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.

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-5 -5 ---~-- TABLE 1. (Continued) ------Veno­ Namell·~~~CNhart o· ------]u;f:{c- Pos~-ion~~W~nu~;~:~~~~~t r· Side ------** graphy 0 1sease Symptoms venography ot Method medmm, ( ) md1· reaction of lower Sex · performed subJect* cates th': length of catheter mserted***t extremity

----~-. i381 liLt. iliof~mor-;;l~hrom-b~T3mos-:--swelli~g.fever aii.if lr I 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 33[ I Lt femor I thrombo- ' Pain of It. inguinal region; ------~------~---~---,-,----- I

15 I K. Y.! F ..58071 hiebitis a 1_it. li~bswelling of 2 mos. 1 H P 0 I P ' duration

~~y .H.~-~6[ **** I Lt. _iliac phlebothrom-~4~s .. sw~lling--~;dpain after I 1 I H I Smag, thigh 11 1 1 1 F 1 bos1s resection of cervical stump i 1 -1 I ·r IL "l" f h b I Lt. limb swelling and pelvic ~~~~~~---c~~~~c--~~--c-1~~~~~~~~-;-l~~~~lc--~~~ 17! T.S. ~ 58127 p~i~bUi~moralt rom o- bone fracture due to trauma 1 H C Smag·Femo (3 em) J~~~m-0 , 4 mon. p.t.a. 1

' I 5911 I Lt femoral thrombo I Lt. limb swelling following I I Smag, thigh-thigh I N I 18 I Y.K.: M 58184 phiebitis - ~-~t.~~sinhalation 6 months H C (3 em) one 2

~-~---~-~~~~~~r~~~~----~~:~:swelling:spontane-l 2 ~ ~ I~~~~~~:~~\·g~highsl, 1 1 I

20 II H N 26 11581781Lt. lil_Il~deep thrombo-1 ~t.leg ulcer and bil. limbs ~~~-2~~-;-~H~~-:-r'~-~~-,-1-S_m_a_g_,_b_i_l.~th_i_g_h_s___,_l~,-,~~-:-~~~2~- , · · F phlebitiS tiredness H I Smag, thigh I

i ~2i 58223 1 Lt. iliofemoral phlebo-l_2 mos. swelling following ap- 1 H I C I Smag, leg-thigh I Phlebitis I 1 21 y · T · i M : thrombosis ! pendectomy 1 ( 30 em)

K-· -~-3zl'.I ; -~d~m~a~d- ~c~---'I,---S_m_a_g_.~le_g_--th_i_g_h~-'1,--N-o-n-e~---;-1, ~~, 0 0 0 0 Swelling, ~arl~-1~~-1~~-'c--~-H~~c-1 ~ 22 [ . E. F 58230 R t. vancose Iliac vemsl in rt. limb for 3 years i ( 10 em) 0

.. I I 271 I I Lt. limb swelling a""ndpain;-~--- I I c I Poplit-Femo I_ Throm- I 1 I op~ra.tion 1 1 1 23 1 F. Z. F 58130 Lt. elephantiasis an was done for ele- 1 H ( 15 em) bosis i phanhaS!S 10 yrs. p.t.a. .

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25 : K. ~J~:~8~~3 i Lt. varicose veins i Lt. l~=~~~~~~s-~o~-~~~ar~J~--__I_ ~-~H~~·--_l~-C~~~_T_f~~~{o~~it______"_ 1 * Position: E (erect), H (horizontal). ** Method: Cindicates catheter method, P-percutaneous puncture. !-incision. ***The name of vein is abbreviated by Smag (V. saphena magna), Cava (V. cava inferior), Subcut (subcutaneous vein), Femo (V. femo­ ralis), Poplit (V. poplitea) and Sparva (V. saphena parva). **** Nagoya Railway Hospital. A STUDY OF PELVIC VENOGRAPHY 21

THE VARIOUS PROBLEMS ON PELVIC VENOGRAPHY -INVESTIGATIONS AND DISCUSSION- 1) Position of Subject For pelvic venography, a horizontal position is concluded to be of choice. The specific gravity of commercially available 76% urografin is 1.422 (60% urografin: 1.322), that of whole blood is 1.050 and of blood plasma 1.020.5) Urografin, therefore, should sink down by gravity in the blood and this phe­ nomenon is readily proved experimentally in a test tube or a syringe. In 2 subjects (Cases 2 and 4), attempts were made to perform pelvic venography in the erect position, but a considerable amount of urografin flew down from the site of injection in the upper thigh, so that sufficient contrast density could not be obtained in the intrapelvic veins. This fact is in accordance with Greitz's description.20 l Contrarily, another attempt was made in Case 1 to utilize the descending phenomenon, by injecting urografin through a catheter which had been inserted 24 em from the greater saphenous vein of the right (healthy) side to the vena cava. The descent of urografin, however, through the left common iliac to the femoral veins of the left (abnormal) side was not so great as expected. This

