VASCULER IMAGING 2012

SUDARMANTA
RADIOLOGIC EXAMINATION OF
VASCULAR

Dr. Sudarmanto, SpRad

Dept of Radiology, School of Medicine

Gadjah Mada University – Dr. Sardjito Hospital
Yogyakarta
 VASCULAR EXAMINATION
There are 2 methods to vascular study:
1. Invasive Method: Angiography
a. Arteriography (Arterial Examination)
b. Venography (Venous Examination)
2. Non-invasive Method
a. Ultrasound (US) and Color Doppler US
b. CT Angiography
c. MR Angiography
INDICATION VASCULAR EXAMINATION

1. Trombosis
2. Embolus
3. Stenosis
4. Occlusive
5. Aneurysm
6. Angiomatosis Malformation
7. Arteriovenous Malformation
8. FeedingVessel Intratumoral
9. Haemorrhage
 ULTRASOUND
Since Vascular US examinations do not
require the injection contrast material (non-
invasive), anytime can do it, cheap, they are
well tolerated by and comfortable for most
patients.
A transducer/probe that emits high
frequency sound wave (usually 2-7 MHz) is
held to the skin
 VASCULAR GRAY SCALE US
Gray Scale US is a powerful tool for defines the
morphology of blood vessel, but it has distinct
limitations.
Air, bone and metal are so highly reflective that
sound waves cannot penetrate to visualize
underling tissues
 COLOR DOPPLER US
Principle of Doppler US
The basis for determines the velocity and direction of
blood flow is the Doppler effect, discovered by the
physicist Christian Johan Doppler.
This effect states that when a sound source and reflector
are moving toward each other the sound waves are
spaced closer together and reach the receiver at a
higher frequency (Fe) than they were originates emitted
(Fo), this is the sound effect responsible for the
appearance rising pitch of and approach ambulance
siren and the falling pitch as the ambulance move away.
Frekwensi yang diterima oleh probe lebih rendah bila aliran
darah menjauhi probe dan lebih tinggi bila mendekati probe
 COLOR FLOW
Flow Direction toward the transducer is generally
encoded in red. While flow away from the transducer
is encoded in blue.
The 90° beam angle at the junction of the red and blue
segments results in color void, which should not be
misinterpreted as a partially occlusive thrombus
The velocity of the flow is represented by the shade on
brightness of the color. Faster velocity are displayed
in brighter colors.
The color scheme (color bar) is usually indicate on
a color scale displayed at the edge of the
screen. The color in the upper half of the scale
encode flow toward the transducer and those
in the lower half encode flow way from
transducer.
Angling the color box can corrected for an
unfavorable beam vessel angle, making vascular
segment that initially show poor color flow
COLOUR FLOW MAPPING
Peta warna yang ditimbulkan oleh adanya Aliran darah

COLOUR BAR

COLOUR BOX
A.Brachialis
 Local effect of arterial stenosis
A High velocities pressent in the narrowed
portion of the arterial lumen
Turbulence flow is shown with blue color
Doppler spectrum analysis shows markedly
elevated peak sistole velocity (350 cm/s)
B Disturbed flow in the poststenotic
(decreased velocity overall)
Extremity venous ultrasound
examination
( Deep vein thrombosis)
definition

•Blood clot (thrombus) in deep vein

in the thigh or leg
(Medicine Net.com)

•Blood clot in deep vein in the body most

commonly in the leg or pelvis
(About.Com)
 DEEP VEINS OF THE LOWER EXTREMITY

 External/common Iliac
 Common Femoral
 Superficial femoral vein
 Deep femoral vein
 Popliteal vein
 Anterior tibial vein
 Posterior tibial vein
 Peroneal vein
Caused-three principal factors (Virchov)
1. Venous statis
2. Injury to the blood vessel wall
3. Hypercoagulobility
 Risk factors

 Trauma  Heart failure

 Major surgical  Oral contraception

 Previous history of DVT

 Elderly
 Prolonged immobilization
 Malignancy

 Pregnancy
 SYMPTOMS AND SIGNS

Swelling

Warmth

Tenderness-pain

Redness
• US Criteria For DVT
Incompressibility
Loss of augmentation
Visualization
(moderately echoic /hyperechoic)
CDF : Absent/abnormal flow
 US ADVANTAGES

• Safe(non invasive)
• Sensitive (about 95 %)
• Anytime
• Anywhere
• Cheap
• Disavantages of US
 Operator dependent
 Tehnical difficulties in patient:
- severe oedema
- wounds
- obesity
 Low sensitivity for DVT in the iliac vein
s
Characteristic Acut chronic
Venous appearence Distended Normal

