hystero and other

8/18/2019 Hystero and Other

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Hysterosalpingography

andOther Interventional Procedures


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The hysterosalpingogram (HSG) primarily

demonstrates the uterus and uterine (fallopian)tubes of the female reproductive system.

Anatomic considerations for hysterosalpingographyinclude the principal organs of the female

reproductive system, including the vagina,

uterus, uterine tubes, and ovaries.


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terine tu!es% The uterine (fallopian) tubes communicate ith the

uterine cavity from a superior lateral aspect !eteen the !ody and

the fundus. This region of the uterus is referred to as the cornu. The uterine tu!es are appro$imately & to &' centimeters in length

and & to millimeters in diameter. They are su!divided into four

segments. The pro$imal portion of the tu!e, the interstitial

segment, communicates ith the uterine cavity. The isthmus is the

constricted portion of the tu!e, here it idens into the central

segment termed the ampulla, hich arches over the !ilateral

ovaries. The most distal end, the infundibulum, contains fingerli*e

e$tensions termed fimbriae, one of hich is attached to each ovary.

The ovum passes through this ovarian fimbria into the uterine

tu!e, hereif it is fertili"edit then passes into the uterus for

implantation and development.

The distal infundi!ulum portion of the uterine tu!es containing

the fim!riae opens into the peritoneal cavity


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PurposeHysterosalpingography is the radiographic demonstration of the

female reproductive tract with a contrast medium. The

radiographic procedure !est demonstrates the uterine cavity and

the patency (degree of openness) of the uterine tubes. The uterinecavity is outlined !y in+ection of contrast medium throughout the

cervi$. 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 tu!es can !e demonstrated

as the contrast flos through the tu!es and spills into the peritonealcavity.


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1ontraindications

Hysterosalpingography is contraindicated ith pregnancy.

To avoid the possi!ility that the patient may !e pregnant,the e$amination typically is performed 2 to & days after the

onset of menstruation.

Other contraindications include acute pelvic inflammatory

disease and active uterine !leeding.


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Patient Preparation

3epartmental protocol should determine patient preparation re4uirements.

These procedures may include proper !oel preparations to ensureade4uate visuali"ation of the reproductive tract uno!structed !y !oel gas

and5or feces. Preparation may include a mild la$ative, suppositories, and5or

a cleansing enema !efore the procedure. In addition, the patient may !e

instructed to ta*e a mild pain reliever !efore the e$amination to alleviate

some of the discomfort associated ith cramping.

To prevent displacement of the uterus and uterine tu!es, the patient should!e instructed to empty her !ladder immediately !efore the e$amination.

The procedure and possi!le complications should !e e$plained to the patient

and informed consent o!tained. In some instances, the physician also may

perform a manual pelvic e$amination !efore the radiographic procedure is

!egun.


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6a+or 74uipmentThe ma+or e4uipment re4uired for an H/0 is a radiographic fluoroscope room.

8eer e4uipment may provide digital fluoroscopy capa!ilities. Ideally, the ta!le

should have the capa!ility to tilt the patient to a Trendelen!urg position if needed.

If availa!le, gynecologic stirrups should !e attached to the ta!le to assist the

patient in the lithotomy position.


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Accessory and Optional 74uipment9outinely, a sterile, disposa!le H/0 tray is used The general contents of

the tray include a vaginal speculum, basin, cotton balls, medicine

cup, sterile gau!e, sterile drapes, sponge"holding forceps, #$ mlsyringes, #% and #& gauge needles, extension tubing, and

lubricating 'elly. In addition to the H/0 tray, sterile gloves, an

antiseptic solution, a cannula or balloon catheter , and contrast

media are necessary.


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1ontrast 6edia

To categories of radiopa4ue (positive) iodinated contrast media have !een used

in H/0. :ater-soluble iodinated contrast media, such as Omnipa4ue , is

preferred. It is a!sor!ed easily !y the patient, does not leave a residue ithin the

reproductive tract, and provides ade4uate visuali"ation. This medium does,

hoever, cause pain hen in+ected ithin the uterine cavity, and the pain may

persist for several hours after the procedure.In the past, oil"based contrast media that alloed for ma$imal visuali"ation of

uterine structures as used. Hoever, it has a very slo a!sorption rate and

persists in the !ody cavities for an e$tended time. It also introduces the ris* that

an oil em!olus that could reach the lungs may form.