FIG. 1. A schema of the intrapelvic venous system based on the author's experience, ex­ fvc clusive of spermatic, uterine and ovarian veins. The abbreviations are used for the purpose of explaining the names of veins on the photo­ graphs, Fig. 2 to 25. l. V. cava inferior ( VC) 2. V. ilica communis-common iliac vein ( CI) 3. V. ilica externa-external iliac vein ( El) 4. V. ilica interna-hypogastric vein ( HY) 5. V. femora lis-femoral vein (F) 18G 6. V. profunda femoris-deep femoral vein (DF) 7. V. saphena magna-greater saphenous vein (Sm) 8. V. obturatoria-obturator vein ( 0) 9. V. epigastrica superficialis-superficial epi- S-F ... -==:;::::==-Ht.\' gastric vein ( SE) 10. V. epigastrica inferior-inferior epigastric vein (IE) 11. V. circumfiexa ilium profunda-deep iliac circumflex vein ( DI) 12. V. circumfiexa ilium superficialis-superf. iliac circumf. (Sl) 13. V. circumfiexa femoris medialis-medial femoral circumf. ( MF) 14. V. circumfiexa femoris lateralis-lateral femoral circumf. ( LF) 15. V. lumbalis ascendens-ascending lumbar vein (AL) 16. V. iliolumbalis-iliolumbar vein (IL) 17. V. lumbalis-lumbar vein (L) 18. V. glutaea-gluteal vein (G) 19. V. mesenterica inferior-inferior mesenteric vein (IM) 20. Vesical plexus ( vp) 21. Presacral plexus ( sp) 22. Pudendal plexus ( pp) 23, Hemorrhoidal plexus ( hp) 22 K. FUKUTA was due to that a large amount of urografin ascended through the vena cava and the necessary density was not given to the intrapelvic veins. The circulating state of venous blood is variable at different regions, and accordingly a great difference exists between the pelvis and the lower extremity, which results in the difference of the venographic technique between the both regions. In the lower extremity, the venous blood flow is slow and the a-fore­ mentioned problem or the descent 47 l of a contrast medium is rather advantage­ ous, and the erect position brings better result.7l At the same time, the erect position is theoretically better for emphasizing the manifestation of venous disorders, such as varicosity, deformity of vein, congestion and valvular dys­ function etc., and consequently this position is of more diagnostic value. Although it is probable that similar theories can be applied to the pelvis, the author recommends the horizontal position in the pelvic venography by the following reasons: (a) The hydrostatic pressure, namely, the static head from the heart is less than at the lower extremity, so that the difference between erect and horizontal positions concerning the pressure to the vein is not so much as in the lower extremity. (b) If horizontal, the disadvantage of the descent of a contrast medium is less. (c) Differing from the lower ex· tremity, it needs to take rapid and serial roentgenography for the pelvis as mentioned later. (d) Therefore, care must be taken to maintain safety when a patient develops pain, vertigo, nausea or orthostatic collapse 19l etc. Thus, all cases in this study, except the three cases above mentioned were examined in the horizontal position.

2) Prone Supine and Oblique Position The horizontal position has been discussed to be suitable for the pelvic venography, but hereupon it comes into question which is better, prone or supine. If considering anatomically the direction and inclination of the intra· pelvic veins particularly the iliac vein, it is favorable to take roentgenograms in both positions.20 l Practically, however, it is almost impossible to take X-rays in both positions in the course of one injection of a contrast medium. Of course, it may be possible if one uses a large amount of contast medium and repeats the procedure; but when considering the annoyance to a patient, the economical aspect, the exposure to radiation, the toxicity of a contrast material and its appearance in the bladder (already explained), the procedure must be as simple and efficient as possible. Also it has been impressed that there is not much difference between the two positions for observing the pathological change in the main veins of the pelvis. From the above viewpoints, the supine position was adopted in all cases except Case 25 (Fig. 25), and the following technique was devised. With a subject in the supine position, antero-posterior projection and oblique projection were taken during one injection of a contrast medium; namely, while injecting 40 cern of urografin, 2 films of A-P projection were taken at the time when injecting 20 cern and 30 cern, 1 film of 10-degree-oblique projection at 35 cern injection and finally 1 film of 30-degree-oblique projection upon completion of 40 <;em injection, It should not i;>e mistaken to lift the hip of the opposite si(le A STUDY OF PEL VIC VENOGRAPHY 23 and place the side where the contrast medium is injected close to an X-ray plate, because it is needless to say that the clearer roentgenogram can be obtained when the portion subject to be examined is placed more closely to the film. Concerning the importance of the oblique projection; the author thinks that the pelvic venography would become more valuable by taking roentgeno­ grams from 2 directions, i.e., anteroposterior and oblique, because one can observe the pelvic veins three-dimensionally and understand the position and direction of collaterals as well, and consequently, upon operative treatment, injury of the collaterals can be minimized and the result of operation would be better. Collateral veins seen in Fig. 10 (Case 14) are not clearly understood re­ garding their positions by this A·P projection alone, but they can be identified as the deep iliac circumflex and the inferior epigastric veins that are running in a fairly anterior region from Fig. 11 taken by the oblique projection. Similar phenomenon can be noted in Case 21 (Figs. 20 and 21).

3) Comparison of Intravenous and Intraosseous Routes Our experience has revealed that, in the lower extremity, the intraosseous and intravenous injections have no difference regarding the pathway of a con­ trast medium from the dorsum of a foot. Therefore, if venipuncture is impossi· ble due to obesity, edema, swelling or collapse of vein, we can utilize the bone marrow to aquire a venogram similar to that with the intravenous injection. In the pelvis, however, there is some diffence between the two routes. In the pelvic venography, the intraosseous injection (to the pecten ossis pubis, tuber ossis ischii, crista iliaca, sacrum or trochanter major) brings the contrast medium first to the hypogastric vein and then into the external iliac and common iliac veins. On the other hand, by the intravenous injection from the thigh, the contrast medium passes the external iliac first, then the hypo· gastric and its tributaries. Hence, it may be said that the transvenous route is superior for investigating the femoral, external iliac and common iliac veins which are of more importance in the thrombosis of the lower extremity. The author dared not perform a transosseous pelvic venography in 25 cases of this report except Case 4, because of the long and extensive studies carried out by Hashimoto 27 > and others in our department, where the results indicated disadvantages, such as the difficulty of positioning a subject, the problem of timing, the pain during and after the injection, beside the a-fore­ mentioned difference in the pathway of a contrast medium. At the present time, therefore, the transvenous method is exclusively adopted for pelvic veno­ graphy in our department.

4) Veins to be Used for Pelvic Venography In this series the vena cava, penis, clitoris, scrotum and hemorrhoidal vein etc. were not utilized. These seem to have certain advantages respectively for specific purposes but have many disadvantages as well. The practical useful­ ness is more important than mere academic interest. Therefore the method with simplicity, safety ano certainty is i<;leal. frorn the ~l:>ove re~sops, the 24 K. FUKUTA author has utilized only the femoral, popliteal, saphenous and subcutaneous veins throughout this study.

5) Comparison of Methods and Regions for Intravenous Injection of Contrast Medium Generally speaking, there are 3 methods for injecting contrast material, namely, percutaneous puncture, incision for exposing a vein and catheterization. In this series, the percutaneous puncture was performed in 16 cases, the incision in 6 and the catheterization in 10 cases. The simplest method is, of course, the percutaneous puncture and if this is impossible an incision must be made. These methods of puncturing a vein should be performed with a great caution as the pelvic venography requires the rapid injection of a contrast material. Frequently the needle will pierce the vein wall and the contrast material leaks. The catheter method is safe in this aspect and also gives very good contrast filling of the pelvic veins, although it demands care not to injure the intima of the vein.

