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Phlebography of the lower extremity and pelvic region
Phlebography of the Lower Extremity and Pelvic Region PAUL A. CARLSON,
As early as 1923, Sicard and Forestier observed via fluoroscopy the progress of 4 ml. of into an antecubital vein. Lipiodol@ injected Independently, Berberich and Hirsch in 1923 produced the first angiograms of peripheral vessels in man. A veritable spectrum of methods followed, employing many assorted routes of introduction of the opaque material [1-.&l. Phlebograms which permit delineation of the entire venous system from the foot through the inferior vena cava may be of great value in certain clinical situations. Despite the fact that phlebography is easily accomplished, it has not been exploited to the same degree as arteriography. There is an aura of indifference to the use of any phlebography in the older reports concerning varicose veins and thrombophlebitis [5-T]. The work of Rogoff and DeWeese [8], describing ‘I. . . . a method of long film functional ascending phlebography,” purports to provide a method of demonstrating the main deep vein of the entire lower extremity by one injection. The length of the radiographic field employed by them was only 34 inches and necessarily omits either the pelvic or caval levels, or perhaps those of the leg, unless the patient is moved between ‘separate exposures. I propose the use of the extralong-field “RIL” table of Roy, Jutras, and Longtin 191, consisting of a 51 inch long radiographic field. I have used this method in thirty large field phlebograms, and the safety and value of this technic in the assessment of venous disorders is herein described. Technic The method of extralong-field used in my series is as follows. From the Scenic * Chief Resident pital, 1959.
632
General Hospital, in Surgery. San
phlebography A formal cut-
Modesto, Francisco
California. General
Hos-
M.D.,*
Modesto, California
down at the ankle exposes the lesser saphenous vein; this vein is cannulated with a small polethyleneor Teflon&-sheathed needle, secured by a ligature, and connected via a threeway stopcock to a pressure injector and an infusion of any common parenteral solution. A standard Teflon cannula 3 inches long is used and sizes 18, 16, and 15 afford a good range for the size of vein that may be encountered. Pressure tubing of the vinyl type, with an inside diameter of 0.118 inch, and 19 inches long exclusive of the Luer-lok” adapters, connects the venous cannula to a pressure injector. The pressure injector is set to deliver either Conray@ or Hypaques at the predetermined low pressure, and immediately after the delivery, the three-way stopcock is positioned to deliver parenteral solution and thoroughly wash any puddled contrast agent out of the extremity. No tourniquet is used, as this may produce some artificial detour of blood and and it is unnecessary to contrast material; place the patient in a dependent or erect position since the large volume of opaque material provides crisp contrast. The pressure injector is merely used for the constancy of the infusion. A Cordis injector (with an 80 ml. syringe), set at about 10 to 25 pounds per square inch on the pressure scale, and 40 ml. on the volume scale, will deliver 80 ml. at about 5 to 12.5 pounds per square inch. This requires about seven to eleven seconds for delivery. Figure 1 shows a nomogram of delivery rates using the connecting tubing of the previously mentioned length, with cannula sizes 18, 16, and 15. I prefer to use a light general anesthetic to avoid any motion occasioned by the pain from injection. The extralong-field seriography mounts five cassettes of 51 inch length in a “stack” on rollers beneath the patient, and as each exposure is completed, that cassette is swiftly pulled from beneath the patient into a shielded The
American
Journal
of
Surgery
Phlebography
of Lower Extremity
and Pelvic Region
box. Slight magnification of the image occurs with each succeeding exposure, because successive cassettes are farther below the patient. Each cassette accommodates three standard 14 by 17 inch sheets of film placed end to end to provide a 51 inch field. This allows processing in any radiographic setup. Films are made at about three to four, seven to eight, fifteen to twenty, thirty to thirty-five, and forty to fifty-five seconds after the ‘start of the injection. The radiographic parameters have been described by Roy [I 01. Case Reports CASE I. The patient, a forty-two year old woman, had swelling of the right leg since her fourth pregnancy approximately eight years ago. One year later she had bilateral vein ligation and stripping of the greater saphenous system, and a right inguinal hernioplasty. The phlebograms showed marked constriction of the common femoral vein at the level of the “femoral ring” which presumably resulted from the previous venous surgery. (Fig. 2.)
o5
0
10
TIME LXCONDSl
Fig. 1. agent.
