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On the basis of previous reports on a possible correlation between phlebographic patterns and diseases of the prostatic gland, indications of the pelvic phlebography in the staging of the prostatic cancer are discussed, in order to carry out informations according to TNM system.
Intraosseous injection of potassium iodide was carried out at the level of the malleolus and the iliac crests in 90 cadavers. Information concerning the anatomy of the veins and concerning different organs was also obtained. We still need to compare this information with that from in vivo phlebography and the results from biopsy. Radiographic films taken at the moment of injection and at various times up to 60 minutes after injection, show the filling not only of the local veins in the lower extremities or the pelvis, but also a flow of contrast material through the abdominal organs and up to the level of the brachio-cephalic veins. Studies on cadavers in the vertical position show little or no difference. We show the filling of the venous system and especially the hepatic and renal veins. Various considerations on the nature of this dynamic effect in the cadaver are discussed, but this will need further study. There are certainly limits of exactitude for this method in comparison with autopsy. The method is not expected to supersede angiography in living patients. It is rather a complementary technique to be used especially in cases where an in vivo angiographic study is lacking or where a biopsy is impossible. In certain cases it is possible to discover radiologically anatomical lesions which are difficult to detect by autopsy or are easily distorted by this procedure.
Various techniques for showing venous function are recognized. The value of isotope phlebography is shown here on 39 unselected cases in whom contrast filling was also carried out. Rapid injection of 2 m Ci TC 99m into a dorsal vein of the foot produced isotope phlebograms with a Dyna camera 2 C.
For the diagnosis of intra- and retro-orbital processes, orbital phlebography occupies a key position whereas carotid arteriography visualizing the ophthalmic artery has only a limited diagnostic value for the assessment of absolute intra-orbital processes. Use of subtraction method and magnification technique brought essential improvement to the vessel representation of the orbit. Combination of these techniques in connection with computerized axial tomography (EMI-Scanner), as a rule, allows localization and identification of intraorbital space-occupying processes without difficulty.
A case of a previously undescribed malformation of the inferior vena cava is reported: there was distal normoposition and proximal transposition, with anterior crossing over the aorta; the right renal vein flowed into the inferior vena cava located on the left, after crossing over the anterior face of the aorta. This anomaly was shown by echography and isotopic phlebography.
The accuracy of occlusive impedance phlebography (IPG) depends on recognition of the artifacts that produce false-positive results. Fifty per cent of a series of studies of patients with normal legs showed abnormal results when the recording was made with the leg held straight. We therefore recommend that the patient's leg position be carefully monitored when an IPG test is being administered.
There are clinical situations that may preclude the use of retrograde pyelography and renal arteriography in the differential diagnosis of the absent, dysgenetic and non-functioning kidney. At times these procedures are non-diagnostic. We present 8 cases to demonstrate the efficacy of selective renal phlebography as an aid in the diagnosis of these entities.
The incidence of venous thrombosis diagnosed with the 125I-fibrinogen uptake test was investigated in a prospective, randomized, double-blind study with the patient serving as his own control, using an ionic contrast medium (methylglucamine iothalamate 280) in one leg and a nonionic medium (metrizamide) in the other. The incidence of thrombosis was significantly lower with metrizamide (7%) than with methylglucamine iothalamate (28.6%). The authors conclude that metrizamide is the contrast medium of choice for phlebography.
A comparison was made of the incidence of venous thrombophlebitis resulting from the use of a high-osmolality contrast medium (Conray 60%, meglumine ioxaglate) and a low-osmolality contrast medium (Hexabrix 59%, meglumine iothalamate). In 30 patients with varicose veins, Conray was injected into one leg and Hexabrix into the other. The incidence of thrombophlebitis was then determined using the iodine-125 fibrinogen uptake test in a prospective, randomized, double-blind study. There was significantly less thrombophlebitis with Hexabrix than with Conray and the authors conclude that Hexabrix is safer for phlebography. Hexabrix is also stable in solution, only slightly more expensive than Conray, and one fifth the cost of metrizamide.