A) Subcutaneous veins of the thigh This is a method to puncture a superficial vein with a needle of 19 or 20 gauge and by the aid of a tourniquet. In this technique, it is not adequate to use anywhere of the thigh but rather its proximal part must be chosen. If injected from its distal part, no sufficient contrast density could be sent to the pelvic veins (Cases 10 and 19). Also a case for which the injection was made to a superficial vein in the lateral side (Case 15) gave worse result than one with an injection from the medial side. This indicates that the injection of a contrast medium is better to be done into the superficial vein close to the femoral or greater saphenous vein. As the 76% urografin solution is viscid, a large gauge needle must be employed. There is, however, not always present in the thigh such a big superficial vein that the large needle can enter easily through the skin. Only when an abnormal dilatation or varicosity either of primary origin or secondary to deep venous occlusion is present, the puncture is readily succeeded. Case 2 (Figs. 2 a and 2 b) is an example of primary varicosity for which the injection was made at the upper 1/4 of the thigh. Case 9 (Fig. 7) and Case 14 (Fig. 10) are examples of deep venous occlusion with injection at the level of the upper 1/3 and 1/4 of the thigh respectively. It must be cautious that even though the presence of adequate superficial veins was noted upon the physical ex­ amination priorly, they frequently collapsed to make the percutaneous puncture impossible during the procedure of venography and resultantly to force us to adopt other methods and routes.

B) Greater saphenous vein This vein has been revealed to be the most useful and convenient for the pelvic venography. In this series, it was utilized 17 times and gave generally better and more reliable venograms than the a-forementioned direct puncture of the subcutaneous veins. A STUDY OF PELVIC VENOGRAPHY 25

Puncture was performed 5 times, incision 5 times and catheterization 7 times (Table 1). Upon comparing these 3 methods, if the technique is correct, the venogram obtained would be indifferent. Case 13 (Fig. 9) is an example of puncture from the lower 1/3 of the thigh, Case 4 (Fig. 3) and Case 8 (Fig. 6) are with incision at the level of the middle and the upper 1/3 respectively of the thigh. Case 22 (Fig. 24), Case 21 (Fig. 20) and Case 18 (Fig. 16) are ex­ amples of catheterization. In general, of course, the method with catheterization has an advantage of being successful regardless of the technique. Further it has another advantage that a catheter can be inserted into any level of the greater saphenous vein, namely from the ankle to the groin and its top can be advanced to any optional level for injecting a contrast medium. In Cases 21 and 22 mentioned above, the catheter was inserted at the upper 1/3 of the leg and advanced for 30 em in the former and 10 em in the latter. In Case 18, the catheter was inserted 3 em from the level of the upper 1/3 of the thigh. There are also cases in which the catheter was further advanced into the femoral vein (Case 1, 5, 12 and (17). Hereupon there arises a problem at what level it is best to inject the con­ trast medium, namely, where the puncture, the incision or the top of a catheter should be made or placed. According to the result of this study, the following can be suggested: For pelvic venography, of course, the nearer to the pelvis, the better the contrast density in the pelvis would be. However, (1) there are many tributaries and communicating veins before the junction with the femoral vein and these are important to be visualized; (2) in many cases, the femoral vein has occlusive pathology and the greater saphenous vein is not infrequently involved simultaneously; the above two reasons make us to recommend that the injection of a contrast medium is best to be performed at the level between the lower 1/3 and upper 1/3 of the thigh. On the other hand, the cases with injection at too distal level, i.e., below the knee, as Case 7 (puncture) and Case 3 (catheterization), failed to give sufficient contrast density in the pelvis.

C) Femoral and popliteal veins To these veins, direct puncture and catheterization through the saphenous veins (greater and small) were conducted. Direct percutaneous puncture of the femoral vein was performed in Case 6 (Fig. 5). Catheterizations were made through the greater saphenous vein in Cases 1, 5, 12 and 17 and through the small saphenous vein in Case 25. Generally speaking, in patients subjected to pelvic venographic examination, their femoral veins frequently have abnormalities such as occlusion due to organized thrombus and others. It is meaningless to inject a contrast medium forcibly into such an abnormal region, because the venogram obtained is sup· posed to be inaccurate and insufficient, so that one can not thoroughly investi· gate recanalization, patency and collateral pathway etc. by it. Contrarily, if considering a normal case without presence of any venous pathology, the vein wall, as a rule, would be injured very easily by the action of a needle or a catheter and the stimulation of a contrast material. Conse­ quently it can be said to be advisable to avoid such an important vein as the 26 K. FUKUTA femoral and to use the saphenous vein which is far less important and safer. Catheterization through the small saphenous into the popliteal vein (Case 25) is an easier and safer method than the catheter method directly to the popliteal vein (Case 23). Also this method has the advantage that venographies of both the pelvis and the lower extremity can be performed successively by changing the position of patient from horizontal to erect, and regulating the length of catheter inserted. This is believed to be an excellent method when a pathology is suspected in the region of thigh.

D) Veins on leg or foot If an injection is made from the dorsum of the foot or the lower portion of the leg, the contrast density is not sufficient for visualization of the pelvic veins. In Cases 7 and 11, although a large amount of urografin was injected rapidly into the dorsum of the foot with a tourniquet applied on, the pelvic venogram obtained was of poor contrast density. Moreover, the contrast medi· urn was found not to fill the vein cavity but to run in its center by this method, so that the state of the vein wall could not be examined satisfactorily.

6) Contralateral Injection Method At the early stage of this study, the author discovered that the contrast material injected from one side flowed into the opposite side to visualize the common iliac, external iliac, hypogastric and femoral veins of bilateral sides simultaneously. Case 2 is an example of this phenomenon. This patient was with primary varicose veins and a localized superficial thrombophlebitis in the left lower limb, but no abnormality was contemplated regarding the intrapelvic veins upon the history and physical examination. Urografin was injected rapidly into a subcutaneous vein of the upper 1/4 of the left thigh by puncture and 4 roentgenograms were taken serially. The contrast medium travelled into the opposite side through the common femoral, external iliac, obturator, hypo­ gastric veins and presacral plexus before ascending to the vena cava (Figs. 2 a and 2 b). They were normal pelvic venograms regarding venous pathology although some anomaly was incidently noted in the right iliac system. In Case 4 (Fig. 3), the external iliac vein was proved to be occluded but the contrast material flowed through the median femoral circumflex, obturator veins, hemorrhoidal and presacral plexuses, and visualized the contralateral pelvic veins. It can be said in this case that the occlusion of the external iliac veins forced the detour of the contrast medium as seen in many other cases (Case 6, 8, and 21), but the former (Case 2) indicated that such a phe­ nomenon can occur even in normal state, which was verified in Case 13 (Fig. 9) and Case 20 (Fig. 19). Utilizing this fact, Case 5 who had a tumor and swelling over the right inguinal region was examined by inserting a catheter to the left saphenous vein through which urografin was injected, and the presence of a sarcoma and its relation with the blood vessels in the opposite side were explored as shown in Fig. 4. Thus, if the presence of thrombus or tumor disturbs the injection qf a contrast medium, one can achieve the purpose by this contralateriil ip- A STUDY OF PELVIC VENOGRAPHY 27

