Technical
Notes
TECHNICAL NOTES An Alternate Technique for Lower Extremity Venography 1 Jaime Tisnado, M.D., Fong Y. Tsai, M.D. 2 , and Michael C. Beachley, M.D. An alternate technique of performing lower extremity venography is described for use in patients in whom injection into a superficial vein of the foot is not possible. INDEX TERMS:
Venography, technique. (Veins of lower limb, venography,
9[3].124) Radiology 133:787-788, December 1979
Lower extremity phlebography is a well accepted and reliable method for evaluating the venous system in patients with suspected thrombophlebitis, chronic venous stasis, or varicose veins. The conventional technique consists of the injection of contrast material into one of the veins of the dorsum of the foot. The puncture of such a vein is usually easy and can be accomplished with little trauma to the patient. The study can be done simply, rapidly, and without complication. Occasionally we have been faced with the problem of having
to perform vetlography on patients with marked swelling or edema of the feet and ankles, excessive obesity, chronic venous stasis, or foot veins too small to be seen or palpated. In such patients, repeated attempts to puncture a suitable vein are very traumatic and often unsuccessful. Alternative methods have been recommended, including application of hot moist towels around the foot to dilate the veins, use of red goggles for better visualization, application of a blood pressure cuff around the foot to displace edematous fluid from the subcutaneous tissue, direct puncture of the popliteal vein, transillumination of the extremities, surgical cutdown, and intraosseous venography. While these methods may be successful, they are time-consuming, requiring special instrumentation or general anesthesia, while others are excessively traumatic. We have successfully performed an alternate technique for lower extremity phlebography in cases where conventional venipuncture was not feasible. TECHNIQUE With the patient sitting on the side of the table and the legs hanging vertically, a tourniquet is firmly applied around the thigh above the knee. The superficial veins of the leg become engorged, making it almost invariably possible to find a superficial 1a,b
Fig. 1. a. Bilateral lower leg venogram. On the right (left part of a), the injection was made into a superficial vein (white arrow), resulting in adequate visualization of the superficial and deep venous systems. A thrombus in the popliteal vein is evident (black arrow). b. Thigh venograms from the same study. The right femoral vein is poorly visualized because of proximal extension of the popliteal thrombus. A thrombus is present in the left femoral vein as well.
787
788
TECHNICAL NOTES
December 1979
vein in the lower leg. Often many veins will become available for puncture. Using a 19-9auge scalp-vein needle, the vein is punctured with the tip of the needle pointing distally towards the foot. The needle is secured with adhesive tape, tubing is connected by a three-way stopcock to an infusion set containing 5 % dextrose in water, and the tourniquet is removed. The patient is placed in the supine position with the feet against the footrest of the table. The table is then elevated to about 45 0 from the horizontal unless the patient cannot tolerate such a degree of tilting, and the tourniquet is reapplied. Fifty milliliters of Renografin 60 % are rapidly injected by hand through the three-way stopcock. At the completion of the injection, radiographs of the lower legs are obtained. The continuous drip infusion is restarted, the tourniquet removed, and radiographs of the thighs obtained in rapid succession. The table is then placed horizontally, and gentle massage or elevation of the legs results in excellent opacification of the iliac veins and inferior vena cava for radiography of the pelvis.
2a,b
DISCUSSION Using this simple technique, we have been successful in performing lower extremity venography in each patient in whom the preferred conventional technique of venipuncture failed. More than 1,500 venograms have been obtained in our respective institutions during the last four years, and we employed this technique in more than 20 cases ..In the majority of cases, the opacification of the deep veins was sufficient to make a diagnosis, although not optimal (Figs. 1 and 2). We have also employed this technique in patients with large dilated deep leg veins and extensive superficial varicosities in whom the superficial femoral vein or iliac veins were not adequately opacified despite the injection of large amounts of contrast material into a vein of the foot, as it often will demonstrate these veins.
Fig. 2. Left lower leg (a) and thigh (b) venogram. The injection was made into a superficial branchof the greater saphenous system (arrow), resulting in excellentopacification of the deepvenous system of the entire lower extremity. Superficial varicosities are evident in the leg.