The amount of contrast medium to !e introduced into the reproductive tract is

varia!le, depending on radiologist preference. On average, appro$imately ; ml isnecessary to fill the uterine cavity, and an additional ; ml is needed to

demonstrate uterine tu!e patency.


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1annula51atheter Placement and

In+ection Process At the !eginning of the procedure, the patient lies supine on the ta!le in the

lithotomy position. If gynecologic stirrups are unavaila!le, the patient !ends her

*nees and places her feet at the end of the ta!le. The patient is draped ith sterile

toels, and ith sterile techni4ue, a vaginal speculum is inserted into the vagina.

The vaginal alls and cervi$ are cleansed ith an antiseptic solution. A cannula or!alloon catheter then is inserted into the cervical canal. 3ilation ith a !alloon

catheter helps to occlude the cervi$, preventing contrast medium from floing out of

the uterine cavity during the in+ection phase.

Once cervical placement of the cannula or catheter has !een o!tained, the

physician may remove the speculum and place the patient in a slight Trendelen!urg

position. This position facilitates the flo of contrast media into the uterine cavity. Asyringe filled ith contrast is attached to the cannula or !alloon catheter. sing

fluoroscopy, the physician sloly in+ects contrast medium into the uterine cavity. If

the uterine tu!es are patent (open), contrast media ill flo from the distal ends of

the tu!es into the peritoneal cavity.


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9A3IO09APHI1 9OTI87/9outine positioning for hysterosalpingography varies ith the method of

e$amination.


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9A3IO09APH>

An overhead AP scout image may !e o!tained on a ' ? -

centimeter (& ? &'-inch) I9. The central ray and I9 are centered to

a point ' inches (; cm) superior to the symphysis pu!is. Iffluoroscopy is unavaila!le, fractional in+ection of contrast medium is

implemented, ith a radiograph performed after each fraction to

document filling of the uterine cavity, the uterine tu!es, and contrast

medium ithin the peritoneum. Additional images as determined !y

the radiologist may include =PO or 9PO positions.


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9A3IO09APHI1 19IT79IA

@ The pelvic ring as seen on an AP pro+ection should !e centered

ithin the collimation field.

@ The cannula or !alloon catheter should !e demonstrated ithin the

cervi$.@ An opacified uterine cavity and uterine tu!es are demonstrated

centered to the I9.

@ 1ontrast medium is seen ithin the peritoneum if one or !oth uterine

tu!es are patent.

@ Appropriate density and short-scale contrast demonstrate anatomy

and contrast medium.@ The patient I3 mar*er should !e clear, and the 9 or = mar*er should

!e visuali"ed ithout superimposition of anatomy


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Other Interventional Procedures


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Interventional imaging procedures are radiologic procedures that intervene in

a disease process, providing a therapeutic outcome. /imply stated,

interventional procedures use angiographic techni4ues for the treatment of

disease, in addition to providing certain diagnostic information.This is a rapidly groing specialty in medical imaging as interventional procedures

have !ecome an increasingly important tool in the management of an ever-

groing list of pathologies.

The purpose of these procedures and !enefits to the patient and health care

system include the folloing%@Techni4ues that are minimally invasive ith loer ris* compared ith traditional

surgical procedures

@Procedures that are less e$pensive than traditional medical and surgical

procedures

@/horter hospital stays for the patient

@/horter recovery time !ecause of a safer, less invasive procedure@Alternatives for patients ho are not candidates for surgery


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These procedures typically are performed in an angiographic

suite under the direction of an interventional radiologist.


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terine fibroid emboli!ationThis procedure is used to treat symptomatic fi!roids.

7m!oli"ation of the uterine artery can shrin* the fi!roids and

eliminate associated pain and !leeding, thus replacing a

hysterectomy.

terine artery emboli!ationThe uterine artery also may !e em!oli"ed to stop life-

threatening postpartum !leeding, potentially preventing

hysterectomy.

hemoemboli!ation

This is used most commonly for hepatic malignancies. The

chemotherapy agent is in+ected into the tumor vasculature. The

survival rate from this procedure is compara!le ith that

folloing treatment !y a more invasive surgical resection.

Investigation is under ay regarding the use of this techni4ue

for other locally advanced cancers (e.g., lung, !reast, !rain).