jection method. For this method, it is necessary to inject a large amount of contrast medium from the level close to the pelvis. If it was tried from the distal level as in Cases 7 and 25, the urografin did not flow to the opposite side but ascended straight through the blood stream from the femoral to the vena cava. If the contrast medium does not flow to the opposite side despite the ex­ istence of an occlusion in the external iliac vein, it must be considered that the external iliac vein of the other side has an occlusive lesion as well (Fig. 7), or the important anastomotic routes such as the median femoral circumflex and obturator etc. are occluded at their junction with the femoral. In the latter case, collaterals develop in various modes (Figs. 5, 10 and 20).

(7) Simultaneous Injection of Contrast Medium to the Bilateral Thighs This is a method to inject 20 cern each of urografin from the bilateral thighs simultaneously for visualizing the main intrapelvic veins of right and left sides by a single roentgenogram. Three patients, Cases 11, 19, and 20, were ex· amined by this method (Fig. 8). This technique is useful when both lower extremities have swelling and tenderness, so that occlusive changes are sus­ pected in the bilateral femoral or external iliac veins. It is also advantageous for understanding completely the extent of occlusion in the case with unilateral involvement. Care, however, must be taken of the fact that the contrast medi­ um can flow over to the contralateral side and consequently, if an occlusive lesion is small, it might be overlooked because the contrast medium fills and covers the space proximal to the lesion. Therefore, when an occlusion is ex­ pected in only one side, it is better to try a single injection to the homolateral side first. The venous stream through collateral pathways can be pursued more clearly by the latter method.

8) Quantity and Concentration of Contrast Medium, Speed of Injection and Timing of Exposure The quantity, concentration and injecting speed of contrast medium are closely related with the venogram to be obtained. Throughout this study, the author employed urografin, and compared various concentrations, amounts and speeds. As the results, it was found essential to inject rapidly a large amount of the material of high concentration. This is a difference from the venography of the lower extremity in erect position. According to our experience, the problems of concentration and in­ jecting speed are little worth consideration for the lower extremity, but it is only necessary to use a large quantity (40 cern) of contrast material. In the pelvis, the blood flows more rapidly, the amount of blood and the size of vessels are larger than in the lower limb, and moreover gravity can not be utilized because of the horizontal position; therefore the injecting speed becomes a problem. If slowly injected, a satisfactory venogram can never be obtained even though a large amount is employed. It is necessary to inject at the rate of 1 cern or more per second for the pelvic venography.

Con<;:erning the concentration1 investigations were <;:arried out by comparing 28 K.FUKUTA

76% (commercially available) urografin and its diluted solutions with normal saline or sterile water, and disclosed that the pelvic venogram required higher than at least 60% urografin concentration. In order to inject the viscid fluid at high speed, the needle or catheter used must be large in size, i.e., 19 or 20 gauge or more. Regarding the quantity, generally a case with 20 cern injected was found unsatisfactory in comparison with a case where 40 cern was used. In regard to the timing and number of exposure, since false interpretation may be produced by spasm of veins or momentary change in contrast density if only a single exposure is made, and also as the circulation time is variable in each patient and the contrast medium flows slowly in some cases while very rapidly in others, it should be advised to take 3 or more roentgenograms serially. Of course, the a-forementioned oblique projection must be included. As the timing, therefore, the author recommends the following technique: if 40 cern is used, while the injection is being performed at the rate of 1 cern per second, 4 exposures are made at the moments when 20, 30, 35 (15o·oblique) and 40 cern (30°-oblique) are injected. The 3rd exposure at 35 em can be omitted. If the function of the veins, namely, the state of venous flow is par· ticularly desired to be examined, another exposure is made after completing the injection of whole contrast material. The density of the contrast medium on the venogram rapidly becomes light, when the venous function is good. This "functional venography", however, is not so valuable as in the lower extremity. Although it is supposed helpful to use a pillow or inflated balloon 'l HJ to press the epigastrium, the author simply made the patient hold a breath and strain as long as possible according to the Valsalva's maneuver.2'l 41 l

9) Conditions of Roentgen Exposure Conditions of roentgen exposure, i.e., exposing techniques have an important influence upon the quality of venogram obtained. The conditions used for this series were as follows:

Capacity 1.0-1.5 mF Amperage 150-200 milliamp. Voltage 62-64 kv Distance (focus-film) 100-120 em (Time 1/15-1/20 second) For the anteroposterior projection, FS intensifying paper (made by Kyokuko Co. Japan) was employed. For the oblique projection, MS intensifying paper (1.5 times more sensitive than the FS) was employed and the conditions were adjusted to 60 kv, 1.5 mF and 150 milliamp. Since the anteroposterior and ob­ lique projections must be taken by quickly changing the conditions in a short period, an intimate cooperation with the X-ray technician is demanded. In all cases, a stationary grid should be employed.

10) Side Reactions No side reaction was encountered in 19 out of 25 cases. The remammg 6 cases are composed of nausea (2), chill (1), phlebitis (1), and thrombosis (2). Compared with this, in the venography of the lower limb in erect position per- A STUDY OF PELVIC VENOGRAPHY 29

formed by the author, out of 27 cases, vertigo and fainting (6), nausea (1), chill (1) and phlebitis (1) have been observed (Table 2).

