Arteriograms and Lower Limb Venograms

Numbers next to items refer to plates in Netter’s Atlas of Atlas of Human Anatomy

Numbers in parenthesis are from the 3rd edition. Numbers not in parenthesis are frrom the 4th edition.

1. Abdominal Aorta2. 4th lt lumbar artery (256) 2643. Stent in the rt common iliac artery4. Lt common iliac artery5. Lt internal iliac artery (383) 4026. Posterior division of the lt iliac artery (382) 4037. Lt external iliac artery8 Anterior division of the lt iliac artery

Iliacs #1

Inflated balloon in the right common iliac artery, deploying a stent.

This is the raw image seen in the previous slide (#1) before it wassubtracted. This process, known asdigital subtraction angiography(DSA) attempts to remove all densities except those in the rangeof the iodine contrast in the arteries.Notice the bones of the pelvis and spine seen on this image are notseen on image 1. Bowel gas is seen due to motion. The success of this process is dependant on there beingno motion between an image takenbefore contrast injection, (the maskimage) and the contrast film. Severalseconds may pass between them, andareas of motion create subtractionartifacts.

Radiographs vs. DSA

#2 #2a

These images are identical. Image 2 is the original, 2a is subtracted and the densities havebeen reversed.

1. Rt renal artery 1. Rt. common iliac artery 2. Pigtail catheter in the abdominal aorta 2. Perirenal branch of rt renal artery3. 1st through 4th lumbar arteries 3. Rt low accessory renal artery (324) 333

Abdominal arteriogram

#3

1. Superior messenteric artery (328) 341 2. Middle suprarenal arteries 332 * 3. Abdominal aorta

* Compare the origin of this vessel, from the abdominal aorta, to the variation labeled “B” on plate (324) 333

This injection of the abdominal aorta is unusual. Typically the aorta fills instantly, and the renalsand SMA fill momentarily, orsometimes not well at all (noticethe lack of filling of the SMA onimage 2). In this case the positionof the catheter and the sideholes were such that everything but asmall portion of the aorta were filled at the moment the image was made.

Bilateral renal arteriogram

1. Catheter* 2. Rt renal artery**3. Segmental arteries (323) 3354. Interlobar arteries5. Rt ureter

1. Tip of the angioplasty catheter2. Opaque markers*** 3. Capsular branches of the renal artery (323) 335

* The tip is in a proximal subdivision of the renal artery, which is a variation of the typical appearance ** Just beyond the arrow is a stenosed segment of the vessel. This is the major area of atherosclerotic disease that is being treated in image 3a. *** Between the markers is where the angioplasty balloon will deploy

Selected renal arteriogram and angioplasty

#3

#3a

1. Common hepatic artery2. Gastroduodenal artery3. Hepatic artery proper 4. Rt hepatic artery5. Lt hepatic artery

On this injection the cathetertip was advanced to the common hepatic artery. OnNetter’s plate (293) 303, the catheter tip is in the celiactrunk. Notice the fillingof the splenic and Lt gastricartery as well. Due to itssmall size and position at the proximal part of the trunkthe Lt gastric does not alwaysfill on a celiac injection.

Selective HepaticPlates (290-293) 300-302

1. Catheter*2. Middle colic artery**3. Rt colic artery 4. Ileocolic artery5. Jejunal & ileal (intestinal) arteries6. Anastomotic loops (arcades)

* In the abdominal aorta. The tip is in the proximal SMA.

** Due to the numerous normal variants of the SMA (note a few of the more common presentations on plate 298) 308 the exact identification of items 2-4 are difficult. These will not be included on the test.

#5

Selected SMA

Plates (296-297) 306-307

1. Descending aorta* 2. Rt. common carotic artery**3. Rt subclavian artery4. Rt vertebral artery 5. Lt common carotid artery6. Lt vertebral artery7. Lt subclavian artery8. Lt thyrocervical artery

* Note the end of the pigtail catheter in the ascending aorta, just beyond the aortic valve.** This arch is anomalous. There is no brachiocephalic trunk. The Rt CCA and subclavian originate from the arch.

To lay the arch out in profile the patientis in an RPO position. (Supine, rolled tothe right side at approximately 30 degrees.)

#6 Arch of the AortaPlate (131) 138

1. Rt subclavian artery * The subclavian becomes the axillary 2. Rt axillary artery* on passing under the clavicle. #2 is3. Rt internal thoracic (mammary) artery** close to the boundary of the 1st &4. Rt thyrocervical trunk*** 2nd segment of the axillary artery5. Rt dorsal scapular artery ** Sometimes used in coronary bypass *** The trunk is lower than the arrow indicates (prior to the bifurcation)

#7

Subclavian arteriogram

Plate (420) 427

Head of thehumerus

Glenoid process

Clavicle

Lung

1. Lt axillary artery2. Lt brachial artery3. Anterior & Posterior circumflex arteries 4. Lt circumflex subscapular artery5. Lt thoracoacromial artery 6. Lt subscapular artery7. Head of the lt humerus

#8Axillary arteriogram

Projection is anterior to posterior with the arm raised

Plate (417) 434

1. Rt internal carotid artery 2. Rt external carotid artery3. Rt common carotid artery4. Tip of catheter5. Swallowing artifact*

Digital subtraction angiography(DSA) requires the patient tobe still or motion artifacts appear.A swallowing artifact is commonto a carotid study.