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Angioplasty

*ercutaneous transluminal angioplasty (*+) uses an angiographic

approach and speciali"ed catheters to dilate a stenosed vessel. This

procedure is a long-standing interventional techni4ue that has applications

for a ide variety of vessel types and si"es (e.g., coronary, iliac, renal

arteries).

A catheter ith a deflated !alloon is advanced to the vessel of interest.Hemodynamic pressures pro$imal and distal to the stenosis are o!tained,

and a preangioplasty angiogram is performed. The !alloon portion of the

catheter is placed at the vessel stenosis, and the !alloon is inflated. The

pressure of the inflation is monitored !y a pressure gauge to prevent

vessel rupture, and more than one inflation may !e re4uired. The duration

of the inflations is carefully timed to eliminate damage to distal tissue!ecause the !lood supply is temporarily occluded.


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/tent placement

To assist in maintaining patency of the vessel, a stent is inserted

across the treated area during the angioplasty. A stent is a

cageli-e metal device that is placed in the lumen of a vessel

to provide support. It can !e a self-e$panding type or a !alloon-

e$panda!le type. The self-e$panding type automatically e$pands

hen the stent cover is removed from the vessel, and the !alloon-e$panda!le type (the compressed stent covers the !alloon on the

catheter) is positioned during the !alloon inflation phase of the

angioplasty. 1urrently, many stents are impregnated ith a

pharmacologic agent that inhibits the regrowth of vascular

tissue ithin the artery and interferes ith the process of

restenosis.


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An inferior vena cava filter is indicated for patients ho have recurrent

pulmonary em!oli or ho are at high ris* for developing them (e.g., post

trauma ith pelvic and loer e$tremity fractures). A filter is placed in theinferior vena cava to trap potentially fatal em!oli that originate in the loer

lim!s. A variety of filter designs are availa!le for this procedure and

A femoral or +ugular vein puncture is used to gain access to the inferior vena

cava. An angiographic techni4ue then is used to deploy the filter !y a

catheter. The filter has struts that anchor it to the alls of the vessel. The filter

must !e placed inferior to the renal veins to prevent renal vein throm!osis.9is*s and complications

Besides the usual angiographic complications (e.g., infection, !leeding), the

added ris* that the filter may migrate into the heart and lungs e$ists. The filter

also may !ecome occluded in the long term.


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8O8A/1=A9 I8T7978TIO8A= P9O17397/

erte!roplasty

Percutaneous verte!roplasty is used to treat patients ho have verte!ral pain

and insta!ility caused !y osteoporosis, spinal metastases, compression

fractures, or verte!ral angiomas. Percutaneous in+ection of acrylic cement into

the verte!ral !ody under fluoroscopic guidance contri!utes to sta!ili"ation of

the spine and long-term pain relief.This procedure is performed in the O9 or in the interventional suite. The

surgeon ill place a small hollo needle through the patient#s !ac* until it

reaches the affected area of the verte!rae. Once the needle is in place and

this has !een verified !y 1-arm fluoroscopy (PA and lateral vies), the surgeon

in+ects an orthopedic cement mi$ture that also may include contrast (for !etter

visi!ility on the monitor). The surgeon usually ill as* for continuous fluorohile the cement mi$ture is !eing in+ected. At this point, the surgeon chec*s to

ensure that the cement has filled the entire affected verte!ral area and

ithdras the needle. The orthopedic cement hardens 4uic*ly and sta!ili"es

the fractured verte!rae, hich results in pain relief.


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Cyphoplasty

The verte!roplasty techni4ue has !een modified recently, resulting in a

procedure *non as kyphoplasty . Through small incisions, a *yphoplasty

!alloon is inserted into a collapsed verte!ral !ody. The !alloon is inflated

for the purpose of restoring the collapsed portion of the verte!rae Acrylic

cement then is in+ected to sta!ili"e the verte!rae.

9is*s and complications

1omplications of verte!roplasty include lea*age of the cement into

ad+acent structures, hich may re4uire emergency surgery. A less

common complication is pulmonary em!olus, hich causes migration of

the cement into periverte!ral veins.

1omplications associated ith *yphoplasty are less than ith

verte!roplasty !ecause less cement is re4uired and it is in+ected in amore controlled fashion.


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