TABLE 2. Incidence of Side Reactions Pelvic venography 25 Lower limb veno­ cases (horizontal graphy 27 cases position)* i (erect posi tioil_)__ _ Nausea 2 (Cases 2 and 9 )** 1 Chill 1 (Case 6) 1 Vertigo and fainting 0 6 Phlebitis 1

The main side reactions can be classified as follows:

a) Allergic reactions due to the contrast medium itself (urticaria, nausea, vomiting, dyspnea, anaphylactic shock etc.) Since the purpose of this study was to investigate the methodological aspect of pelvic venography, urografin was constantly and exclusively employed as contrast material. According to the experience in our department, urografin was proved to be excellent and with less side reaction than other kinds which had been used priorly. In this series, only 3 cases manifested mild allergic reactions, namely, 2 nausea and 1 chill out of 25 cases. The treatment is the administration of antihistamine drug. In fact, this was necessary in only 2 patients (Cases 6 and 9). It is, however, important to inquire the allergic history of the patient and to perform sensitivity tests by placing a drop of the contrast material under the tongue or by injecting about 1 cern of the material intravenously prior to the procedure.

b) Temporary cerebral anoxemia resulting from pain, fear or orthostatic po­ sition (vertigo, collapse, fainting, convulsion etc.) As indicated previously and in Table 2, the occurrence of side reaction was found to vary with the position of subject. Vertigo and fainting which scarcely developed in the horizontal position were encountered in the erect position (Cases 13, 24 and 25). One of the examples is Case 25 who was a neurotic patient and when the lower limb venography was about to be per­ formed in the erect position he suddenly fainted and continued convulsions for a few minutes. A surprising fact was that this happened when a needle was being inserted to the dorsum of foot and no urografin had been injected yet. The procedure was discontinued, and a painless catheter method was performed several days later when he had no trouble during pelvic venography in the horizontal position and even during subsequent lower limb venography in the erect position. This case speaks for that pain or fear plays an important role as the proximate cause of cerebral anoxemia other than being in the erect position. 30 K.FUKUTA

The treatments for these reactions are immediate bed rest, Trendelenburg position and oxygen if necessary. It is more important, prior to the procedure, to instruct the patient not to have any fear. Also local anesthesia must be sufficiently utilized. c) Phlebitis and thrombosis Similarly to many other reports,19132 ' 39 ' phlebitis and thrombosis have been believed to be most important among the side reactions encountered by the author. In 66 venographic examinations for the pelvis and the lower limb on 36 patients, phlebitis developed in 2 cases (9 and 21) and thrombosis in 2 cases (17 and 22). Case 9: Immediately after a pelvic venography had been taken, another venography for the right lower limb from the dorsum of the foot was per­ formed with the patient in the erect position. Next day he developed acute superficial phlebitis over the right leg. As efficient treatments were started immediately, the symptoms disappeared in several days without advancing to thrombus formation. This patient had swelling in both lower limbs, of which the left side was of spontaneous onset 7 months priorly but the right side resulted from the venography performed 3 months later in some other hospital; namely, he had a history of thrombus formation due to venography (Fig. 7). Case 21: Left iliofemoral phlebothrombosis following appendectomy (Fig. 20). A pelvic venography was taken by inserting a catheter through the greater saphenous vein from the leg to mid-thigh (30 em). Phlebitis appeared along the saphenous vein next day, but was healed by instant and adequate treatments. This was considered to be closely connected with an injury due to the catheter. Case 17: Left iliofemoral thrombophlebitis due to trauma (Fig. 14). Upon a venographic examination, an incision was made over the upper thigh and a catheter was inserted into a subcutaneous vein near the saphenofemoral junc­ tion; but it was instantly plugged by a blood clot, hence another new catheter was introduced to the greater saphenous and advanced to the femoral vein through which urografin was injected. An operation was performed to resect the obliterated vein two days later, when there was found a newly developed thrombus accompanied by an old organized thrombus. Case 23: Left lower extremity elephantiasis. A catheter was inserted to the popliteal vein through an incision over the popliteal fossa, but produced a blood clot shortly before being connected to a bottle of 5% glucose solution for irrigation, so that the procedure was discontinued. Although the lower limb did not develop swelling or redness, a transmedullary venography from the calcaneous 5 days later revealed a segmental occlusion of the popliteal vein with development of new collateral pathways. From the above and other experiences, the author would suggest the follow­ ing cautions for preventing phlebitis and thrombosis. 1) It must be cautious not to injure the vessel with a needle or catheter any more than least neces· sary. 2) Immediately after the procedure, the lower limb examined should be moved passively and actively. 3) Administrate heparin 50 mg (5 000 unit) about A STUDY OF PEL VIC VENOGRAPHY 31

10 minutes prior to the procedure. 4) If use a catheter, it must be connected, in advance, to a bottle or syringe for continuous irrigation with water or saline solution.

1.1) Cautions for the Interpretation of the Pelvic Venogram The anatomy of veins in the pelvis is rather complicated and shows indi· vidual differences to a considerable extent. The number, location and form of venous 1l 42 l 43 l valves are not constant. The state of tributaries and anastomoses in normal state and the development of collaterals in abnormal are also variable in each individual. Further, the absence of contrast material due to spasm or technical difficulties is occasionally misinterpreted as occlusion. Therefore the interpretation of pelvic venogram must be made with caution. The clinical purpose of the pelvic venography is mainly to observe the state of large veins and the development of collaterals. It can be said to be normal if a vein on venogram appears to be filled completely with contrast medium but, if a vein has a filling defect, it can not always be concluded to be abnormal, for it may mean a pathological change or be due to spasm or inadequate technique. In the latter case, the figure of collaterals furnishes a helpful information.

