A simplified technique of phlebography for the localisation of incompetent perforating veins of the legs

Clin. Radiol. (1972) 23, 486-491

A SIMPLIFIED LOCALISATION

TECHNIQUE OF PHLEBOGRAPHY FOR THE OF INCOMPETENT PERFORATING VEINS OF THE LEGS

M. LEA THOMAS, V. McALLISTER, D. H. ROSE and K. TONGE •From the Department o f Radiology, St. Thomas' Hospital, London, S.E.1.

Fifty legs in 43 patients were examined by a simplified phlebographic technique to demonstrate incompetent perforating veins. All the patients subsequently underwent surgery and the findings are compared. The technique is simple in that it involves a percutaneous venous puncture and the use of an ordinary fluoroscopy table. Only 15 minutes is needed to examine each leg. Assuming the surgical findings to be 100 per cent accurate, incompetent perforating veins were precisely localised by phlebography in 81 per cent. leg, in the medical aspect of the upper half of the INTRODUCTION MORE than 10 per cent of the population of Europe leg, and in the middle third of the inner thigh. and North America over the age of 20 yrs. suffer (Sherman, 1949; Dodd and Cockett, 1956). The clinical diagnosis of incompetent perforating from varicose veins. (Borschberg, 1967). The veins is a very poor guide and at its best only aetiology of varicose veins is in doubt but the main underlying defect is incompetence of venous valves, detects about 60 per cent of such veins. (Massell either in the long or short saphenous systems or in and Ettinger, 1948; Rosenberg and Marchese, the communicating veins. Such incompetent per- 1963; Townsend et al., 1967, B.M.J. Leading forating, or communicating veins were found in article, 1970). It is claimed that thermography 90 per cent of patients with varicose veins in a (Patel et al., 1970) gives correct localisation in 94.5 per cent but this examination requires series reported by Sherman (1949). The deep veins of the calf are composed of specialised equipment. Phlebography is a reliable method of diagnosing muscular tributaries in the soleal muscles and 3 paired stem veins. These are connected by per- incompetent perforating veins with a claimed forating veins which penetrate the deep fascia of the accuracy rate of up to 90 per cent. (Mathieson, leg to join the superficial veins which lie outside this 1959; Townsend et al., 1967). The examination also fascia. Valves are numerous in the lower leg and demonstrates the patency of the deep veins and the direct the blood from the superficial to the deep, presence of valves, factors which may influence and from the distal to the proximal veins. This treatment. However, it has been suggested that the mechanism of blood flow in the superficial veins is technique is costly, time-consuming, uncomfortable totally disrupted if the valves in the veins which for the patient and that the sites of perforating connect the superficial and deep venous systems veins shown on radiographs are difficult to relate to become incompetent because of destruction of the the patient's leg. (Patel et al., 1970; B.M.J. Leading valve mechanism. This results in the high pressure article, 1970). This paper describes a simple, rapidly performed in the posterior tibial and peroneal veins being transmitted to the superficial tissues resulting in and accurate method for the localisation of incompetent perforating veins. A single leg can be varicose veins and venous ulceration. Thus the logical method of treating varicose examined in about 15 minutes with minimum veins is to occlude the incompetent perforating discomfort to the patient. veins between the superficial and deep systems and MATERIALS AND METHODS so restore the pressure and flow in the superficial Fifty legs in 43 patients were examined by preveins to normal. Therefore successful treatment depends on accurate localisation of the incompetent operative phlebography. Surgical exploration was carried out using Cockett's incision (Cockett and perforating veins. There are about 50 communicating veins in the Jones, 1953). The extra-fascial space was explored entire leg (Mathieson, 1953). The majority lie in the by blunt dissection and each perforating vein medial and lateral aspects of the lower half of the tested for incompetence by the "bleed-back sign" 486

A SIMPLIFIED

TECHNIQUE

487

OF P H L E B O G R A P H Y

TAnL~ COMPARISON OF PHLEBOGRAPHIC AND SURGICAL FINDINGS.

No. of veins considered incompetent at phlebography (P)

No. of incompetent perforators found at surgery (S)

+ ve P + ve S

- ve S + ve P

+ ve S - ve P

108 (100%)

--

97 (90.4%)

11 (9.6%)

--

119 (100K)

97 (81.5%)

--

22 (18.5%)

--

FIG. 2 FIG. 1. InJection technique. Note position of adjustable tourniquet and needle. FIG. 2. There is an incompetent perforating vein (arrowed) filling a superficial vein. A second proximal tourniquet prevents further filling of superficial veins. FIG. 1

