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A Study of Pel Vic Venography

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A Study of Pel Vic Venography 17 A STUDY OF PEL VIC VENOGRAPHY Kouzo FuKuTA 1st Department of Surgery, Nagoya University School of Medicine (Director: Prof. Yoshio Hashimoto) Venography is very important in the diagnosis of various venous diseases and also is utilized for examining tumor or inflammation, as well as for studying the anatomy and physiology of the venous system. Especially it is essential for the diagnosis of venous thrombosis and its sequelae i.e. postthrombotic syndromes. In our department, there have long been many studies 27 > 28 > 29 > 46 > 49 > on the venous thrombosis and a number of venographies have been performed. The purpose of this paper is to present studies on pelvic venography, criticizing and comparing its various methods, and to report on new findings and techniques. The importance of the pelvic venography stems from the fact that thrombi very frequently develop in the intrapelvic veins. According to Hashimoto,27 l his investigation of 20 pathological departments in Japan concerning the location of a thrombus disclosed that out of 180 autopsy cases, in which venous thrombi were discovered, 115 cases (63.9%) belonged to the lower half of the body with the iliac vein involved in 63 cases and the femoral vein in 46 cases, while the veins of the leg were involved in only 6 cases. It was noted that 18 patients showed thrombosis at a point above the femoral vein among 43 patients with venous thrombosis admitted to our department in the past 30 months (January 1956 to June 1958). Greitz 20 l reported that 73 cases out of 310 routine phlebo­ graphies failed to fill the vein and were explored by means of an additional pelvic phlebography. According to Allen et al., 2l their observation for the site of clinically diagnosed postoperative thrombophlebitis indicated 254 cases with involvement of the iliofemoral vein versus 655 cases with that of the more distal veins. Fontaine 18l found that 60% of the patients with venous thrombosis subjected to phlebographic studies showed involvement of the femoral, the iliac or the pelvic veins. Ducuing/81 Gery 181 and Mclachlin 37 l likewise reported the fact that venous thrombosis developed more frequently in the veins of the thigh and pelvis. Therefore, it can be said that, if there is swelling, pain, discoloration or varicosity on the lower extremity and accordingly an abnormality of the venous system is contemplated, a venographic exploration must be performed to the pelvis as well as the lower extremity. Generally speaking, a sufficient diagnosis is very frequently obtained by only the pelvic venography. Upon reviewing the literature,1 119 l 20 l 31 > the history of venography has been fairly long and started in 1923 by Berberich and Hirsch, but the first formal Received for publication December 19, 1958. 18 K. FUKUTA publication on pelvic venography was seemingly made by Hutter in 1935, since when many studies concerning the pelvic venography have been reported by a number of researchers. Hereon the author would classify the various methods and techniques re­ ported in the literature: (1) As the intravenous method, there are a percutane­ ous injection of a contrast medium to a superficial vein of the thigh or pubic region, an injection to the greater saphenous vein by percutaneous puncture or incision, an injection to the small saphenous vein through an incision over its proximal end, a direct puncture to the femoral or the inferior caval vein, and also the method utilizing the veins of penis, clitoris, scrotum and anus. (2) As the catheter method, the greater saphenous,48 ' femoraP' 451 and popliteal veins have been employed. (3) As the intraosseous method, since Drasnar10 ' and Hashimoto's 27 ' first attempts, the injection of a contrast medium through the bone marrow of several parts of the pelvis has been reported.ll' 19' 27 ' 281 CLINICAL SUBJECTS Twenty-five patients (14 males and 11 females) were employed for this study and the number of pelvic venography performed was 32. The age ranged from 19 to 60 and was distributed equally (Table 1). 