A) Explanation of various pelvic venogram Normal cases-Case 2 (Figs. 2-a and 2-b), Case 11 (Fig. 8), Case 13 (Fig. 9) and Case 25 (Fig. 25) are normal examples. Filling of contrast medium is good, without any defect, and the vein wall appears smooth with no irregularity or tortuosity. Abnormal cases-are characterized by filling defect or tapering of contrast medium, tortuosity, dilation or irregularity of veins and abnormal development of collaterals. Case 22 (Fig. 24) indicates varicosity or abnormal dilation of the external iliac vein and others. Case 5 (Fig. 4) shows an interruption of venous pattern due to sarcoma in the right pelvis. Incidently a metastatic lesion was found lateral to the left common iliac vein and these findings were confirmed by Ba­ enema. Case 4 (Fig. 3) is an example of occlusion of the external iliac vein due to thrombosis. The pathway from the left common femoral to the common iliac vein is almost completely obliterated, so that the venous stream travels over the opposite side through the median femoral circumflex, obturator and hypogastric veins, lateral, presacral and hemorrhoidal plexus. The right iliac veins show no pathological change but the tortuous appearance of intrapelvic communicating veins is abnormal. Case 6 (Fig. 5) has likewise an occlusion in the iliac veins, although the pudendal plexus is the main communicating route to the opposite side. Case 14 (Fig. 10) has similarly an iliofemoral oc­ clusion but the main collaterals are the deep iliac circumflex and inferior epi­ gastric veins of the same side without such communications to the other side as seen in the above 2 cases. In Case 21 (Fig. 20), the collateral routes against the iliofemoral occlusion consist of the inferior epigastric of the same side and 32 K. FUKUTA the pudendal plexus to the iliac vein of the opposite side. The above 4 cases are examples with complete occlusion of the external iliac vein etc. Meanwhile, Fig. 7 and Fig. 14 demonstrate the presence of a considerable amount of blood stream in the external iliac vein and the marked tortuosity and irregularity of venous pattern. These are the appearances of incomplete occlusion which retains canals in the vein resulting from recanali­ zation or parietal formation of thrombus. Occlusion of a small segment is seen in Figs. 6, 16 and 19. It is typical for the collaterals to bridge the gap in these cases.

B) Observation on the venous collaterals resulting from obstruction of specific intrapelvic veins Occlusion of the external iliac vein: 1114, 29133144148 ' 491 The collateral route passes through the median femoral circumflex, obturator, hypogastric veins, and then the hemorrhoidal or sacral plexus to the iliac veins of the opposite side (Fig. 3), communicates with the opposite iliac veins via the pudendal plexus (Fig. 5 ), or utilizes the pudendal to connect with the opposite side and simultaneously the inferior epigastric of the same side to reach the internal mammary vein (Fig. 20). Differing from the above, there are cases which by-pass the obstruction mainly through the inferior epigastric or deep iliac circumflex veins without passing through the opposite side (Figs. JO and 14). These are believed to have thrombotic involvement near the saphenofemoral junction which disturb the venous return through the opposite iliacs via the median femoral circumflex or external pudendal veins etc. Of course, when the iliac vein of the con­ tralateral side is also occluded, namely, in the case with the bilateral iliac occlusions, a similar phenomenon should occur, but these two patients, Case 14 (Fig. 10) and Case 17 (Fig. 14), could not be considered to have bilateral occlusions from their histories and physical examinations. Occlusion of the femoral vein: If the obstruction is localized in the region of the femoral vein, the median femoral circumflex (Fig. 6) or the lateral femoral circumflex (Fig. 16) becomes the detouring route. There may also be some return through the obturator vein, leading into the hypogastric and then the common iliac vein. Occlusion of the inferior vena cava or the common iliac vein: The collateral pathways are considered as follows: (1) The inferior epi­ gastric-internal mammary vein. (2) The deep iliac circumflex-ascending lumbar-azygos-superior vena cava. (3) The superficial iliac circumflex or superficial epigastric-thoracoepigastric -lateral thoracic-axillary vein. In the patients subjected to this study, there was no case with diagnosis of complete occlusion of the vena cava, either clinically or roentgenographically. These routes, however, can be utilized by the cases with more distal occlusion, e.g., in the external iliac vein as mentioned already. The last route, which passes through the superficial abdominal wall, can not be visualized by an ordinary pelvic venography unless by injecting the A STUDY OF PELVIC VENOGRAPHY 33 contrast medium directly into the dilated vein on the abdomen. It appeared slightly in Fig. 5 and Fig. 20 but the contrast density was very poor, because the most of urografln passed through other pathways. After all, the author believes that it is not easy to make generalized pat­ terns of collateral venous networks naturally developed in phlebothrombosis unlike those following ligation either in an animal experiment or as a prophy­ lactic procedure to prevent pulmonary embolism; because the extent of oc­ clusion is different from case to case, the involvement of the junction with a tributary is variable and the mode of collaterals may change in the process of recanalization.

C) Comparison of microscopic finding and venogram Important problems involved in the interpretation of venogram are the recanalization and the intraluminal space remaining in parietal thrombus for­ mation. The recanalized streams which appear as only a few fine lines on venogram are frequently overlooked to be misinterpreted as a complete oc­ clusion. Contrarily, the vein which has only a little space with very poor patency sometimes falsely appears on the venogram as if a considerable space were present in it due either to pressure by the injection of contrast material or to direction of roentgen exposure. The author has experienced four inter­ esting cases which were operated upon for the resection of occluded vein after venographic examination, hence the above views may be explained below by comparing the venographic appearance with the microscopic finding. Case 14 (Figs. 10, 11, 12 and 13): Fig. 12 is the enlarged picture of a part of Fig. 10. A black arrow sign indicates the external iliac vein demonstrated by several fine lines of a contrast medium which gives an impression of almost complete occlusion. The patient was operated upon for resection of this por­ tion, about 5 em in length. The vein appeared like a hard cord and adhered with the accompanying artery and surrounding tissue, but a large amount of blood, more than expected, escaped from a cut end upon resection. Fig. 13 is a photomicrograph of the thrombosed portion which is filled with an organized thrombus showing deposition of hemosiderin and cellular infiltration but there can be seen a considerable number of canals in it. Case 21 (Figs. 20, 21, 22 and 23): A part of Fig. 20 is enlarged to demon­ strate the left femoral vein which appears almost completely occluded in Fig. 22. The portion indicated by an arrow sign was resected, 4 em in length, but its microscopic picture revealed the presence of a parietal space and development of canalization. When this venogram was taken with catheter method through the greater saphenous vein, the injection of contrast medium could be performed very smoothly. This point is different from the following Case 17. Case 17 (Figs. 14 and 15): An operation was performed to explore and resect the portion indicated by an arrow sign in Fig. 14. When this venogram was taken, a considerable resistance was felt, unlike the above case, upon in­ jecting urografin through a catheter inserted into the left femoral via the greater saphenous vein. Although the femoral vein appeared being dilated on 34 K.FUKUTA the venogram, it was found at the operation not to have such a size but to be like a slender cord and an organized thrombus filled its lumen so that the canals were very small. Fig. 15 is the photomicrograph of the resected femoral vein which shows canalization in the thrombus. This may give a false im­ pression on venogram if the injection of a contrast medium is done forcibly. Case 18 (Figs. 16, 17 and 18): For venographic examination (Fig. 16), an incision was made to insert a catheter into the greater saphenous vein which appeared whitish pink in color and hard in consistency. The catheter was inserted for 3 em rather forcibly and urografin was injected. It flowed to the proximal part of the common femoral via the lateral femoral circumflex vein. Fig. 16 demonstrated that the proximal end of the greater saphenous vein ap­ pears almost normal, but it can be said that this is only a dilation due to pressure upon the injection of urografin because of the finding above mentioned. Subsequently, an ordinary venogram of the lower extremity was taken in the erect position. It revealed an abnormality of the femoral and an occlusion at the proximal part of the greater saphenous vein, as shown in Fig. 17. The portion indicated by a black arrow sign was resected and its microscopic view demonstrated that the lumen was almost obliterated by a thrombus with cellu­ lar infiltration, hemosiderin deposition, organization and recanalization (Fig. 18). In this case, the contrast medium ascended from the dorsum of the foot, and consequently it can be said that the veins in the thigh were visualized in their natural states. Therefore, the fact that such a small space as seen in Fig. 18 yet gave the wide figure on the venogram (Fig. 17) is believed to relate closely with the angle of projection at the roentgen exposure.

