1) The document provides an overview of venography procedures including patient preparation, indications, contraindications, and technique. 2) Key steps in patient preparation include reviewing prior imaging, restricting oral intake, evaluating renal function, and obtaining consent. 3) Indications for lower extremity venography include evaluating deep vein thrombosis, varicose veins, venous malformations, and tumor involvement. 4) Potential pitfalls include underfilling veins, air injection, and valve turbulence which can create false positives, while complications can include contrast reactions, embolism, and local hematoma or infection at the puncture site.

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

5. 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)

6. 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.

13. INDICATIONS (Lower Extremity Venography)
1. 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

19. • 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.

20. Normal
ascending
phlebogram
of the deep
veins.

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

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

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

26. 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.

27. Klippel–Trenaunay syndrome
• Characterised 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.
• Can be associated with superficial varicosities.

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

34. Arm phlebogram showing
normal appearances.

47. (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.

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

49. (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.

50. (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.

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

52. (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.

54. (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.

61. 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.

62. (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.

63. (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.

71. (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.

72. CEREBRAL VENOGRAPHY

79. 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

80. 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

81. 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

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

83. THANK YOU

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