Nomogram
I5 TO
DELIVER
20
25
8Occ
of rate of delivery
of contrast
A, type of angiogram seen with the extra long-field serioFig. 2. Case 1. graph. B, detailed view at the femoral area shows constriction of the femoral vein at the level of the femoral ring. Vol. 118, October 1969
633
Carlson
Fig. 3. Case II. Obstruction of the right iliac vein is demonstrated by the presence of large collateral channels at the level of the groin and diversion of flow from the right common femoral vein to the left iliac system. of the femoral portion of the large field Fig. 4. Case 111. En’argement study shows occlusion of the popliteal and distal segment of the superficial femoral vein and a free thrombus (“streamer”) above the area of complete occlusion. CASE II. The patient, a thirty-year old white woman, had multiple recurrent bilateral ulcers of the ankle and chronic swelling of both legs since the age of fourteen. Extralong-field phlebograms showed the myriad varicosities in the leg and thigh, virtually no flow through the right iliac system, and diversion of the contrast material from the right to the left iliac system. Subsequent bilateral percutaneous transfemoral phlebograms were taken which showed enormous dilatation of the deep and superficial epigastric systems through the left side of the trunk, and almost complete occlusion of the inferior vena cava immediately above the confluence of the iliac veins. (Fig. 3.) CASE III. The patient, a sixty year old man, had severe swelling of the entire right leg. A phlebogram was taken by inserting the cannula retrograde into the saphenous vein at the ankle, which resulted in filling of the entire venous system of the foot, ensuring pervasion of both deep and superficial venous systems by the contrast agent. A thrombus in the superficial femoral vein with a “streamer” was easily seen. (Fig. 4.) Systemic anticoagulation was immediately instituted. 634
Comments The purpose of this report is to encourage the use of phlebographic evaluation. The lesser saphenous vein provides an excellent portal of entry to the venous system for phlebography of the lower extremity. With the extralongfield seriograph equipment now available, and the biologic safety of current opaque substances even in large volumes, some of the obstacles to crisp phlebography are eliminated. Experience to date with more than thirty phlebographic studies has demonstrated its safety and values. There have been no complications. Precise diagnosis has facilitated treatment and has been of great help in determining prognosis. The British have used phlebography and have been successful in demonstrating the finite lesion responsible for symptoms in the leg. Aggressive medical and surgical treatment of intrinsic or compressive lesions has led to impressive clinical results [II]. The American
Journal
of
Surgery
Phlebography
Sherman [IZ] performed anatomic studies of the venous system of the leg and concluded that about 9 per cent of the incompetencies in the perforators between deep and superficial venous systems occur in the thigh level, and the other 91 per cent are below the knee. This suggests that phlebography is particularly valuable in delineating the 9 per cent in the thigh level, since the average surgeon concerns himself primarily with the varicosities and perforators in the level below the knee. Sevitt 1131 in necropsy studies favored six main sites of origin of deep vein thromboses. Three were in the iliofemoral channel, one in the popliteal vein, and two in the calf. This suggests the intrinsic value of extralong-field phlebography in identifying the exact location and extent of thrombosis, even after screening studies with radioactive isotopes. The demonstration of patency after repair of a severed deep vein needs no comment, but should be valuable in prognosis. Congenital abnormalities may also be disclosed. Early interest in anatomic sidelights are noted in studies by Ehrich and Krumbhaar [14], in which they describe “a frequent obstructive anomaly of the mouth of the left common