DAVID SUTTON PICTURES Only for study purpose

1. 16
PHLEBOGRAPHY
DAVID SUTTON

2. DAVID SUTTON PICTURES
DR. Muhammad Bin Zulfiqar
PGR-FCPS III SIMS/SHL

3. • Fig. 16.1 Diagram of the
deep and superficial veins
of the lower limb.
(Copyright Eastman Kodak
Co. Reprinted by courtesy
of the Health Sciences
Division, Eastman Kodak
Co.)

4. • Fig. 16.1 Diagram of
the deep and
superficial veins of
the lower limb.
(Copyright Eastman
Kodak Co. Reprinted
by courtesy of the
Health Sciences
Division, Eastman
Kodak Co.)

5. • Fig. 16.2 (A,B)
Normal ascending
phlebogram of the
deep veins.

6. • Fig. 16.3 Incompetent
perforating veins in the calf
(arrows).

7. • Fig. 16.4 Incompetent
perforating veins in the
thigh.

8. • Fig. 16.5 Descending
phlebogram showing
incompetent valves and reflux
down to the popliteal vein.

11. • Fig. 16.8 (A,B) Extensive
clot in the femoral vein
adherent in part.

12. • Fig. 16.9 (A,B)
Extensive clot in
the femoral vein.

13. • Fig. 16.10 The four types of
recurrence in the thigh are
shown diagrammatically.
More than one type may
apply in a given patient.
(Reproduced from Starnes
et al (1984), with
permission.)

14. • Fig. 16.11 DSA. (A) Normal left iliac veins, shown by catheter from
right iliac both sides shown by injection from right side. (B) Venous
drainage and connections of the IVC. A = superior vena cava; B =
inferior vena cava; C = hepatic veins; D = renal veins; E = iliac veins;
F = ascending lumbar veins; G = vertebral venous plexus; H =
hemiazygos vein; I = ascending hemiazygos vein; J = azygos vein.

15. • Fig. 16.12 (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
IVC with the right side now occluded. which

16. • Fig. 16.12 (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
IVC with the right side now
occluded. which

17. • Fig. 16.13 Two-phase MRA.
Normal iliac veins with
duplication of IVC.

18. • Fig. 16.14 (A) Recent clot 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.

19. • Fig. 16.15 (A,B) Thrombosis of the IVC and common iliacs. Collateral drainage
from the right leg via internal iliacs and haemorrhoidal plexus e- inferior
mesenteric vein ~- portal vein. (C) Same patient. Collateral drainage from the left
leg mainly via ascending lumbar veins and vertebral venous plexus

20. • Fig. 16.15 (A,B) Thrombosis of the IVC and common
iliacs. Collateral drainage from the right leg via
internal iliacs and haemorrhoidal plexus e- inferior
mesenteric vein ~- portal vein. (C) Same patient.
Collateral drainage from the left leg mainly via
ascending lumbar veins and vertebral venous plexus

21. • Fig. 16.16 (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.

22. • Fig. 16.17 (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.

23. • Fig. 16.17 (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.

24. • Fig. 16.18 (A) Invasion of the IVC by hypernephroma spreading up the
right renal vein. (B) Tumour envasion (arrow) of right common iliac vein
from giant cell tumour of the sacrum. (C,D) CT scans of lesion.

25. • Fig. 16.18 (A) Invasion of the IVC by
hypernephroma spreading up the right renal
vein. (B) Tumour envasion (arrow) of right
common iliac vein from giant cell tumour of
the sacrum. (C,D) CT scans of lesion.

26. • Fig. 16.19 (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.

27. • Fig. 16.19 (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.

28. • Fig. 16.20 DSA. (A) Normal right hepatic vein
catheterized from femoral vein. (B) Occluded
right hepatic vein with typical spider's web
appearance. (C) Thrombosis in left hepatic
vein. B and C are from same patient as in Fig.
16.19C.

29. • Fig. 16.21 Selective right renal (A) and left
renal (B) vein phlebograms. (C) Circumaortic
ring formed by renal veins. A = aorta; IVC =
inferior vena cava.
• PHLEBOGRAPHY

30. • Fig. 16.22 Venous drainage of the arm. A = median basilar
vein; B = median cephalic vein; C = cephalic vein; D = basilic
vein; E = axillary vein; F = subdavian vein; G = superior vena
cava; H = azygos vein; L = internal jugular vein; J = external
jugular vein; K = innominate vein; L = hemiazygos vein.

