Hysterosalpingography

and
Other Interventional Procedures

The hysterosalpingogram (HSG) primarily

demonstrates the uterus and uterine (fallopian)
tubes of the female reproductive system.
Anatomic considerations for hysterosalpingography
include the principal organs of the female
reproductive system, including the vagina,
uterus, uterine tubes, and ovaries.

The uterus is the central organ of the female pelvis. It is a pear-shaped,

hollow, muscular organ that is bordered posteriorly by the rectosigmoid
colon and anteriorly by the urinary bladder The size and shape of the uterus
vary, depending on the patient's age and reproductive history. The uterus is
positioned most commonly in the midline of the pelvis in an anteflexed
position supported chiefly by the various ligaments. The position may vary
with bladder or rectosigmoid distention, age, and posture.
The uterus is subdivided into four divisions: (1) the fundus, (2) the corpus (body),
(3) the isthmus, and (4) the cervix (neck) The fundus is the rounded, superior
portion of the uterus. The corpus (body) is the larger central component of the
uterine tissue. The narrow, constricted segment, often described as the lower
uterine segment that joins the cervix at the internal os, is the isthmus. The cervix
is the distal cylindrical portion that projects into the vagina, ending as the external
os.
The uterus is composed of inner, middle, and outer layers. The inner lining is the
endometrium, which lines the uterine cavity and undergoes cyclic changes in
correspondence to the woman's menstrual cycle. The middle layer, the
myometrium, consists of smooth muscle and constitutes the majority of the uterine
tissue. The outer surface of the uterus, the serosa, is lined with peritoneum and
forms a capsule around the uterus.

Uterine tubes: The uterine (fallopian) tubes communicate with the

uterine cavity from a superior lateral aspect between the body and
the fundus. This region of the uterus is referred to as the cornu.
The uterine tubes are approximately 10 to 12 centimeters in length
and 1 to 4 millimeters in diameter. They are subdivided into four
segments. The proximal portion of the tube, the interstitial
segment, communicates with the uterine cavity. The isthmus is the
constricted portion of the tube, where it widens into the central
segment termed the ampulla, which arches over the bilateral
ovaries. The most distal end, the infundibulum, contains fingerlike
extensions termed fimbriae, one of which is attached to each ovary.
The ovum passes through this ovarian fimbria into the uterine
tube, whereif it is fertilizedit then passes into the uterus for
implantation and development.
The distal infundibulum portion of the uterine tubes containing
the fimbriae opens into the peritoneal cavity

Purpose
Hysterosalpingography is the radiographic demonstration of the
female reproductive tract with a contrast medium. The
radiographic procedure best demonstrates the uterine cavity and
the patency (degree of openness) of the uterine tubes. The uterine
cavity is outlined by injection of contrast medium throughout the
cervix. The shape and contour of the uterine cavity are assessed to
detect any uterine pathologic process. As the contrast agent fills the
uterine cavity, the patency of the uterine tubes can be demonstrated
as the contrast flows through the tubes and spills into the peritoneal
cavity.

Pathologic Indications
Infertility assessment: One of the most common indications for HSG
is seen in the assessment of female infertility. The procedure is
performed to diagnose any functional or structural defects. A
blockage of one or both uterine tubes may inhibit fertilization. In some
cases, HSG can be a therapeutic tool. Injection of contrast media
may dilate or straighten a narrowed, tortuous, or occluded uterine tube

Contraindications
Hysterosalpingography is contraindicated with pregnancy.
To avoid the possibility that the patient may be pregnant,
the examination typically is performed 7 to 10 days after the
onset of menstruation.
Other contraindications include acute pelvic inflammatory
disease and active uterine bleeding.

Patient Preparation
Departmental protocol should determine patient preparation requirements.
These procedures may include proper bowel preparations to ensure
adequate visualization of the reproductive tract unobstructed by bowel gas
and/or feces. Preparation may include a mild laxative, suppositories, and/or
a cleansing enema before the procedure. In addition, the patient may be
instructed to take a mild pain reliever before the examination to alleviate
some of the discomfort associated with cramping.
To prevent displacement of the uterus and uterine tubes, the patient should
be instructed to empty her bladder immediately before the examination.
The procedure and possible complications should be explained to the patient
and informed consent obtained. In some instances, the physician also may
perform a manual pelvic examination before the radiographic procedure is
begun.

Major Equipment
The major equipment required for an HSG is a radiographic fluoroscope room.
Newer equipment may provide digital fluoroscopy capabilities. Ideally, the table
should have the capability to tilt the patient to a Trendelenburg position if needed.
If available, gynecologic stirrups should be attached to the table to assist the
patient in the lithotomy position.

Accessory and Optional Equipment

Routinely, a sterile, disposable HSG tray is used The general contents of
the tray include a vaginal speculum, basin, cotton balls, medicine
cup, sterile gauze, sterile drapes, sponge-holding forceps, 10 ml
syringes, 16 and 18 gauge needles, extension tubing, and
lubricating jelly. In addition to the HSG tray, sterile gloves, an
antiseptic solution, a cannula or balloon catheter, and contrast
media are necessary.

