp: 80-85Centering: midway btwn diploid and crestAngle 10* or 40* caudal

AP IVU Criteria + Protocol

Criteria:no rotationno motionappropriate techniqueminute marker visble
Protocol: KUBSID: 100 cmkVp: 80-85Centering: perp to iliac crest

AP Erect Post-Void IVU Criteria + Protocol?

Criteria:pubic symphysis includedno rotationerect/post-void markers visible
Protocol: KUBSID: 100 cmkVp: 80-85Centering: perp to iliac crest

Why is a posterior oblique image taken in IVU? Best seen downside? Upside?
RPO + LPO IVU - Protocol?

elevated side- kidney parallel to IR
downside- ureter free from superimposition of spine
EX: RPO = left kidney & right ureter!!!
Protocol:SID: 100 cmkVp: 80-8530* obliquityCR: crest

Ureteric Compression

enhance filling of pelvicalyceal system
Contraindications1. ureteric stones2. abdominal mass3. AAA4. recent abdominal surgery5. severe abdo pain6. acute abdominal trauma

What is an alternative to ureteric compression?

Trendelenburg position

CT IVU Benefits

1. minimal bowel prep (water 1 hr prior)2. non-contrast images3. optional contrast (structural/functional study)4. fast procedure5. 3D recons

Retrograde Urography

nonfunctional exam of urinary system where contrast is introduced retrograde by catheter
determines location of stones

Retrograde Cystography

nonfunctional exam of bladder where contrast is introduced via catheterization
rules out trauma, calculi, tumor, or inflammatory disease

Indications for Cystography

-Vesicoureteral reflux- recurrent UTI- neurogenic bladder- bladder trauma- urinary tract fistula- urethral stricture- post urethral valves

Contraindication of Urethra Catheterization

- recent bladder surgery- blockage of urethra- acute phase of UTI

AP Axial Bladder: Cystogram (Special Projection)

10-15* caudal 2" superior to SP (projects SP inferior to bladder)

AP Oblique Bladder: Cystogram (Special Projection)

45-60* post oblique (CR 2" sup to SP)
(visualize posterolateral portion of bladder)

voiding cystourethrography (VCUG)

functional study of urethra that evaluates patients ability to urinate
CR perp to SP

Retrograde Urethrography

- retrograde injection of contrast, performed on males to demonstrate the full length of the urethra
- 30* RPO position
RPO 30* centered perp to SP

extracorporeal shock wave lithotripsy (ESWL)

shock waves break kidney stone into small pieces for easier exit from body

Arthrography

radiographic examination or soft tissue structures of a joint after contrast injection
\*** Mainly replaced by MRI due to it being non-invasive / no contrast \***
Equipment- prep sponge- fenestrated drape- syringes- flexible connector- needle

Arthrography Guidelines

- local anesthetic- aseptic conditions- radiologist manipulates joint- spot films taken

What are some common joints examined during arthrography?

hipkneeankleshoulderelbowwristTMJ

hysterosalpingography (HSG)

a radiographic examination of the uterus and fallopian tubes using contrast media
Equipment- HSG tray- speculum- sterile drapes- canula/balloon catheter- contrast media

Why is a hysterosalpingogram (HSG) performed?

- size, shape, position of uterus- delineate lesions- patency of uterine tubes in patients unable to conceive- eval after tubal ligation

hysterosalingogram (HSG) procedure

1. scout images2. lithotomy position3. speculum in vagina4. uterine canula in cervix5. contrast injected into uterus (spills into peritoneal cavity if tubes are patent)
Positions- AP scout- AP post injection- LPO/RPOcentered 2" above pubis symphysis

When should a hysterosalpingogram (HSG) be performed?

w/in 10-13 days following onset of menstruation- endometrium less congested- less risk of irradiation fertilized ovum

Patient Prep for Hysterosalpigogram (HSG)

- empty bladder- irrigate vagina- laxative to clean bowels

What are contraindications of HSG?

-pregnancy-acute pelvic inflammatory disease-active uterine bleeding

Myelography

a radiographic study of the spinal cord after the injection of a contrast medium through a lumbar puncture

What are indications for myelography?

- herniated nucleus pulposus (HNP)- tumors- cysts- trauma

What are contraindications for myelography?

- Blood in CSF- Arachnoiditis- Increased ICP- recent lumbar puncture

Myelogram Procedure

1. skin prep2. lumbar puncture3. CSF collection4. contrast insertion5. needle removed

Orthoroentgenography

measurement of long bones for limb length discrepancy
Indications- back pain due to leg length- developmental anomalies- epiphysiodesis- bone length surgery

Orthoroentgenography Procedure

- both side examined for comparison- special metal ruler
3 exposure made of limbupper: shoulder, elbow, wristlower: hip, knee, ankle

hip to ankle long bone measurement:

allows physicians to determine limb length discrepancies
Procedure- remove shoes- knees in true AP- include crest to ankle joint

CT Scanogram

advantage over conventional radiographs in limb measurement- more consistent- less radiation

EOS

- 2D/3D low dose scanner- 80% overall radiation reduction- continuous scan- 8-15 sec- surgical planning tool
*The EOS Imaging System is a low-dose, 3-D imaging system that scans your child standing up.*