(Turner-Warwick, 1931). As none o f the patients had lateral ankle ulceration, the lateral aspects o f the calves were not explored surgically and in no patient was it considered necessary to tie an incompetent perforating vein in the thigh. Thus the correlation between phlebography and the operative finding in this series is confined to those incompetent communicating veins demonstrated on the medial aspect of the calf. The phlebograms and the operative findings were studied independently and assessed by marking both on a standard chart o f the leg. Practical positive correlation was considered to be present when the corresponding marks on the chart were less than 2 cm. apart. False positives and negatives were also noted. PHLEBOGRAPHIC TECHNIQUE The patient lies supine on an ordinary tilting screening table equipped with television and automatic exposure control. A self fastening adjustable

rubber tourniquet* is applied as low as possible around the ankle or in the presence o f extensive ulceration around the mid foot. The skin is prepared with iodine solution. A 20 gauge needle bent about 20 ° on its hub is connected with a luer locking polyethylene tube and a 10 ml syringe containing normal saline. The needle is inserted percutaneously into a vein towards the lateral aspect o f the foot pointing towards the toes (Fig. 1). I n an oedematous foot a vein at the base o f the great toe m a y need to be used. Obviously varicose veins are avoided as these tend to burst with the pressure of injection. The bent needle allows it to lie flat on the dorsum o f the foot. After positioning the needle and testing for flow, the saline syringe is replaced by 50 ml syringe containing the contrast medium Meglumine Iothalamate 60 per cent. The screening is table *Setoniquet, Seton Products Ltd., Oldham, Lanos.

488

CLINICAL

tilted 15 ° - 20 ° foot downwards and the foot rotated inwards to separate the images of the tibia and fibula. A hand injection is started slowly under screen control and the tightness of the tourniquet and the tilt of the table adjusted to ensure that the superficial venous system is occluded and that only deep venous filling occurs. By rotation of the leg under the screen, superficial and deep veins can be distinguished, as the former have a much greater rotational arc. When superficial veins are inadvertently filled these are cleared with normal saline. The sites of incompetent perforating veins are indicated by the passage of contrast from the deep to the superficial veins. The sites of these incompetent perforating veins are noted and recorded on a 35.5 cm × 35.5 cm film split into 3, using the undercouch tube. Routinely postero-anterior and slightly oblique projections only are taken. After one incompetent perforating vein has been demonstrated another tourniquet is placed above this to prevent any proximal superficial venous filling which would obscure the field (Fig. 2). More contrast is then injected. The patient is asked to perform a Valsalva manoeuvre when the deep venous system of the thigh is filled with contrast (Fig. 3). The whole venous system from ankles to the groin is screened and radiographed. At completion of the examination the venous system is flushed with normal saline to clear the contrast from the veins to prevent phlebitis. The films are immediately processed and the sites of any incompetent perforating veins marked on the films with a grease pencil. Interpretation of Phlebograms.---The diagnosis of an incompetent perforating vein is only made when contrast is seen to pass on screen examination through the vein from the deep to the superficial venous system (Fig. 4). Further radiographic features of an incompetent communicating vein are dilatation, irregularity and peripheral tortuosity (Figs. 5 and 6). A localised varix may be seen at the superficial end of a communicating vein. RESULTS These are shown in the Table. Fifty legs of 43 patients were examined by phlebography and subsquently operated upon. The total number of communicating veins considered incompetent either at phlebography or surgery was 130. This number comprises 108 veins demonstrated at phlebography, and a further 22 veins found at surgical exploration which had not been shown by phlebography. Of the 108

RADIOLOGY

veins considered to be incompetent at phlebography, 97 (90.4 per cent) were found to be so at exploration. Incompetence was not confirmed surgically in the remaining 11 veins (9-6 per cent). Thus of the 119 incompetent perforating veins found at surgery, 97 (81.5 per cent) had been accurately localised by phlebography before operation and 22 (18.5 per cent) had been missed. DISCUSSION The most accurate method of demonstrating incompetent perforating veins is probably by intraosseous injection of contrast medium into the medial malleolus (Townsend et al., 1967), as by this method contrast medium passes directly into the deep venous system (Halliday, 1967). Townsend et al., 1967, claim a 90 per cent accuracy rate for this method. Its main disadvantage is that, being painful it requires a general anaesthetic and in the presence of ulcerated ankles there is a danger of osteomyelitis. These objections may be to some extent overcome by combining the examination with the operation (Townsend et al., 1967). Since Bauer's classical work (Bauer, 1940 and 1942) there have been many further descriptions of intravenous phlebography of the lower limbs (Cockett, 1953; Greitz, 1955; Gullmo, 1956; Halliday, 1968). All these methods are blind, involving injection of contrast medium and taking serial films with an overcouch tube. More recently the use of a screening table has been recommended to confirm deep venous filling in the demonstration of venous thrombosis (Lea Thomas, 1970) and the technique described here is a modification of that method. The main advantage of screening is that the incompetence of a perforating vein can only be assured by seeing contrast pass through the vein from the deep to the superficial venous system. The upright position as recommended by Greitz (1955) promotes deep venous filling but the examination requires specialised radiographic equipment and the position is uncomfortable for the patient. The disadvantages of this method are overcome by using a screening table. Halliday (1968) recommends ligation of the proximal (lower) end of the long saphenous vein to ensure that this does not fill with contrast medium. We have found this neither necessary nor desirable. A cut-down on to a vein lengthens the time of the examination and may be slow to heal because of infection and ischaemia. We choose a vein towards the lateral side of the foot to avoid too close communication with the long saphenous vein which may be difficult to occlude