iliac vein.” This anomaly was characterized as a valve, occurring in about 24 per cent of 399 cadavers. The obstruction occurred most frequently at the upper pole of the orifice of the common iliac vein, and they postulated that pressure from an overlying right common iliac artery was the mechanism involved in this frequent obstruction. Cockett [IS] utilized phlebography to evaluate edema in the leg. He was able to classify the causes of swollen leg as follows : I. Deep venous disease A. From surgical ligature B. From external pressure by conditions such as aneurysms and malignant glands C. From the iliac compression syndrome and iliofemoral thrombosis II. Superficial venous disease due to venous valvular incompetence He notes that the external iliac and common iliac vein thromboses are slow to recanalize, and attributes this to compression of those veins in varying degrees at the crossing points of the great arteries at the pelvic brim. The British surgeons have been more agVol. 118, October 1969
of Lower Extremity
and Pelvic Region
gressive in surgical approaches to the problems of venous disease--+bstructive, thrombotic, and congenital. They have had to obtain high quality phlebograms to adequately evaluate these problems. Perhaps with the sharply delineating phlebographic methods afforded by the extralong-field seriograph, and the use of the lesser saphenous vein as a portal of entry, patients having surgically remediable lesions may be benefitted earlier. Summary Extralong-field phlebograms are described. Lesser saphenous vein cutdown at the ankle for portal of entry of contrast material, a pressure injector delivering a large volume of contrast material at low pressure, and the extralong-field seriograph combine to produce crisp radiographs of diagnostic quality over a field of 51 inches. Availability of this method has increased our indications for phlebography in patients with suspected venous disease. Situations in which phlebography has been of greatest value are : 1. Unexplained edema of either or both legs. 2. Localization of perforating veins and acute thromboses in cases with stasis ulceration of the leg. 3. Suspected thrombosis, particularly when pulmonary embolism has occurred in the absence of any physical findings localizing the source of the emboli. 4. Demonstration of patency and therefore prognosi,s after repair of a severed deep vein. References 1. ALLEN, E. V. and BARKER, N. W. Roent-
2. 3. 4. 5.
6. 7.
genologic visualization of the veins of the extremities : preliminary description of a method. Proc. Staff Meet. Mayo Clin., 9: 71, 1934. DEWEESE,J. A. Functional popliteal phlebography in patient with complicated varicose vein problem. Surgery, 44:390,1958. LUKE, J. C. The deep vein valves. Surgery, 29:381,1951. SUTTON, D. Arteriography. Edinburgh and London, 1962. E. and S. Livinastone. ALLEN, E: V., BARKER,N. W., and HINES, E. A. Peripheral Vascular Diseases, 2nd ed., p. 38. Philadelphia, 1955. W. B. Saunders co. FOOTE,R. R. Varicose Veins, D. 72. London, 1954. Butterworth and Co., Ltd. HOMANS, J. Nelson Loose-Leaf Surgery, vol. 3, p. 729. New York, 1940. Thomas Nelson and Sons. 635
Carlson 8. 9. 10. 11.
636
ROGOFF,S. M. and DEWEESE,J. A. Phlebography of the lower extremity. J.A.M.A., 172 : 1599,196O. ROY, P., JIJTRAS,A., and LONGTIN,M. Extralarge field angiography: technic and results. J. Canad. A. Radial., 12:27, 1961. ROY, P. Peripheral angiography in ischemic arterial diseases of the limbs. Radial. C&L North America, 5 :467,1967. KINMONTH, J. B. Investigation of chronic oedemas of the lower limb. &it. J. Surg., 64 :890, 1967.
12. 13. 14.
15.
SHERMAN,R. S. Varicose veins: further findings based on anatomic and surgical dissection. Ann. Surg., 130:218, 1949. SEVITT, S. The acutely swollen leg and deep vein thrombosis. Brit. J. Surg., 54:891, 1967. EHRICH, W. E. and KRUMBHAAR,E. B. A frequent obstructive anomaly of the mouth of the left common iliac vein. Am. Heart J.. 26 :737,1943. COCKETT,F. B. Venous causes of swollen leg. Brit. J. Surg., 54:891, 1967.