The Use of Xylocaine to Diminish Leg Cramps in Venograph y 1 Spencer Silverbach, M.D. A double-blind study was performed using the BettmannPaulin technique to test the hypothesis that small quantities of Xylocaine mixed with diluted contrast medium would reduce leg cramps in patients during venography. Under random selection, one group of patients received 10 mg/50 ml of Xylocaine per diluted contrast medium; a second group, 20 mg/50 ml; and a third group, plain contrast medium. The findings support the hypothesis, with drug hypersensitivity the only contraindication.
INDEX TERMS: Contrast media. effects. Venography, technique • (Veins of lower limb, venography, 9 [3] .124)
Radiology 133:788-789, December 1979
1 From the Departments of Radiology, MedicalCollegeof Virginia, Richmond, Va. (J.T., M.C.B.) andAlbany Medical College, Albany, N.Y. (F.Y.T.). (Reprint requeststo J.T.,Dept. of Radiology, VCU/MCV, Box 615, Richmond, VA 23298.) Received Oct. 13, 1978; revision requested Jan. 4, 1979; revision accepted Feb. 7. 2 Present address: Dept. of Radiology, University of Southern California, Los Angeles, Calif. as
It has been reported that patients undergoing leg venography had a significant decrease in discomfort when the contrast medium was diluted to 75% of its full strength (1). We administered low doses of Xylocaine 2 to patients in a double-blind study to determine whether lower leg cramps during venography would be diminished or even ablated. Results showed that the addition of very small amounts of Xylocaine to the diluted contrast medium definitely diminished or prevented cramps following intravenous injection. MATERIALS AND METHOD Fifty-two patients scheduled for leg venography at our institution during the period January 1, 1978 through February 28, 1978 were included in the study. Selection of patients who received Xylocaine versus plain diluted contrast medium was made by supervisory technical personnel. The contrast medium was Renografin 60 % 3 and consisted of a solution of 8 % sodium diatrizoate and 52 % meglumine diatrizoate diluted to 75 %
Notes
TECHNICAL NOTES An Alternate Technique for Lower Extremity Venography 1 Jaime Tisnado, M.D., Fong Y. Tsai, M.D. 2 , and Michael C. Beachley, M.D. An alternate technique of performing lower extremity venography is described for use in patients in whom injection into a superficial vein of the foot is not possible. INDEX TERMS:
Venography, technique. (Veins of lower limb, venography,
9[3].124) Radiology 133:787-788, December 1979
Lower extremity phlebography is a well accepted and reliable method for evaluating the venous system in patients with suspected thrombophlebitis, chronic venous stasis, or varicose veins. The conventional technique consists of the injection of contrast material into one of the veins of the dorsum of the foot. The puncture of such a vein is usually easy and can be accomplished with little trauma to the patient. The study can be done simply, rapidly, and without complication. Occasionally we have been faced with the problem of having
to perform vetlography on patients with marked swelling or edema of the feet and ankles, excessive obesity, chronic venous stasis, or foot veins too small to be seen or palpated. In such patients, repeated attempts to puncture a suitable vein are very traumatic and often unsuccessful. Alternative methods have been recommended, including application of hot moist towels around the foot to dilate the veins, use of red goggles for better visualization, application of a blood pressure cuff around the foot to displace edematous fluid from the subcutaneous tissue, direct puncture of the popliteal vein, transillumination of the extremities, surgical cutdown, and intraosseous venography. While these methods may be successful, they are time-consuming, requiring special instrumentation or general anesthesia, while others are excessively traumatic. We have successfully performed an alternate technique for lower extremity phlebography in cases where conventional venipuncture was not feasible. TECHNIQUE With the patient sitting on the side of the table and the legs hanging vertically, a tourniquet is firmly applied around the thigh above the knee. The superficial veins of the leg become engorged, making it almost invariably possible to find a superficial 1a,b
Fig. 1. a. Bilateral lower leg venogram. On the right (left part of a), the injection was made into a superficial vein (white arrow), resulting in adequate visualization of the superficial and deep venous systems. A thrombus in the popliteal vein is evident (black arrow). b. Thigh venograms from the same study. The right femoral vein is poorly visualized because of proximal extension of the popliteal thrombus. A thrombus is present in the left femoral vein as well.