Effect of compression Noncompressible Partial compressible

Thrombus appearence Hyopoechoic Isoehoic
continue Skip area
Doppler Minimal -no flow Antegrade-refluks
CHRONIC THROMBUS in FEMORAL V
Thrombus kronis di v femoralis
 ARTERIOGRAPHY
Historical of Arteriography
Roentgen announced discovery of X-ray in
December 1895 and the first arteriogram was
produced within month by Haschek and
Lindental
Percutaneus arterial catheterization is based on
original work of Seldinger (1953)
 TWO BASIC TECHNIQUE
1. Percutaneus Needle Puncture (Direct
arteriography)
2. Percutaneus Arterial Catheterization
 PERCUTANEUS NEEDLE PUNCTURE
Investigation practiced for different area include:
a. Common carotid arteriography
b. Subclavia arteriography
c. Femoral arteriography
For most practiced purposes direct needle
puncture, has now been superseded by
percutaneus catheterization in the head and
neck, upperlimb and abdomen. Through it is
still widely use to femoral arteriography
 PERCUTANEOUS ARTERIAL CATHETERIZATION
(SELDINGER TECHNIQUE)
There are 5 principal techniques for arteriography:
1. Percutaneous puncture of blood vessel with hollow needle
2. Introduction of an a-traumatic guide wire through the needle into the
blood vessel lumen
3. Needle is removed, while guide wire remains in place compression
over puncture. Secures the guide wire and prevent bleeding
4. Angiographic introducer/sheath is advanced into the vessel over guide
wire
5. Angiographic catheter (example Head hunter) is advanced into vessel
via sheath

Most arteriography is now performed under local anesthesia, though general

anesthesia is necessary for babbies and young children
 TOOLS
1. Access Needle
2. Guide Wire
3. Catheter
4. Sheaths (Introducer)
5. Injection Apparatus
6. Radiographic Apparatus
7. Contrast Media
 ACCESS NEEDLE
Disposable needle with solid beveled tip central
sty let (Abbocath)
The most common size for vascular access
needle are 18 – 21 Gauge in diameter and 2 ¼
- 5 inch in length
 GUIDE WIRE
• Short Guide Wire
To introduce sheathes entry lumen of vascular
in generally, the guide wire thickness (usually
0.032 – 0.038 inch). Should match the
diameter of lumen at tip of catheter. The
length of most standard short wire 45 cm
• Long Guide Wire
The length of most standard wire is 100-150
cm, and in diameter 0.032 – 0.038 inch
 CATHETER
• Most modern catheter are made of
polyethylene, polyurethane or nylon are radio-
opaque
• In general terms the type of material influence
the stiffness and flexibility of catheter
• The smoothness of its walls and its ability to
be tapered and its generally handling
characteristics
 SHEATHS / INTRODUCER
• Sheath are short tapered catheter, usually
made of a stiffness plastic than diagnostic
angiographic catheter
• The length of sheaths approximately 20-25 cm
and 5 Fr in diameter
 INJECTION APPARATUS
• Contrast medium injected at hand pressure
will produce adequate opacification of the
smaller vascular beds, but it is necessary to
use a pressure injection when into large
vessels with rapid flow such as aorta,
pulmonary artery, celiac axis.
• That have extremely sophisticated control
which give wide ranges possible pressure and
flow
 RADIOGRAPHIC APPARATUS
• Good equipment is vital factor in producing
good arteriogram.
• Arteriography machine should be able to
flouroscopy,save the images of bone can be
removed so that the artery can be more
picture
 CT ANGIOGRAPHY

Blood vessels are well shown in

cross sectional by CT, especially
when the procedure is performed
with intravenous contrast material
(contrast material is like
arteriography)
 DEVELOPMENT Of CT SCAN EQUIPMENT
TECHNOLOGY
1. First generation :
Single detector, single source of x-ray
2. Second generation :
Single slice detector
Single source of x-ray
Single spiral CT
3. Single source of x-ray
Multiple slice detector ( 4 detector )
4. Now : Single source of x-ray
16 – 64 detector
 Magnetic Resonance Angiography
Although MRI has not supplanted other
imaging modalities in the field of vascular
imaging yet, inevitably it seems set to do so
and advances have been so rapid in recent
years that there is a very real prospect of
considerable areas of diagnostic angiography
passing into the realm of MRI.
• One of the most exciting prospect offered by
MRA in its ability to represent vascular
structure in 3-D reconstruction
 Venography(Phlebography)
• Surflow/wingneedle (no 21) is inserted
percutaneusly into vein dorsum pedis
• Compression is applied by tourniquets just
above the ankle and also above the knee
• The pressure used is just sufficient to occlude
the superfisial Vein( greater/lesser saphena )
so contras through into deep
vein(tibia/poplitea,femoralis vein)
Venogram
shows DVT
 ECHOCARDIOGRAPHY

Echocardiography tool for diagnosis

-Structural/anatomic
- Functional abnormalities of heart
Indications
• Heart failure
• Pathologic of valve (mur mur)
• Congental heart disease
• Pericard efussion
• Arytmia
• Cardiomegaly