Phlebography

Phlebography by Dr. Bishnu Khatiwada

1. PHLEBOGRAPHY/VENOGRAPHY Dr Bishnu Khatiwada Resident, MDRD NAMS, Bir Hospital

2. Presentation Outline Introduction Classification of venographic procedures Patient preparation Indications Contraindications Procedure of venography Pitfalls Complications

3. PATIENT PREPARATION 1. Clarify the indication for the procedure. 2. Review all prior ultrasounds, venous plethysmography , and available crosssectional imaging. 3. Restrict oral intake to clear liquids; nil per os (NPO) if planning conscious sedation (as guided by hospital policy)

4. 4. Evaluate recent creatinine and hydration status, especially in patients with diabetes. a. If a large contrast volume is anticipated, intravenous (IV) hydration may be appropriate. b. Hold metformin in patients with diabetes and/or compromised renal function; restart following creatinine evaluation in 48 hours. 5. Obtain informed consent.

5. INDICATIONS (Lower Extremity Venography ) Diagnosis of deep vein thrombosis (DVT) following nondiagnostic or incomplete ultrasound examination; also , when there is a high clinical suspicion for DVT but an extremity ultrasound study is negative 2 . Evaluation of varicose veins, venous reflux and valvular incompetency by descending lower extremity venography 3. Evaluation of venous malformations 4. Evaluation of venous encasement by tumor 5 . Planning for catheter-directed venous thrombolysis

6. In Tilt table ascending leg venography , spot images are obtained as follows . A: Below the knee with table tilted 45 to 60 degrees: AP and lateral projections . B: Over the knee with table tilted 30 to 45 degrees : AP and lateral projections. C : Over the thigh and groin with table tilted 15 to 30 degrees: AP projection . D : Supine frontal overhead image of pelvis and lower abdomen. A Valsalva maneuver, performed during elevation of the examined leg, facilitates opacification of the iliac veins and inferior vena cava .

7. Normal ascending phlebogram of the deep veins.

8. Incompetent perforating veins in the calf (arrows) and thigh.

9. Descending phlebogram showing incompetent valves and reflux down to the popliteal vein.

10. Phlebogram Showing deep vein thrombosis in the calf and femoral vein. The clot shows as a central filling defect with marginal contrast (arrow).

11. Congenital Anomalies Duplication: popliteal or femoral vein or of both or GSV Congenital absence of the venous valves: Children or teenagers presenting with varicosities or chronic leg swelling. Ehlers– Danlos syndrome: This may cause the development of large venous aneurysms . Large varix or venous aneurysm: at the termination of the long or short saphenous veins.

12. Klippel–Trenaunay syndrome C haracterised by a naevus with hypertrophy of bones and soft tissues of affected limbs, usually legs, though arms may also be affected . There is venous dysplasia, and the normal venous return is replaced by persistence of a more primitive system, usually a single large lateral venous channel in the leg, or a single large medial venous channel in the arm. C an be associated with superficial varicosities.

13. (A,B) Klippel–Trenaunay syndrome involving the left arm. Drainage is via a single medial vein which appears valveless with very sluggish flow.

14. Arm phlebogram showing normal appearances.

15. (A) Left-sided IVC as a chance finding in a patient undergoing renal vein catheterisation . (B ) The catheter has passed over to the right renal vein through the left IVC where it joins the left renal vein; the upper part of the IVC is normally sited. ( C) Double inferior vena cava. A Mobin—Uddin umbrella (arrows) has been inserted in the normal right-sided IVC. The postoperative phlebogram shows an unsuspected double NC with the right side now occluded.

16. Two-phase MRA. Normal iliac veins with duplication of IVC.

17. (A) Recent Thrombosis obstructing the left common iliac and partially obstructing the lower IVC. ( B) Thrombosis of the IVC and common iliacs with collateral circulation. There is some irregular recanalisation of the common iliacs .

18. (A) Thrombosis of left iliac veins with partial recanalisation and drainage of the left leg mainly by collaterals to the right iliacs via pubic veins. (B) Thrombosis of the IVC with recanalisation and collateral circulation.

19. Lymphedema praecox This was the term used for swelling of the left leg, usually occurring in young females S ometimes associated with partial obstruction of the left common iliac vein by the right common iliac artery passing over it

20. (A) Obstruction of the left common iliac vein by pressure from the right common iliac artery (arrow). Note collateral circulation via the ascending lumbar vein. (B) Iliac vein obstruction by a glandular mass . (C) Obstruction of the left iliac veins in a patient with carcinoma of the cervix treated by radiotherapy.

21. (A) DSA . Normal suprarenal IVC. ( B) Obstruction of hepatic veins with compression and distortion of the upper IVC by liver neoplasm resulting in Budd– Chiari syndrome . The patient was performing the Valsalva manoeuvre . Note reflux filling of the renal veins, but not the hepatic veins. (C) Another patient with Budd– Chiari syndrome and thrombosed hepatic veins.

22. Double SVC . A catheter has been passed from the right arm for pulmonary angiography. Instead of entering the ventricle it has passed through the dilated coronary sinus and into the left SVC draining into it, as evident on contrast injection. Note the widened mediastinum .

23. (A) Right arm phlebogram confirms malignant occlusion of the innominate and SVC with reflux up the right internal jugular, and vertebral collaterals . (B) Occlusion of the SVC and innominate , and termination of the right subclavian vein. Collaterals are seen to the vertebral plexus.

24. (A). Right arm phlebogram in fibrosing mediastinitis with involvement of the SVC and the right innominate vein. (B) Left arm phlebogram in a patient with fibrosing mediastinitis ( tuberculous ). Note the kinked trachea. The SVC and left innominate are occluded. Collateral circulation via the left internal jugular and vertebral plexus.

25. (A) Transhepatic portal phlebogram showing the main portal vein and mesenteric tributaries. (Courtesy of Dr Janet Murfitt .) (B) Gastric and oesophageal varices demonstrated by transhepatic portal vein catheterisation .

26. CEREBRAL VENOGRAPHY

27. Pitfalls In extremity evaluation for DVT, sensitivity is 100% for clots larger than 0.5 cm. Specificity is 95% using the strict criteria of a filling defect noted on more than one view. False-positive exams can occur as a result of: ( 1) Underfilling of a vein, creating a pseudothrombus ( 2) Inadvertent injection of air ( 3) Extrinsic defects that may be due to compression by adjacent muscles or positional entrapment 4) Artefacts due to layering 5 ) Streaming effect- d/t entry of large non- opacified tributary veins 6 ) Turbulence aroung valves

28. Complications of contrast angiography A. General 1. Contrast reactions a . Severe life-threatening b . Intermediate c . Minor (coughing, sneezing, mild, urticaria ) 2. Embolus a . Catheter clot b . Cholesterol c . Cotton fibre d . Air 3 . Septicaemia 4. Vagal inhibition

29. B. Local 1. Puncture site a. Haemorrhage and haematoma b. False aneurysm c. Arteriovenous fistula d. Perivascular or subintimal contrast injection e. Local thrombosis f. Local infection g. Damage to adjacent nerves 2. Damage to target or other organs due to a. Excess of contrast b. Catheter clot embolus

30. 3. Fracture and loss of guide-wire tip 4. Knot formation in catheters 5. Embolisation accidents 6. Angioplasty accidents

31. THANK YOU

32. References Textbook of Radiology & Imaging, David Sutton, 7 th edition Handbook of interventional radiological procedures, Krishna Kandarpa , 5 th edition A guide to radiological procedures, Chapman Meryll’s atlas of radiological procedures