Contrast Media
Two categories of radiopaque (positive) iodinated contrast media have been used
in HSG. Water-soluble iodinated contrast media, such as Omnipaque 300, is
preferred. It is absorbed easily by the patient, does not leave a residue within the
reproductive tract, and provides adequate visualization. This medium does,
however, cause pain when injected within the uterine cavity, and the pain may
persist for several hours after the procedure.
In the past, oil-based contrast media that allowed for maximal visualization of
uterine structures was used. However, it has a very slow absorption rate and
persists in the body cavities for an extended time. It also introduces the risk that
an oil embolus that could reach the lungs may form.
The amount of contrast medium to be introduced into the reproductive tract is
variable, depending on radiologist preference. On average, approximately 5 ml is
necessary to fill the uterine cavity, and an additional 5 ml is needed to
demonstrate uterine tube patency. Fractional injections may be performed during
the study.

Cannula/Catheter Placement and

Injection Process
At the beginning of the procedure, the patient lies supine on the table in the
lithotomy position. If gynecologic stirrups are unavailable, the patient bends her
knees and places her feet at the end of the table. The patient is draped with sterile
towels, and with sterile technique, a vaginal speculum is inserted into the vagina.
The vaginal walls and cervix are cleansed with an antiseptic solution. A cannula or
balloon catheter then is inserted into the cervical canal. Dilation with a balloon
catheter helps to occlude the cervix, preventing contrast medium from flowing out of
the uterine cavity during the injection phase.
Once cervical placement of the cannula or catheter has been obtained, the
physician may remove the speculum and place the patient in a slight Trendelenburg
position. This position facilitates the flow of contrast media into the uterine cavity. A
syringe filled with contrast is attached to the cannula or balloon catheter. Using
fluoroscopy, the physician slowly injects contrast medium into the uterine cavity. If
the uterine tubes are patent (open), contrast media will flow from the distal ends of
the tubes into the peritoneal cavity.

RADIOGRAPHIC ROUTINES
Routine positioning for hysterosalpingography varies with the method of
examination. Fluoroscopy, conventional radiography, or a combination of
both may be used.

FLUOROSCOPY/SPOT FILMING OR
DIGITAL FLUOROSCOPY/IMAGING
Imaging of the reproductive tract is most commonly acquired with the use of
spot-film fluoroscopy or, more recently, digital fluoroscopy. Typically, a
collimated scout image is obtained with fluoroscopy. During injection of the
contrast medium, a series of collimated images may be taken while the
uterine cavity and uterine tubes are filling After injection of the contrast
medium, an additional image may be taken to document spillage of the
contrast into the peritoneum The patient most commonly remains in the
supine position during imaging, but additional images may be taken with the
patient in an LPO or RPO position to adequately visualize pertinent anatomy

RADIOGRAPHY
An overhead AP scout image may be obtained on a 24 30centimeter (10 12-inch) IR. The central ray and IR are centered to
a point 2 inches (5 cm) superior to the symphysis pubis. If
fluoroscopy is unavailable, fractional injection of contrast medium is
implemented, with a radiograph performed after each fraction to
document filling of the uterine cavity, the uterine tubes, and contrast
medium within the peritoneum. Additional images as determined by
the radiologist may include LPO or RPO positions.

RADIOGRAPHIC CRITERIA
The pelvic ring as seen on an AP projection should be centered
within the collimation field.
The cannula or balloon catheter should be demonstrated within the
cervix.
An opacified uterine cavity and uterine tubes are demonstrated
centered to the IR.
Contrast medium is seen within the peritoneum if one or both uterine
tubes are patent.
Appropriate density and short-scale contrast demonstrate anatomy
and contrast medium.
The patient ID marker should be clear, and the R or L marker should
be visualized without superimposition of anatomy

Scout

Other Interventional Procedures

Interventional imaging procedures are radiologic procedures that intervene in

a disease process, providing a therapeutic outcome. Simply stated,
interventional procedures use angiographic techniques for the treatment of
disease, in addition to providing certain diagnostic information.
This is a rapidly growing specialty in medical imaging as interventional procedures
have become an increasingly important tool in the management of an evergrowing list of pathologies.
The purpose of these procedures and benefits to the patient and health care
system include the following:
Techniques that are minimally invasive with lower risk compared with traditional
surgical procedures
Procedures that are less expensive than traditional medical and surgical
procedures
Shorter hospital stays for the patient
Shorter recovery time because of a safer, less invasive procedure
Alternatives for patients who are not candidates for surgery

These procedures typically are performed in an angiographic

suite under the direction of an interventional radiologist.
Fluoroscopic guidance is crucial to follow the path of the
required needles and catheters.
The increase in complexity of the type of interventional
procedures currently performed has resulted in the upgrading of
many angiography units to meet operating room specifications.
This reduces the risk for infection and allows rapid surgical
management in case of complications.
Interventional procedures may be categorized as vascular or
nonvascular procedures

VASCULAR INTERVENTIONAL PROCEDURES

Embolization
Transcatheter embolization is a procedure that uses an angiographic
approach to create an embolus in a vessel, thus restricting blood
flow. A number of clinical indications for this procedure exist, including
the following:
Stop blood blow to a site of pathology.
Reduce blood flow to a highly vascular structure and tumor before
surgery.
Stop active bleeding at a specific site.
Deliver a chemotherapeutic agent

Uterine fibroid embolization

This procedure is used to treat symptomatic fibroids.
Embolization of the uterine artery can shrink the fibroids and
eliminate associated pain and bleeding, thus replacing a
hysterectomy.