SUMMARY AND CONCLUSION Transvenous pelvic venography was performed on 25 patients in order to investigate its various problems, namely, the position of subject, the quantity, concentration and injecting speed of contrast medium, the timing of exposure, the region and method of injection, the conditions of roentgen exposure, the side reactions, and the relation between venographic appearance and microscopic finding. 1) For pelvic venography, the horizontal position is of choice and the con­ trast medium must be high in concentration (urografin 76-60.%) and large in amount (40 cern). The best technique is to take 3 or 4 roentgenograms seri­ ally, including an oblique projection, while injecting the contrast medium rapidly ( 1 cern per second) . 2) Regarding the region and method for the intravenous injection of con­ trast medium. no standardized technique must be employed but it is essential to choose the route best suited for each subject. Generally speaking, however, it is recommended to utilize the greater saphenous vein at the level between lower 1/3 and upper 1/3 of the thigh for reasons of safety, simplicity and visualizing as many tributaries and communicating veins in the pelvis as possible. 3) It was found even in normal cases that the contrast medium injected A STUDY OF PEL VIC VENOGRAPHY 35

from one side flowed into the iliac veins of the opposite side through midpelvic communicating veins. Utilizing this fact, the contralateral injection method was devised. 4) Regarding side reaction, thrombus formation must be cautioned. Several notes were made for its prevention. 5) Explanation of various pelvic venograms was attempted. From com­ parison with microscopic finding, it was emphasized that there could exist a considerable number and size of canals in the portion which appeared on veno­ gram as if completely obliterated, and conversely a little space in a thrombotic vein could be dilated by pressure due to injection of a contrast medium and cause misinterpretation.

ACKNOWLEDGMENTS I wish to express my appreciation to Professor Dr. Yoshio Hashimoto for his hearty ad vices throughout this work; to Lecturer Dr. Kisaku Kamiya for his encouragement and valuable suggestions; and to many persons of the surgi­ cal and roentgenological departments for their cooperation.

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27. HASHIMOTO, Y. ]. ]. S. S. 58: 939, 1957 and 47: 10, 1946 (Japanese). 28. HASHIMOTO, Y. Venography (Japanese), Nihongekazensho Vol. 9, p. 137. Tokyo: Nan- kodo, 1955. 29. HAYAISHI, A. ]. ]. S. S. 40: 1826, 1940 (Japanese). 30. HELANDER, C. G. Acta Radio/. 44: 410, 1955. 31. HILSHER, W. M. Fortschr. Rontgenstr. 82: 741, 1955. 32. HOMANS, J. ]. A. M. A. 119: 136, 1942. 33. HOMANS, J. Surg. Gynec. and Obst. 79: 70, 1944. 34. LESSER, A. AND G. DANELIUS. Ann. Surg. 119: 903, 1944. 35. LESSMANN, F. P. ET AL. Acta Radio/. 44: 397, 1955. 36. MARK, J. Ann. Surg. 118: 469, 1943. 37. MCLACHLIN, J. AND J. C. PATERSON. Surg. Gynec. and Obst. 93: 1, 1951. 38. MILES, R. M. ET AL. Surgery 33: 849, 1953. 39. MONCRIEF, J, A. Ann. Surg. 147: 166, 1958. 40. MOORE, T. C. Archiv. Surg. 72: 122, 1956. 41. O'LOUGHLIN, B. J. Amer. ]. Roent. Rad. Th. 58: 617, 1947. 42. PECK, M. E. Ann. Surg. 146: 619, 1957. 43. POWELL, T. Surg. Gynec. and Obst. 92: 453, 1951. 44. QUIRING, D. P. Collateral Circulation p. 83-94. Philadelphia: Lea and Febiger, 1949. 45. RAPPAPORT, A. M. Canada M. A.]. 67: 93, 1952. 46. SAITO, M. ]. ]. S. S. 37: 1479-1791, 1937 (Japanese). 47. SHUMACKER, H. B. Surg. Gynec. and Obst. 98: 257, 1954. 48. SURINGTON, C. T. AND A. F. JONAS, JR. Archiv. Surg. 65: 605, 1952. 49. TAKEUCHI, M. ]. Nagoya Med. Ass. 74: 1315, 1957 (Japanese). 50. VEAL, J. R. Amer. Heart]. 19: 275, 1940.

EXPLANATION OF PLATES

FIG. 2 (a and b). Caes 2: 22-year-old Male. Normal pelvic venogram except anomaly of right iliac system. Horizontal (supine) position. 61% urografin 50 cern ( 76% urografin 40 cern+ saline 10 cern) was injected rapidly (1.5 cern/sec.) into a subcutaneous vein of upper 1/4 of the left thigh by puncture. Fig. 2a was taken when 25 cern being injected. Fig. 2b was immediately after 50 cern being injected. Note that the contrast medium flows into the opposite side through obturator, hypogastric veins and presacral plexus before going up to the vena cava. FIG. 3. Case 4: 29-year-old Male. 76% urografin 30 cern mixed with saline 10 cern was injected into the greater saphenous vein through an incision in the middle of the left thigh. This veno­ gram was taken after injecting all 40 cern of contrast medium. Note a com­ plete occlusion of the It. common and external iliac veins and resulting venous detours. FIG. 4. Case 5: 60-year-old Female. This patient had a big tumor in right inguinal region and a swelling over rt. limb, which disturbed the injection of contrast medium from this side. There­ fore, the left greater saphenous vein was utilized to insert a catheter, through which 40 cern of 76% urografin was injected. This picture was taken upon in­ jecting 30 cern in 30 seconds. An obvious tumor (sarcoma) in rt. pelvis interrupts the rt. iliac veins. FIG. 5. Case 6: 31-year-old Female, A STUDY OF PEL VIC VENOGRAPHY 37