The
American
Journal
of
Surgery
As early as 1923, Sicard and Forestier observed via fluoroscopy the progress of 4 ml. of into an antecubital vein. Lipiodol@ injected Independently, Berberich and Hirsch in 1923 produced the first angiograms of peripheral vessels in man. A veritable spectrum of methods followed, employing many assorted routes of introduction of the opaque material [1-.&l. Phlebograms which permit delineation of the entire venous system from the foot through the inferior vena cava may be of great value in certain clinical situations. Despite the fact that phlebography is easily accomplished, it has not been exploited to the same degree as arteriography. There is an aura of indifference to the use of any phlebography in the older reports concerning varicose veins and thrombophlebitis [5-T]. The work of Rogoff and DeWeese [8], describing ‘I. . . . a method of long film functional ascending phlebography,” purports to provide a method of demonstrating the main deep vein of the entire lower extremity by one injection. The length of the radiographic field employed by them was only 34 inches and necessarily omits either the pelvic or caval levels, or perhaps those of the leg, unless the patient is moved between ‘separate exposures. I propose the use of the extralong-field “RIL” table of Roy, Jutras, and Longtin 191, consisting of a 51 inch long radiographic field. I have used this method in thirty large field phlebograms, and the safety and value of this technic in the assessment of venous disorders is herein described. Technic The method of extralong-field used in my series is as follows. From the Scenic * Chief Resident pital, 1959.
632
General Hospital, in Surgery. San
phlebography A formal cut-
Modesto, Francisco
California. General
Hos-
M.D.,*
Modesto, California
down at the ankle exposes the lesser saphenous vein; this vein is cannulated with a small polethyleneor Teflon&-sheathed needle, secured by a ligature, and connected via a threeway stopcock to a pressure injector and an infusion of any common parenteral solution. A standard Teflon cannula 3 inches long is used and sizes 18, 16, and 15 afford a good range for the size of vein that may be encountered. Pressure tubing of the vinyl type, with an inside diameter of 0.118 inch, and 19 inches long exclusive of the Luer-lok” adapters, connects the venous cannula to a pressure injector. The pressure injector is set to deliver either Conray@ or Hypaques at the predetermined low pressure, and immediately after the delivery, the three-way stopcock is positioned to deliver parenteral solution and thoroughly wash any puddled contrast agent out of the extremity. No tourniquet is used, as this may produce some artificial detour of blood and and it is unnecessary to contrast material; place the patient in a dependent or erect position since the large volume of opaque material provides crisp contrast. The pressure injector is merely used for the constancy of the infusion. A Cordis injector (with an 80 ml. syringe), set at about 10 to 25 pounds per square inch on the pressure scale, and 40 ml. on the volume scale, will deliver 80 ml. at about 5 to 12.5 pounds per square inch. This requires about seven to eleven seconds for delivery. Figure 1 shows a nomogram of delivery rates using the connecting tubing of the previously mentioned length, with cannula sizes 18, 16, and 15. I prefer to use a light general anesthetic to avoid any motion occasioned by the pain from injection. The extralong-field seriography mounts five cassettes of 51 inch length in a “stack” on rollers beneath the patient, and as each exposure is completed, that cassette is swiftly pulled from beneath the patient into a shielded The
American
Journal
of
Surgery
Phlebography
of Lower Extremity
and Pelvic Region
box. Slight magnification of the image occurs with each succeeding exposure, because successive cassettes are farther below the patient. Each cassette accommodates three standard 14 by 17 inch sheets of film placed end to end to provide a 51 inch field. This allows processing in any radiographic setup. Films are made at about three to four, seven to eight, fifteen to twenty, thirty to thirty-five, and forty to fifty-five seconds after the ‘start of the injection. The radiographic parameters have been described by Roy [I 01. Case Reports CASE I. The patient, a forty-two year old woman, had swelling of the right leg since her fourth pregnancy approximately eight years ago. One year later she had bilateral vein ligation and stripping of the greater saphenous system, and a right inguinal hernioplasty. The phlebograms showed marked constriction of the common femoral vein at the level of the “femoral ring” which presumably resulted from the previous venous surgery. (Fig. 2.)
o5
0
10
TIME LXCONDSl
Fig. 1. agent.