Uterine artery embolization

The uterine artery also may be embolized to stop lifethreatening postpartum bleeding, potentially preventing
hysterectomy.
Chemoembolization
This is used most commonly for hepatic malignancies. The
chemotherapy agent is injected into the tumor vasculature. The
survival rate from this procedure is comparable with that
following treatment by a more invasive surgical resection.
Investigation is under way regarding the use of this technique
for other locally advanced cancers (e.g., lung, breast, brain).

Angioplasty
Percutaneous transluminal angioplasty (PTA) uses an angiographic
approach and specialized catheters to dilate a stenosed vessel. This
procedure is a long-standing interventional technique that has applications
for a wide variety of vessel types and sizes (e.g., coronary, iliac, renal
arteries).
A catheter with a deflated balloon is advanced to the vessel of interest.
Hemodynamic pressures proximal and distal to the stenosis are obtained,
and a preangioplasty angiogram is performed. The balloon portion of the
catheter is placed at the vessel stenosis, and the balloon is inflated. The
pressure of the inflation is monitored by a pressure gauge to prevent
vessel rupture, and more than one inflation may be required. The duration
of the inflations is carefully timed to eliminate damage to distal tissue
because the blood supply is temporarily occluded.
Final steps of the procedure include obtaining arterial pressures proximal
and distal to the dilated portion of the vessel and performing a postangioplasty angiogram. This allows assessment of the effectiveness of the
procedure.

Stent placement
To assist in maintaining patency of the vessel, a stent is inserted
across the treated area during the angioplasty. A stent is a
cagelike metal device that is placed in the lumen of a vessel
to provide support. It can be a self-expanding type or a balloonexpandable type. The self-expanding type automatically expands
when the stent cover is removed from the vessel, and the balloonexpandable type (the compressed stent covers the balloon on the
catheter) is positioned during the balloon inflation phase of the
angioplasty. Currently, many stents are impregnated with a
pharmacologic agent that inhibits the regrowth of vascular
tissue within the artery and interferes with the process of
restenosis.

An inferior vena cava filter is indicated for patients who have recurrent
pulmonary emboli or who are at high risk for developing them (e.g., post
trauma with pelvic and lower extremity fractures). A filter is placed in the
inferior vena cava to trap potentially fatal emboli that originate in the lower
limbs. A variety of filter designs are available for this procedure and
A femoral or jugular vein puncture is used to gain access to the inferior vena
cava. An angiographic technique then is used to deploy the filter by a
catheter. The filter has struts that anchor it to the walls of the vessel. The filter
must be placed inferior to the renal veins to prevent renal vein thrombosis.
Risks and complications
Besides the usual angiographic complications (e.g., infection, bleeding), the
added risk that the filter may migrate into the heart and lungs exists. The filter
also may become occluded in the long term.

NONVASCULAR INTERVENTIONAL PROCEDURES

Vertebroplasty
Percutaneous vertebroplasty is used to treat patients who have vertebral pain
and instability caused by osteoporosis, spinal metastases, compression
fractures, or vertebral angiomas. Percutaneous injection of acrylic cement into
the vertebral body under fluoroscopic guidance contributes to stabilization of
the spine and long-term pain relief.
This procedure is performed in the OR or in the interventional suite. The
surgeon will place a small hollow needle through the patient's back until it
reaches the affected area of the vertebrae. Once the needle is in place and
this has been verified by C-arm fluoroscopy (PA and lateral views), the surgeon
injects an orthopedic cement mixture that also may include contrast (for better
visibility on the monitor). The surgeon usually will ask for continuous fluoro
while the cement mixture is being injected. At this point, the surgeon checks to
ensure that the cement has filled the entire affected vertebral area and
withdraws the needle. The orthopedic cement hardens quickly and stabilizes
the fractured vertebrae, which results in pain relief.

Kyphoplasty
The vertebroplasty technique has been modified recently, resulting in a
procedure known as kyphoplasty. Through small incisions, a kyphoplasty
balloon is inserted into a collapsed vertebral body. The balloon is inflated
for the purpose of restoring the collapsed portion of the vertebrae Acrylic
cement then is injected to stabilize the vertebrae.
Risks and complications
Complications of vertebroplasty include leakage of the cement into
adjacent structures, which may require emergency surgery. A less
common complication is pulmonary embolus, which causes migration of
the cement into perivertebral veins.
Complications associated with kyphoplasty are less than with
vertebroplasty because less cement is required and it is injected in a
more controlled fashion.