A SIMPLIFIED

TECHNIQUE

OF

PHLEBOGRAPHY

FIGS. 3, 4, 5 FIG. 3 (A) Lower femoral vein filled with contrast; no perforating vein shown. (B &C) Note progressive filling of incompetent perforating vein as patient performs the Valsalva manoeuvre. FIG. 4 On screening, contrast passed directly from the posterior tibial vein through the incompetent perforator (large arrow) to a superficial vein (small arrow). FI~. 5 There are two medial incompetent perforating veins (arrowed). The lower one is dilated with a ~uperficial varix. The upper one is tortuous and irregular.

489

490

CLINICAL

Fro. 6 The incompetent perforating vein is dilated and there is a large superficial varix.

with the tourniquet. We arrange the fastening of the tourniquet on the lateral side of the ankle in order to obtain the maximum pressure on the long saphenous vein. Injection of contrast in a distal (upstream) direction allows the medium to pass from the numerous communicating veins on the dorsum of the foot through the deep veins of the sole to the deep calf veins. (Browse et aL, 1967). The combination of table tilt, tightness of the adjustable tourniquet and the distal injection of contrast medium results in deep venous filling. We believe that if it is impossible to find a suitable vein for percutaneous vene-puncture, intraosseous phlebography should be carried out, although this has not been necessary in any of the patients in the present series. Like Townsend et aL (1967) we routinely take only a single projection in our examination, postero-anterior. This view is adequate because nearly all the clinically important perforating veins lie in the tibial and peroneal groups which show best in this projection. Lateral projections, taken in 10 patients in our series, did not provide any further useful information, although this view is recommended by others. (Halliday, 1967 and

RADIOLOGY

1968). We do however use oblique projections turning the patient's foot outwards or inwards under screen control in some instances if this is necessary to show the origin and overall direction of an incompetent perforating vein. The patient is asked to perform a Valsalva manooeuvre when the thigh veins are filled with contrast as this increases the pressure in the system and may show an incompetent perforating vein which otherwise might be missed (Fig. 3). We have found the contrast medium Meglumine Iothalamate 60 per cent painless on injection and we have had no complications from its use in this technique. Usually 50ml of contrast is sufficient to examine each leg but if doubtful areas are reexamined 200 ml may be needed for a bilateral examination. Infection has been prevented by not using a cut-down and thrombosis of veins prevented by flushing with normal saline after the examination. The time taken for our examination is about half an hour for both legs. In the 50 patients in this series, Cockett's incision was employed to display the incompetent perforating veins but in view of the accuracy of phlebography it would probably be justified to make small incisions over veins shown on the phlebograms. To overcome the objection that it is difficult to relate the localisation of perforating veins on the radiographs, to the patients, we recommend that the radiographs (with the incompetent perforating veins marked on them with a grease pencil) should be placed on the patient's legs and these marks transcribed on to the patient's legs using a felt pen, before operation. In the abnormal conditions of phlebography with the patient still, contrast may pass from the deep venous system to the superficial venous system through valves which are incompetent at rest but competent during exercise. For this reason it is probably advisable to rely on additional signs of incompetence such as enlargement of the vein and dilatation at its superficial end. Incompetent perforating veins, missed at phlebography but found at operation are more difficult to explain but it is noteworthy that such expressions as "weak bleedback sign" were present in the notes in some instances and most surgeons would agree that it can be difficult even at operation to be completely certain of the presence of venous incompetence. Nevertheless, in this series there was good correlation between the phlebographic and surgical findings. The phlebographic technique is simple to perform and well tolerated by the patient so that repeat examinations do not present a problem.