31. • Fig. 16.23 Arm phlebogram showing normal
appearances.

32. • Fig. 16.24 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.

33. • Fig. 16.25 (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 subdavian vein. Collaterals are seen to
the vertebral plexus.

34. • Fig. 16.25 (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 subdavian vein. Collaterals
are seen to the vertebral plexus.

35. • Fig. 16.26 (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.

36. • Fig. 16.27 (A,B) Klippel-Trenaunay syndrome involving
the left arm. Drainage is via a single medial vein which
appears valveless with very sluggish flow.

37. • Fig. 16.28 (A) Portal circulation. A = portal vein;, B = splenic vein;
C=superior mesenteric vein; D = inferior mesenteric vein; E = left
gastric vein; F = gastroepiploic vein; G = oesophageal vein. (B)
Spiral CT reconstruction showing a patent portal vein. (Courtesy of
Dr A. AI-Kutoubi.)

39. • Fig. 16.30 Arterioportography subtraction
film. Venous phase of selective splenic
angiogram. The portal vein is compressed by a
mass of malignant glands. The spleen is
grossly enlarged. SV = splenic vein; L = liver; S
= spleen. (Courtesy of Dr Janet Murfitt.)

40. • Fig. 16.31 DSA. (A) Gastro-oesophageal varices
and patent left umbilical vein containing some
thrombus filling from left portal vein. (B) Gastric
varices and patent inferior mesenteric vein filling
from splenic vein.

41. • Fig. 16.32 * (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.

42. • Fig. 16.33 Normal compression of the left
common femoral vein. The vein is seen in the
left image on the left side of the artery. On
compression the vein lumen disappears and
only the vein walls are visible.

43. • Fig. 16.34 (A) Predominantly hypoechoic
thrombus expanding the common femoral
vein. (B) A transverse view showing the
thrombus occupying most of the vein lumen,
with only a small amount of flow around the
periphery.

44. • Fig. 16.35 (A) A tail of fresh thrombus
extending up a superficial femoral vein. (B)
The same thrombus on power Doppler.

45. • Fig. 16.36
Moderately
echogenic thrombus
in a superficial
femoral vein. A
small amount of
blood flow is seen
posteriorly.

46. • Fig. 16.37 Longitudinal view of the popliteal
vein with a popliteal cyst immediately deep to
the vessel.

47. • Fig. 16.38 Echogenic thrombus in a long
saphenous vein.

48. • Fig. 16.39 Transverse view of the superficial
femoral vessels. The artery is seen in the
middle with a patent vein on the left but a
thrombosed vein lying inferiorly.

49. • Fig. 16.40 (A) The left saphenofemoral
junction in a patient with recurrent varicose
veins. The upper long saphenous vein is
replaced by multiple irregular channels,
compatible with recanalisation after surgery.
The colour Doppler image (B) shows abnormal
flow patterns.

50. • Fig. 16.41 (A) The saphenofemoral junction
on colour Doppler showing flow upwards
(orange), followed by (B) reflux downwards
(blue).

51. • Fig. 16.42 Colour and spectral Doppler trace
showing significant reflux of approximately 3
second.

52. • Fig. 16.43 Acute thrombosis (arrow) within
the IVC and left iliac veins on (A) coronal and
(B) transverse T,-weighted spin-echo images
(SE 560/25).

53. • Fig. 16.44 Thrombotic
obstruction of the IVC and
common iliac veins in a 64-
year-old woman with
contrast outlining a
collateral venous
circulation, on a 3D CE-PIRA
study using the left pedal
vein as the injection site.
Note the normal hepatic
vein (arrow) draining into a
patent portion of the IVC
adjacent to the right
atrium. Contrast is seen in
the abdominal aorta.

54. • Fig. 16.45 Coronal plane maximum intensity
projection (MIP) of a 2D phase-contrast MRA
showing normal hepatic veins (short arrows). P =
portal vein; s = splenic vein; a = aorta; arrowhead
= superior mesenteric artery.