Direct percutaneous puncture into the left femoral vein for injecting 30 cern of 76% urografin. This venogram was taken at completion of the injection. There are seen obstruction of the left external iliac and recanalization of the common femoral vein. FIG. 6. Case 8: 28·year·old Female. An incision was made on the upper 1/3 of left thigh to inject 30 cern of 76% urografin through left greater saphenous vein. This picture was taken upon completing the injection. Note irregularity and incomplete occlusion of the It. common femoral vein and the development of collateral net works. FIG. 7. Case 9: 32-year·old Male. This patient demonstrated "postphlebitic syndromes" in the bilateral lower limbs. By a percutaneous puncture, 30 cern of 76% urografin mixed with 10 cern of sterile water was injected into a dilated superficial vein in the upper 1/3 of right thigh. The right external iliac vein, although patent, is irregular and tortuous, accompanying the obturator and hypogastric veins as collaterals. The contrast medium does not flow into the opposite side, suggesting possible ab­ normality in the left iliac system. FIG. 8. Case 11: 44-year-old Male. Simultaneous injection of contrast medium to the bilateral thighs; 20 cern of 76% urografin was injected to a superficial vein of each thigh. No abnormality was demonstrated in the intrapelvic veins. FIG. 9. Case 13: 31-year-old Male. By a percutaneous puncture at the level of lower 1/3 of left thigh, 30 cern of 76% urografin was injected into the greater saphenous vein. Intrapelvic veins appear essentially normal. Note that the contrast medium travels to the oppo­ site side via the obturator, hypogastric veins and lateral and presacral plexuses. FIG. 10. and FIG. 11. Case 14-a: 38-year-old Male. By a percutaneous puncture, 40 cern of 76% urografin was injected into a super· ficial vein in the upper 1/4 of left thigh. Fig. 10 was taken at the time when 20 cern was injected (antero-posterior projection). Fig. 11 was taken when 35 cern was injected (about 30-degree-oblique projection). The left external iliac is oc­ cluded and collateral routes through the inferior epigastric and deep iliac circum­ flex veins are developed. FIG. 12 and FIG. 13. Case 14-b. A part of Fig. 10 is enlarged to demonstrate several fine lines corresponding to the external iliac vein, indicated by a black arrow sign in Fig. 12. The pa­ tient was operated upon for resection of this portion, about 5 em in length. The vein appeared like a hard cord and adhered with the accompanying artery and surrounding tissue, but a large amount of blood, more than expected, escaped from a cut end upon resection. Fig. 13 is a photomicrograph of the thrombosed portion. Hematoxylin-eosin staining. x24. FIG. 14 and FIG. 15. Case 17: 33-year-old Male. Iliofemoral thrombophlebitis following trauma. See fractures of pelvic bone. 40 cern of 76% urografin was injected with resistance through a catheter into the left femoral via the greater saphenous vein. Fig. 14 was taken when 30 cern was injected. Note tortuosity and irregularity of the left external iliac vein. The femoral vein, however, appears dilated. An operation was performed to explore and resect the portion indicated by an arrow sign. Fig. 15 is photo­ micrograph ( x 24) showing canalization of a thrombus in the femoral vein, which may give a false impression on venogram if the injection of a contrast medium 38 K. FUKUTA

is done forcidly. PAS staining. FIG. 16, FIG. 17 and FIG. 18. Case 18: 59-year-old Male. 30 cern of 76% urografin was injected through a catheter into the greater sapen­ ous vein of the left thigh (Fig. 16). The femoral vein is ob[tructed and the lateral femoral circumflex veins are bridging the gap. Fig. 17 is an ordinary venogram of the lower extremity, in erect position, using the dorsal vein of foot for dye-injection. Fig. 18 is photomicrograph of a section of the femoral vein indicated by a black arrow sign in Fig. 17. Hematoxylin-eosin staining. x24. FIG. 19. Case 20: 26-year-old Female. 20 cern of 76% urografin with 10 cern of sterile water was injected into the left greater saphenous vein through an incision. Partial obstructions and resultant collateral bridges are noted in the left external iliac and femoral veins. FIG. 20 and FIG. 21. Case 21-a: 42-year-old Male. Through a catheter inserted from the leg along the greater saphenous vein to the mid-thigh of left side, 40 cern of 76% urografin was injected. Fig. 21 ( antero· posterior projection) was taken when 30 cern was injected. Fig. 22 (20-degree­ oblique projection) was taken when 40 cern was injected. Note the complete obstruction of the left iliac veins and development of collateral pathways. FIG. 22 and FIG. 23. Case 21-b. A part of Fig. 20 is enlarged to demonstrate the left femoral vein which appears almost completely occluded in Fig. 22. A portion of this femoral vein indicated by an arrow sign was resected and its microscopic picture is shown in Fig. 23. PAS staining. x 24. FIG. 24. Case 22: 34-year-old Female. A catheter was inserted from the right leg to the greater saphenous vein and its top was placed at the level of lower 1;5 of t}1e thigh. While injecting 40 cern of 76% urografin at a rate of 1 cern per 1.5 second, 4 pictures were taken and this figure is the last. The other 3 venograms could not visualize the varicosity along the right external iliac vein. This suggests that the venous circulation time of this region is rather slow. FIG. 25. Case 25: 22-year-old Male. In prone position, a catheter was introduced into the left popliteal vein via the small saphenous vein. 40 cern of 76% urografin injected from a level10 em above the saphenopopliteal junction. FIG. 2·a FIG. 2-b

FIG. 3 FIG. 4 FIG. 5 FIG. 6

FIG. 7 FIG. 8 FIG. 9 FIG. 10

FIG. 11 FIG. 12 FIG. 13

FIG. 14 FIG. 15 FIG. 16 FIG. 17 FIG. 18

FIG. 19 FIG. 20 FIG. 21 FIG. 22 FIG. 23

FIG. 24 FIG. 25