16 out of these 25 cases had usual venography of the lower limb taken on the same or different day of pelvic venography. METHOD The contrast medium was urografin (Schering) and no other kind was used for the purpose of equalizing the condition in all cases. Enema was given to a subject early in the morning and then immediately before the procedure. Breakfast was light and no lunch was given to prevent vomiting. Care must be taken of the fact that a few cases without sufficient enema or with a heavy breakfast failed to give clear roentgenogram due to the intestinal content. All cases were performed in the afternoon at the X·ray room. No premedication was used. For the case of incision, catheterization or transosseous method, the necessary procedure was done in the operating room under local anesthesia, before bringing the subject to the X-ray room. These procedures should be performed under a strictly sterile condition. The subject was placed in horizontal and supine position except for a few cases mentioned later. While injecting the contrast material of various concen­ trations and amounts with different techniques through a site variable in each individual case, several roentgenograms were taken serially with some interval, by the aid of a simple hand-operating casette changer made by us. Not infrequently, it is necessary to take venographies of both the pelvis and the lower extremity at the same time. In such a case, the pelvic veno­ graphy must be taken first, because if one handles the lower extremity first the contrast medium would appear in the bladder and resultantly complicate the succeeding pelvic venogram. TABLE 1. Clinical Subjects - Number Veins used for in- Vena- Chart Position jection of contrast -[Age of pelvic "* Side graphy Nameland No. Disease Symptoms venography of Method medium; ( ) indi- reaction of lower Sex subject* cates the length of extremity performed catheter inserted*** -~T-K 1191157467 1 Lt. iliac thrombophle-13 mo~ths It. limb swelling 1 E C I Smag-Cava (24 cm)l None I 0 1 · · M I bitis i followmg appendectomy I I primary varicose I L r .--:--- ------ --- I -~·-Lt. I -;------ilc----- 21 T.S. 22 57520 veins with superficial I t. Imb vancies; tef!derness 2 E p Subcut, thigh Nausea 1 I M / thrombophlebitis and redness on It. thigh H p 11 ' ! I I I ---:-------e---el'---- -----.1 . I 31 A. s.r ~ 1575321 Sarcoma rt. thigh ITumor in rt. upper thigh 1 H c T~ac~~nkle-knee None 1 ---~-- -~- -1 I L T hi b --h--r-z yrs. -It. limb swelling and-- E p I Smag, thigh I I 1_ 11 4 M.K. ~ 57467 b t. i~ Iac P e ot rom- heavy feeling following ap- 2 H I 1 I os I pendectomy 11 -5 I M T l 60 1575751· Sarcoma rt. pelvis I Tumor palpab_le in rt. in_guinal 1 H 1 C I Smag-Femo (5 em)\ 11 I 0 1 · ·1 F area and rt. limb swelling 1 -6-l·s····-s-! 31 1580321 Lt. ilioferr_wral phlebo- I 2 ~OS. it. l_imb swelling and H I p r· I I 0 , • "j F thrombosis 1 pam followmg rt. nephropexy Femo Chill 7 I y T I 261 57031 1 Lt. femo~al phlebo- 1 4 yrs. it. li.mb swelling and 3 H I p I Smag, thigh, leg I None I 1 j • ·1 M 1 thromboSIS 1 pam followmg trauma and ankle 1 28 1 I 14 mos. swelling, pain and I I I I 8 F .N ·1 F 57544 II ~ired ness of It. limb follow- 1 H I Smag, thigh 11 0 I 1 1 mg appendectomy l-----,------+---___o----- '1321 I Bil. limbs postphle- I Bil. pain and swelling; It. with I I I I 1 9 Y1 .M. M 57538 i bitic syndromes ~f.o~~~n~~u~e~~er~~~os ~t~~:; 1 H P j Subcut, thigh Nausea 4 I' None - -~--Y-N--~271 ~--Thro-mbophlebitis no- : Localized redness and sore- H I p -~------ 10 1 . · M 27585 dosa , ness on It. leg 11 1 1 1 I I 1 44 I Epithelial cyst of left 1 A drafning sinus from a tum-or ·• H p Subcut, foot 11 I 11 ·~ M. T .. M 57600 buttock. and bil. vari- in It. buttock and bil. limb 1 2 H I h 1 , case vems varicies____ Subcut, bil. thig s j i[ It. I' C Smag-Femo (8 0 ¥157653 Palpable tumor in pelvis 1 H I I cr:)/1-,----'~- ~~-~-;.:;-~~~, , tis~~f:~~!~i of tuberculous ~~~dph:J~~~-~ ongm 2 1j ! 580361 I It. limb ______1_ . __ H I P I Smag, thigh____ ~.T.I ~ ;~itfsrima:~v:ricose varici~s~~~~:ars !_"____ _[ TABLE 1. (Continued) - ------------ Veno­ CNhart o· ------ ---- ---]u;f:{c- ----** r· Side Namell·~~~ Pos~-ion ~~W~nu~;~:~~~~~t graphy 0 1sease Symptoms venography ot Method medmm, ( ) md1· reaction of lower Sex · performed subJect* cates th': length of catheter mserted***t extremity I ----~- . i381 liLt. iliof~mor-;;l~hrom-b~T3 mos-:--swelli~g. fever aii.if lr I . I 14 1 S. I ·I M 58017 phlebitis j redness followmg rt. nephrec- 1 H P Subcut, thigh None 0 , ! i tomy I I ~---,-, 33[ I Lt femor thrombo- ' Pain of It. inguinal region; ---------~-------- ---~--- ----- I 15 I 58071 hiebitis a it. swelling of 2 mos. 1 H P 0 K. Y.! 1_ li~b F .. I P ' duration y Lt. _iliac .. pain after I I H I Smag, thigh 1 ~~ .H.~-~6[ **** I phlebothrom-~4~s sw~lling--~;d 1 11 1 1 F 1 bos1s resection of cervical stump i 1 -1 I ·r IL "l" f h b I Lt.
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