#9

#9

Carotid injection

Plate (130) 136

1. Rt internal carotid artery2. Rt external carotid artery3. Rt middle cerebral artery4. Rt anterior cerebral artery5. Anterior communicating artery6. Rt anterior cerebral artery

#10

#10

Cerebral arteriogramPlates (132-134) 139-141

1. Rt superior sagittal sinus2. Rt cerebral veins3. Rt transverse sinus4. Confluence of sinuses*5. Rt sigmoid sinus6. Rt internal jugular vein

* The confluence of sinuses appears to be shifted to the right. This is due to the patient’s head being slightly rotated to the left.

#11

#11

Cerebral arteriogram, venous phase

Plates (96- 98) 103-104

1. Rt middle cerebral artery2. Lt anterior cerebral artery3. Anterior cerebral artery4. Rt posterior cerebral artery5. Basilar artery6. Internal carotid artery

There is a trace of the right posterior communicating artery, but the left is not seen.

#12

MRA:axial Magnetic Resonance Angiography Plate (133) 140

#12

This magnetic resonance angiography (MRA) image is a3D reconstruction of the circle of willis, view in the axialplane. The two triangular shapes on the top are the superiorsurface of the orbital part of the frontal bone (roof of orbit).

1. Rt internal carotid artery 2. Rt internal carotid artery in the carotid canal (130) 3. Rt middle cerebral artery4. Rt anterior cerebral artery5. Anterior communicating artery

#13

MRA: Coronal

Orientation marker indicates right, superior, and anterior

This 3D reconstruction is the resultof extracting the vasculature in thevolume of the MR scan, and displayinga selected portion in the coronal plane.

#13

1. Radial artery2. Ulnar artery3. Common palmar digital arteries4. Proper palmar digital arteries5. Superficial palmar arch

Hand arteriorgram

#14Plate (449) 466

1. Joint space of Rt knee 2. Lt popliteal artery3a. Lt tibioperoneal trunk*3b. Lt posterior tibial artery4. Lt anterior tibial artery5. Lt peroneal (fibular) artery6. Adipose tissue**

* Netter labels 3a and 3b only as the posterior tibial artery. Identifying 3a as the tibioperoneal trunk helps differentiate that section of the vessel. This area (3-5) is also known as a trifurcation.** When doing a bilateral study of the femoral arteries the legs must be close together, causing an overlap of soft tissue.

#15

Femoral arteriogram

Plate (494) 512

a.

b.

1. Inferior vena cava 2. Rt common iliac vein3. Lt common iliac vein4. Rt external iliac vein5. Rt internal iliac vein6. Posterior branch of Rt internal iliac vein

#16

Rt leg venogram Plates (257, 283) 265, 403

Iliac crest

Lumbarspine

1. Rt ilium of the pelvis2. Rt common iliac vein3. Rt femoral vein4. Rt great saphenous vein5. Pubic symphysis6. Rt external iliac vein7. Rt internal iliac vein

#17

Rt leg venogramPlates (257, 283) 265, 403

Femoralhead

1. Rt femoral vein 2. Rt deep (femoral) vein (487) 5053. Rt femoral vein*4. Rt obturator foramen

* The inverted V shape is a valve. Another is seen in the deep vein.

The previous image showed the veins as black. Thisis the typical fluoroscopic presentation. The gray scale can be reversed electronically, but in this casewas filmed in the fluoroscopic mode. When contrast filled vessels are white, that is the radiographic presentation.

#18

Rt leg venogram

Femoralhead

1. Rt femoral vein2. Rt popliteal vein

The proliferation of veins below the head of the fibula are superficial. They disappear so dramaticallydue to a tourniquet at that level. Prior to vascular ultrasound venograms were the “gold standard” forvisualizing deep vein thrombosis (DVT). The injectionwas made through a superficial vein in the dorsum of the foot, and tourniquets at the ankle, below the knee, and on the distal thigh helped drive the iodine contrast into the deep system.

Finding a vein in edematous tissue was a challenge, and filling the deep venous system was a tricky and exacting process, and most uncomfortable for the patient. There are undoubtedly few, if any, radiologic technologists who are not thankful that vascular ultrasound has supplanted there need to perform thisexam.

#19

Rt leg venogram

Plates (498, 526-528) 502, 516-517

1. Rt. Popliteal vein 2. Rt short saphenous vein (498)3. Rt great saphenous vein

#20Rt leg venogram

Plates (498, 526–528) 502, 516-517