Nomogram
I5 TO
DELIVER
20
25
8Occ
of rate of delivery
of contrast
A, type of angiogram seen with the extra long-field serioFig. 2. Case 1. graph. B, detailed view at the femoral area shows constriction of the femoral vein at the level of the femoral ring. Vol. 118, October 1969
633
Carlson
Fig. 3. Case II. Obstruction of the right iliac vein is demonstrated by the presence of large collateral channels at the level of the groin and diversion of flow from the right common femoral vein to the left iliac system. of the femoral portion of the large field Fig. 4. Case 111. En’argement study shows occlusion of the popliteal and distal segment of the superficial femoral vein and a free thrombus (“streamer”) above the area of complete occlusion. CASE II. The patient, a thirty-year old white woman, had multiple recurrent bilateral ulcers of the ankle and chronic swelling of both legs since the age of fourteen. Extralong-field phlebograms showed the myriad varicosities in the leg and thigh, virtually no flow through the right iliac system, and diversion of the contrast material from the right to the left iliac system. Subsequent bilateral percutaneous transfemoral phlebograms were taken which showed enormous dilatation of the deep and superficial epigastric systems through the left side of the trunk, and almost complete occlusion of the inferior vena cava immediately above the confluence of the iliac veins. (Fig. 3.) CASE III. The patient, a sixty year old man, had severe swelling of the entire right leg. A phlebogram was taken by inserting the cannula retrograde into the saphenous vein at the ankle, which resulted in filling of the entire venous system of the foot, ensuring pervasion of both deep and superficial venous systems by the contrast agent. A thrombus in the superficial femoral vein with a “streamer” was easily seen. (Fig. 4.) Systemic anticoagulation was immediately instituted. 634
Comments The purpose of this report is to encourage the use of phlebographic evaluation. The lesser saphenous vein provides an excellent portal of entry to the venous system for phlebography of the lower extremity. With the extralongfield seriograph equipment now available, and the biologic safety of current opaque substances even in large volumes, some of the obstacles to crisp phlebography are eliminated. Experience to date with more than thirty phlebographic studies has demonstrated its safety and values. There have been no complications. Precise diagnosis has facilitated treatment and has been of great help in determining prognosis. The British have used phlebography and have been successful in demonstrating the finite lesion responsible for symptoms in the leg. Aggressive medical and surgical treatment of intrinsic or compressive lesions has led to impressive clinical results [II]. The American
Journal
of
Surgery
Phlebography
Sherman [IZ] performed anatomic studies of the venous system of the leg and concluded that about 9 per cent of the incompetencies in the perforators between deep and superficial venous systems occur in the thigh level, and the other 91 per cent are below the knee. This suggests that phlebography is particularly valuable in delineating the 9 per cent in the thigh level, since the average surgeon concerns himself primarily with the varicosities and perforators in the level below the knee. Sevitt 1131 in necropsy studies favored six main sites of origin of deep vein thromboses. Three were in the iliofemoral channel, one in the popliteal vein, and two in the calf. This suggests the intrinsic value of extralong-field phlebography in identifying the exact location and extent of thrombosis, even after screening studies with radioactive isotopes. The demonstration of patency after repair of a severed deep vein needs no comment, but should be valuable in prognosis. Congenital abnormalities may also be disclosed. Early interest in anatomic sidelights are noted in studies by Ehrich and Krumbhaar [14], in which they describe “a frequent obstructive anomaly of the mouth of the left common iliac vein.” This