A SIMPLIFIED

TECHNIQUE

REFERENCES BAUER, G. (1940). A venographic study of thromboembolic problems. Acta Chirugica Scandinavica, 84, Supplement 61. BAUER,G. (1942). A roentgenological and clinical study of the sequels of thrombosis. Acta Chirugica Scandinavica, 86, Supplement 74. ~ORSCHBERG,E. (1967). The prevalence of varicose veins in the lower extremities. Published by S. Karger, Basel, Switzerland. BRrrIsH MEDICAL JOURNAL,Leading Article (1970). The Hidden Perforating Veins. British Medical Journal, 1, 186. BROWSE~N. L., LEA THOMAS,M. & SOLAN, M. J. (1967). Management of the source of pulmonary emboli: the value of phlebography. British Medical Journal, 4, 596-597. COCKETT, F. B. (1953). The practical uses of phlebography British Journal of Radiology, 26, 339-345. COCKETT, F. B. & JONES, D. E. E. (1953). The ankle blow-out syndrome - a new approach to the varicose ulcer problem. Lancet, 1, 17-23. DODD, H. & COCKETT, F. B. (1956). The pathology and surgery of the veins of the lower limb. Published by E. & S. Livingstone Ltd., p. 358. GREITZ, T. (1955). Ascending phlebography in venous insufficiency. Acta Radiologica, 44, 145-162. GtrLLMO, A. (1956). On the technique of phlebography of the lower limbs. Acta Radiologica, 55, 220-226. HALLmAV, P. (1957). Intraosseous phlebography of the lower limbs. British Journal of Surgery, 54, 248-258. I-IALLmAY, P. (1968). Phlebography of the lower linabs. British Journal of Surgery, 55, 220-226.

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LEA THOMAS,M. (1970).

Radiologieal diagnosis of deed vein thrombosis and its sequelae. Proceedings of the Royal Society of Medicine, 63, 123-126. MASSELL, T. B. & ETT~NGER, J. (1948). Phlebography in the localisation of incompetent communicating veins in patients with varicose veins. Annals of Surgery, 127, 1217-1225. MATmESON, F. R. (1953). Late results following 293 operations for varicose veins - significance of surgical procedure and the communicating veins. Acta Chirugica Scandinavica, 105, 376-389. MATntESON, F. R. (1959). Clinical manifestations of primary varicose veins I1 - an evaluation of incompetent communicating veins diagnosed by tilting plalebography. Acta Chirugica Scandinavica, 117, 468-479. PATEL, A. D., WILLIAMS, J. R.. & LLOYO W~LUAMS, K. (1970). Thermographic localisation of incompetent perforating veins. British Medical Journal, 1, 195-197. ROSENBERG, N. & MARCHESZ, F. P. (1963). Perforator vein loealisation by heat emission detection. Surgery, 53, 575-578. SI~RMAN, R. D. (1949). Varicose veins - further findings based on anatomic and surgical dissection. Annals of Surgery, 130, 218-232. TOWNSEND, J., JONES, H. & WILLIAMS, J. E. (1967). Detection of incompetent veins by venography at operation. British Medical Journal, 3, 583-585. Ttn~NER-WARWICI,:, W. T. (1931). The rational treatment of varicose veins and varieocoele. Published by Faber and Faber, p. 60.

BOOK REVIEW Introduction to Neuroradiology by HAROLD O. PETERSON and STEPHEN A. KIEFFER. Published by Harper and Row, New York. Pp. 276. Illustrations 374. Price£15.00. According to the preface, this book grew out of a chapter in the new loose-leaf edition of Baker's Clinical Neurology. The authors hope that it will serve as an introduction to the field of Neuroradiology for the student, intern, resident or practitioner in radiology, neurology or neurosurgery, and stimulate further interest in the subject, for which a fairly complete bibliography is included with the text. The book is very nicely produced, and the quality of the reproduction is excellent. The b o o k covers plain film examination of the skull, arteriography, encephalography and myelography, and there are short sections on echo-encephalography, isotope studies and thermography. However some of the figures are several pages away from the corresponding text, and in some cases more use of diagrams alongside figures could be made, which would help the more inexperienced reader. In the angiography section, the lateral film lay-out does not always follow the convention of left and right, so that some are printed the wrong way round. Also, the lay-out of the text is not always clear, with no properly defined headings, but instead a continuous run of small paragraph headings lacking ordered classification. For example, in the

section on abnormal intra-cranial calcification, tuberculosis is described first, which might lead the uninitiated to think this is the most common cause. Perhaps this is so, in the authors' experience, but this would not be true in many other clinics. Some of the techniques advised would not always meet general agreement. For example, their preference for selective three or four vessel angiography via a transfemoral catheter, or alternatively a combination of direct carotid puncture and retrograde brachial studies, in the examination of cases of subarachnoid haemorrhage. The importance they attach to the use of a somersaulting chairs in encephalography overlooks the experience in many other centres where this examination has been carried out for years, and still is, quite adequately without such sophisticated apparatus. Their use of large quantities of Pantopaque in the range 36-60 ml. (or oven more) for outlining small lesions in the mid or lower thoracic spinal canal, might not be accepted elsewhere as necessary. In summary, although there is much useful information in this book (the size of which is about right for the intended reader), there is bound to be some hesitation in its general recommendation, especially perhaps outside the country of its origin. GORDON THOMPSON