The frequency of superior central venous thrombosis was studied in a consecutive retrospective series of 27 patients with severe gastrointestinal disorders in whom long-term catheterization of the subclavian vein for parenteral nutrition was carried out. The patients had 35 periods of catheterization ranging from 14 to 766, mean 86, days and a total of 51 catheter periods. Only one patient showed clinical signs of thrombosis in spite of phlebographic findings revealing seven cases of central venous thrombosis. Recanalization was not seen. Exchange of catheter was performed 17 times in 10 patients using the Seldinger technique. This did not influence thrombosis rate. Septicaemia was found in five patients subsiding after catheter exchange. No fatalities occurred, and no correlation between the septicaemia and thrombosis rate was found. Catheters used for more than 100 days showed changes of mechanical properties. It is therefore advisable to exchange catheters after 3 months' use by the Seldinger technique. The discrepancy between the clinical and phlebographic findings emphasizes that repeated subclavian catheterization should be preceded by bilateral phlebography.
Increased intraspinal venous pressure, resulting according to ABOULKER in numerous spastic paraplegias and quadriplegias is due to multiple venous abnormalities demonstrated by cavo-spinal phlebography. The most frequent are stenoses of the internal jugular veins, the left renal, the left iliac veins, the azygos veins and compressions of the innominate venous trunks. These abnormalities cause a permanent stasis in the intraspinal plexuses through excessive supply or insufficient drainage. Out of 80 patients, 60 per cent had at least 2 abnormalities, 38 per cent at least 3 abnormalities.
Phlebography of the left renal vein was performed in 80 patients with left-sided varicocele demonstrating the nutcracker phenomenon. In 39 cases we could prove a compression of the left renal vein. In 10 varicocele patients additional intravascular pressure measurements were studied in both renal veins in the supine and erect position. We found no significant difference between the pressure in the left and right renal vein in the supine position: values varied with respiration. Changing from the supine to the erect position one can note a significantly elevated pressure, higher on the left side than on the right side due to the longer excursion of the left kidney. Urine investigations were done in 153 patients before and in 191 after sclerotherapy to detect protein or blood. Only in 4 patients we found proteinuria but no microhematuria. The results suggest that the aetiology of the varicocele formation is not the nutcracker phenomenon or renal vein hypertension; the predominant cause is a congenital incompetence of the valves in the left testicular vein. The driving force for the retrograde blood flow from the left renal vein into the testicular vein was the increase in pressure: in the supine position caused by respiration, the continuous reflux in the erect position caused by the hydrostatic pressure. The varicocele does not cause a congested kidney with hematuria and proteinuria.
A technique for assessing the anatomy and luminal diameter of the long saphenous vein by direct injection phlebography in patients being considered for reversed femoropopliteal vein bypass surgery is described. In 25 consecutive patients, 20 single veins, four double veins and one network of veins were all correctly delineated by this technique and subsequently confirmed at operation. Five saphenous veins could not be demonstrated above the knee but at operation one vein was found to be present and double from knee to groin. The minimum mean luminal diameter of the saphenous vein estimated from the X-ray after correction for magnification was 3.5 mm +/- 1.12 which was significantly less than the mean external diameter found at operation, 4.6 mm +/- 1.33 (P less than 0.001). The vein diameter found at operation invariably proved to be larger than the luminal diameter estimated from the X-ray. This allows a confident preoperative assumption of the minimum diameter that will be obtained after dissection and distension of the vein.
Three observations of peripheral aneurysms complicated by venous compression or thrombosis are reported. The clinical and angiographic patterns referred to popliteal, femoral and subclavian localization suggest the role of phlebography in all cases of aneurysms of the limbs.
Thirty patients with suspected obstruction of blood flow in the iliofemoral venous segment were examined by radioisotope phlebography and ultrasonic flowmetry. Comparative appraisal of the diagnostic precision of both methods of examination was made. In 93.3% of cases the results of these methods of examination coincided. Combination of the two methods makes the examination more exact and widens their diagnostic possibilities.
The diagnosis of deep venous thrombosis of the lower limbs often poses difficult problems. Whilst it is usually obvious in cases of massive thrombosis of the ilio-femoral veins, it is often much more difficult in the presence of isolated minimal obstruction of a leg vein. Clinical findings are often inadequate, various laboratory investigations fail to provide definite arguments and only phlebography can confirm venous occlusion. Ultrasound examination by Doppler effect can offer great service in all cases by confirming the clinical impression and aiding in determining the indication for radiological investigation. The reliability of the examination is excellent above the knee and much more hazardous below. At any event, it is based upon a strict protocol and depends essentially upon the experience of the individual performing it.
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