anomaly was characterized as a valve, occurring in about 24 per cent of 399 cadavers. The obstruction occurred most frequently at the upper pole of the orifice of the common iliac vein, and they postulated that pressure from an overlying right common iliac artery was the mechanism involved in this frequent obstruction. Cockett [IS] utilized phlebography to evaluate edema in the leg. He was able to classify the causes of swollen leg as follows : I. Deep venous disease A. From surgical ligature B. From external pressure by conditions such as aneurysms and malignant glands C. From the iliac compression syndrome and iliofemoral thrombosis II. Superficial venous disease due to venous valvular incompetence He notes that the external iliac and common iliac vein thromboses are slow to recanalize, and attributes this to compression of those veins in varying degrees at the crossing points of the great arteries at the pelvic brim. The British surgeons have been more agVol. 118, October 1969
of Lower Extremity
and Pelvic Region
gressive in surgical approaches to the problems of venous disease--+bstructive, thrombotic, and congenital. They have had to obtain high quality phlebograms to adequately evaluate these problems. Perhaps with the sharply delineating phlebographic methods afforded by the extralong-field seriograph, and the use of the lesser saphenous vein as a portal of entry, patients having surgically remediable lesions may be benefitted earlier. Summary Extralong-field phlebograms are described. Lesser saphenous vein cutdown at the ankle for portal of entry of contrast material, a pressure injector delivering a large volume of contrast material at low pressure, and the extralong-field seriograph combine to produce crisp radiographs of diagnostic quality over a field of 51 inches. Availability of this method has increased our indications for phlebography in patients with suspected venous disease. Situations in which phlebography has been of greatest value are : 1. Unexplained edema of either or both legs. 2. Localization of perforating veins and acute thromboses in cases with stasis ulceration of the leg. 3. Suspected thrombosis, particularly when pulmonary embolism has occurred in the absence of any physical findings localizing the source of the emboli. 4. Demonstration of patency and therefore prognosi,s after repair of a severed deep vein. References 1. ALLEN, E. V. and BARKER, N. W. Roent-
2. 3. 4. 5.
6. 7.
genologic visualization of the veins of the extremities : preliminary description of a method. Proc. Staff Meet. Mayo Clin., 9: 71, 1934. DEWEESE,J. A. Functional popliteal phlebography in patient with complicated varicose vein problem. Surgery, 44:390,1958. LUKE, J. C. The deep vein valves. Surgery, 29:381,1951. SUTTON, D. Arteriography. Edinburgh and London, 1962. E. and S. Livinastone. ALLEN, E: V., BARKER,N. W., and HINES, E. A. Peripheral Vascular Diseases, 2nd ed., p. 38. Philadelphia, 1955. W. B. Saunders co. FOOTE,R. R. Varicose Veins, D. 72. London, 1954. Butterworth and Co., Ltd. HOMANS, J. Nelson Loose-Leaf Surgery, vol. 3, p. 729. New York, 1940. Thomas Nelson and Sons. 635
Carlson 8. 9. 10. 11.
636
ROGOFF,S. M. and DEWEESE,J. A. Phlebography of the lower extremity. J.A.M.A., 172 : 1599,196O. ROY, P., JIJTRAS,A., and LONGTIN,M. Extralarge field angiography: technic and results. J. Canad. A. Radial., 12:27, 1961. ROY, P. Peripheral angiography in ischemic arterial diseases of the limbs. Radial. C&L North America, 5 :467,1967. KINMONTH, J. B. Investigation of chronic oedemas of the lower limb. &it. J. Surg., 64 :890, 1967.
12. 13. 14.
15.
SHERMAN,R. S. Varicose veins: further findings based on anatomic and surgical dissection. Ann. Surg., 130:218, 1949. SEVITT, S. The acutely swollen leg and deep vein thrombosis. Brit. J. Surg., 54:891, 1967. EHRICH, W. E. and KRUMBHAAR,E. B. A frequent obstructive anomaly of the mouth of the left common iliac vein. Am. Heart J.. 26 :737,1943. COCKETT,F. B. Venous causes of swollen leg. Brit. J. Surg., 54:891, 1967.
The
American
Journal
of
Surgery