787
788
TECHNICAL NOTES
December 1979
vein in the lower leg. Often many veins will become available for puncture. Using a 19-9auge scalp-vein needle, the vein is punctured with the tip of the needle pointing distally towards the foot. The needle is secured with adhesive tape, tubing is connected by a three-way stopcock to an infusion set containing 5 % dextrose in water, and the tourniquet is removed. The patient is placed in the supine position with the feet against the footrest of the table. The table is then elevated to about 45 0 from the horizontal unless the patient cannot tolerate such a degree of tilting, and the tourniquet is reapplied. Fifty milliliters of Renografin 60 % are rapidly injected by hand through the three-way stopcock. At the completion of the injection, radiographs of the lower legs are obtained. The continuous drip infusion is restarted, the tourniquet removed, and radiographs of the thighs obtained in rapid succession. The table is then placed horizontally, and gentle massage or elevation of the legs results in excellent opacification of the iliac veins and inferior vena cava for radiography of the pelvis.
2a,b
DISCUSSION Using this simple technique, we have been successful in performing lower extremity venography in each patient in whom the preferred conventional technique of venipuncture failed. More than 1,500 venograms have been obtained in our respective institutions during the last four years, and we employed this technique in more than 20 cases ..In the majority of cases, the opacification of the deep veins was sufficient to make a diagnosis, although not optimal (Figs. 1 and 2). We have also employed this technique in patients with large dilated deep leg veins and extensive superficial varicosities in whom the superficial femoral vein or iliac veins were not adequately opacified despite the injection of large amounts of contrast material into a vein of the foot, as it often will demonstrate these veins.
Fig. 2. Left lower leg (a) and thigh (b) venogram. The injection was made into a superficial branchof the greater saphenous system (arrow), resulting in excellentopacification of the deepvenous system of the entire lower extremity. Superficial varicosities are evident in the leg.
The Use of Xylocaine to Diminish Leg Cramps in Venograph y 1 Spencer Silverbach, M.D. A double-blind study was performed using the BettmannPaulin technique to test the hypothesis that small quantities of Xylocaine mixed with diluted contrast medium would reduce leg cramps in patients during venography. Under random selection, one group of patients received 10 mg/50 ml of Xylocaine per diluted contrast medium; a second group, 20 mg/50 ml; and a third group, plain contrast medium. The findings support the hypothesis, with drug hypersensitivity the only contraindication.
INDEX TERMS: Contrast media. effects. Venography, technique • (Veins of lower limb, venography, 9 [3] .124)
Radiology 133:788-789, December 1979
1 From the Departments of Radiology, MedicalCollegeof Virginia, Richmond, Va. (J.T., M.C.B.) andAlbany Medical College, Albany, N.Y. (F.Y.T.). (Reprint requeststo J.T.,Dept. of Radiology, VCU/MCV, Box 615, Richmond, VA 23298.) Received Oct. 13, 1978; revision requested Jan. 4, 1979; revision accepted Feb. 7. 2 Present address: Dept. of Radiology, University of Southern California, Los Angeles, Calif. as
It has been reported that patients undergoing leg venography had a significant decrease in discomfort when the contrast medium was diluted to 75% of its full strength (1). We administered low doses of Xylocaine 2 to patients in a double-blind study to determine whether lower leg cramps during venography would be diminished or even ablated. Results showed that the addition of very small amounts of Xylocaine to the diluted contrast medium definitely diminished or prevented cramps following intravenous injection. MATERIALS AND METHOD Fifty-two patients scheduled for leg venography at our institution during the period January 1, 1978 through February 28, 1978 were included in the study. Selection of patients who received Xylocaine versus plain diluted contrast medium was made by supervisory technical personnel. The contrast medium was Renografin 60 % 3 and consisted of a solution of 8 % sodium diatrizoate and 52 % meglumine diatrizoate diluted to 75 %
