Phlebography Of Lower Extremity

SUPPLEMENT TO THE SYMPOSIUM ON BLOOD VESSEL SURGERY PHLEBOGRAPHY OF LOWER EXTREMITY DAVID C. BULL, M.D.o VISUALIZATION of veins of lower extremities by injection of radiopaque media is not new-it was first done by Berberich and Hirsch in 1923. Others have used it for various purposes as the demonstration of downward flow of varicosis by McPheeters and Rice and of details like communication by Edwards. Interest reached its crest after the publication of Dougherty and Homans in 1935 who demonstrated thrombosis and studied normal veins. Neuhof a few years later stated that by routine use of phlebography in cases of unexplained temperature on the surgical service of Mount Sinai Hospital, New York, femoral phlebitis was demonstrated with astonishing frequency. Enthusiasm was dampened, however, by Allen in 1938 who found the results unsatisfactory in one-third of his cases due to artefacts. Today the diagnosis of femoral phlebitis is usually made on clinical evidence. False positives in phlebography are inevitable but if by phlebogram a normal deep vein shadow is demonstrated, the mistake can be corrected and the patient spared some vigorous treatment or an operation. This indication alone justifies maintenance of interest in the x-ray visualization of veins. The technic varies considerably in different institutions and ours has changed from that originally used. We install a Lindeman needle cannula on the ward, usually in the internal saphenous vein at the ankle. Sometimes the external saphenous vein, beside the Achilles tendon is used. Occasionally we have been unable to introduce the needle without exposing the vein. With the obturator in place the cannula can be left in the vein indefinitely. Depending on the vein used, the patient is placed supine or prone on the x-ray table with the upper one-half of the field over the Bucky diaphragm and the lower over a simple cassette. Two tubes are used each at the usual 32-inch distance. Forty cubic centimeters of 35 per cent diodrast are injected rapidly and the distal exposure is made. The cassette is immediately withdrawn and the second tube exposure made within five seconds of From the Department of Surgery, Columbia University, and the Surgical Service of the Presbyterian Hospital, New York City. o Assistant Professor of Clinical Surgery, College of Physicians and Surgeons, Columbia University; Assistant Visiting Surgeon, Presbyterian Hospital. 541

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the first. Another cassette is slipped behind the knee, the patient turned on his side and a lateral view quickly taken. Taking all pictures with the same tube at 2 meters was abandoned, as it did not give as good detail. We have been unable to use tourniquets successfully. Even with a blood pressure cuff, obstructing the saphenous vein without com-

Fig. 156.-A 45 year old truck driver was admitted to a surgical service in October 1945 with complaint of pain advancing up the right leg for four days. A similar process in the opposite limb had kept him in another hospital for the previous sixteen days. His temperature was 102 F. Phlebogram on the right revealed thrombosis of the femoral vein up to the entrance of the long sanhenous. Clinically it had anneared to stop at midthigh. Some others do not advocate ligation in this. the inflammatory type, which does not give rise often to emboli: but the opportunity of stopping the advance induced us to ligate and divide the femoral just proximal to the bulb. The clinical course seems to have endorsed the procedure as the untreated left side two years later is still grossly enlarged, whereas on the right the edema is minimal. Note how clear are shadows of external and common iliac veins. 0

pressing somewhat the deep veins has been too difficult. To shunt the fluid into the deep vein we have used digital pressure on the previously marked site where the saphenous vein crosses the femoral . condyle. When the films have been exposed, saline is washed through the system and the obturator is replaced in the cannula. The patient waits

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while developing is done. If the wet films are found unsatisfactory the same cannula is available and through it another injection may be made immediately or a few hours later. For interpretation of the films it must be realized that in direct phlebography the contrast medium takes the shortest, easiest route to the heart. It does not perfuse the entire venous system as in the indirect method where the injection is made into an artery. Therefore,

Fig. 157.-A 31 year old executive had been advised by a specialist in vascular disease that an immediate operation for ligation of the femoral vein was indicated because of phlebothrombosis. He was spared operation because phlebograms demonstrated a patent deep system.

if the internal saphenous vein at the ankle 'is used, failure to visualize the femoral does not necessarily mean occlusion unless an appropriate block was used to shunt the fluid into the deep system. On the other hand, if the short saphenous is used, the fluid should go directly to the femoral and absence of its shadow is significant. In hypersensitive individuals or when irritating solutions are used, allowance for vasospasm must be made. Pressure caused by lying on the table can obstruct calf veins.

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Much has been learned from phlebograms. With improved apparatus and technic, especially the rapid film changer, better pictures will be obtained. Meanwhile, phlebography remains the best means of resolving doubts about diagnosis involving the deep veins in the lower extremity and other locations.