Calcified External Iliac Vein
Diagnostic Radiology
Thrombosis 1
Vincent P. Banker, M.D. Linear calcification in the soft tissues of the pelvis in the region of the external iliac vein should suggest the possibility of calcified external iliac vein thrombosis, particularly in patients with a suspicious clinical history or physical findings. Extremity and pelvic venography corroborate the plain film findings. INDEX TERMS:
Thrombosis, iliac vein. Veins, iliac. Venography, indications
Radiology 117:311-314, November 1975
• puncture of the right common femoral vein. A preliminary radiograph (Fig. 2, B) showed linear calcification in the region of the right external iliac vein. Following injection of contrast material, an irregular group of collateral veins was filled, suggesting that the iliac system was partially occluded (Fig. 2, C). Inferior venacavography showed a patent left-sided inferior vena cava that crossed to the right as it received the left renal vein. Because of the extensive deep vein occlusive disease in the lower extremities, vein stripping was contraindicated. The patient was discharged with supportive therapy and anticoagulation.
are seen daily in the form of pelvic phleboliths and frequently as phleboliths in the spleen and lower extremities. Other forms of venous calcifications are much less frequent, but have been reported in the inferior vena cava in children (1, 2), in the portal venous system (3, 4), and in arteriovenous malformations and vein of Galen aneurysm (5). Iliac vein calcification, however, has not been described previously. Four cases of calcified external iliac vein thrombosis are presented.
V
ENOUS CALCIFICATIONS
CASE III: C. S., a 23-year-old woman, was admitted for evaluation of persistent swelling of the right leg. Deep phlebitis of the right leg had developed in 1966, following vigorous physical exercise. At that time she was temporarily placed on anticoagulants and has had intermittent swelling of the right leg since that initial episode. Her father also has a history of venous insufficiency. Physical examination showed the right calf to be about 5 cm larger than the left calf, as well as mild pitting edema of the right ankle. A preliminary radiograph disclosed a linear calcific density in the region of the external iliac vein in the pelvic area on the right side (Fig. 3, A). The venogram demonstrated patent superficial and deep right calf veins, but total occlusion of the superficial femoral vein and external iliac vein (Fig. 3, B and C) was suggested by filling of scattered collateral channels. The patient was discharged with supportive therapy.
CASE REPORTS CASE I: A. S., a 67-year-old man, was admitted with pain and swelling of the left leg of four days duration. He had been hospitalized with recurrent episodes of thrombophlebitis and pulmonary infarction for the previous six years. Preliminary radiographs for leg venography (Fig. 1, A and B) demonstrated linear and nodular calcification extending from the region of the left common iliac vein to the femoral vein at the upper thigh level. Venography of the left lower extremity (Fig. 1, C) showed evidence of complete occlusion of the left femoral and saphenous system with filling of numerous anastomoses in the thigh. A right iliac venogram (Fig. 1, D) showed retrograde filling of the left common mac vein down to the level of the calcified linear density as well as filling of numerous dilated collateral branches of the internal iliac venous system. The impression was that the long calcification represented a calcified thrombus and the nodules were perhaps calcified deformed valves. The patient was discharged on anticoagulant therapy.
CASE IV: P. S., a 69-year-old man, was admitted for prostatism characterized primarily by frequency and a diminished stream. Pertinent history revealed that he had suffered some type of major injury to the left lower extremity many years earlier that had left him with persistent swelling and discomfort for many years thereafter. Excretory urography revealed a linear calcification in the soft tissues of the pelvis in the area of the external iliac vein, which was presumed to represent calcified external iliac vein thrombosis (Fig. 4). Venography was not performed. Absence of any arterial calcification in the pelvic area and the straight configuration suggested that the calcification was venous in nature. The patient was discharged following prostatectomy without further evaluation of the left lower extremity.
CASE II: D. M., a 34-year-old man, was admitted for vein stripping with a history of bilateral leg varicosities of sixteen years duration. He had had recent episodes of apparent superficial phlebitis of the left leg. Leg and thigh venography demonstrated numerous leg varicosities as well as bilateral occlusion of the femoral veins except for the most superior portion of the right femoral vein which appeared to be partially patent (Fig. 2, A). Right iliac venography was attempted via 1
From the Department of Radiology, Waukesha Memorial Hospital, Waukesha, Wis. Accepted for publication in June 1975.
311
dk
Fig. 1. CASE r. A. Plain radiograph of the soft tissues of the left side of the pelvis showing the linear calcification in the left external iliac vein area (arrows). B. Plain radiograph of the left hip showing the continuous linear calcification extending into the common and superficial femoral veins (arrows). Minimal nodularity along the calcification suggests deformed calcified venous valves. C. Lower extremity venogram demonstrates filling of extensive collateral channels in the left thigh, but no filling of the superficial or common femoral veins . D. Right iliac venogram via a right common femoral vein puncture demonstrates retrograde filling of the left common internal and external iliac veins. The latter vein fills down to its junction with the calcified external iliac vein (closed arrows). Note also the thrombus adherent to the wall of the left common iliac vein and inferior vena cava (open arrows).
312
CALCIFIED EXTERNAL ILIAC VEIN THROMBOSIS
Vol. 117
313
Diagnostic Radiology
,, "
Fig. 2. CASE II. A. Lower leg venogram shows filling of numerous collateral channels with probable reconstitution of the superficial femoral vein (arrow). B. Plain radiograph of the soft tissues of the right side of the pelvis showing the linear calcification in the right external iliac vein (arrows). C. Iliac venogram shows filling of numerous collateral channels in the region of the external iliac vein and perhaps partial filling of the external iliac vein itself.
DISCUSSION
Soft-tissue calcification is ubiquitous, having been described with arterial and venous disease, hypercalcemia, collagen disorders, myositis ossificans, calcinosis universalis, parasitic infestation, Ehlers-Danlos syndrome and cretinism (6). Calcification of the venous system in the form of phleboliths is known in the pelvis, spleen, and lower extremities, but has been described much less frequently in other forms. Calcification of the inferior vena cava as an amorphous calcified mass has been described in children (1, 2) as well as calcified thrombosis of the portal system (3, 4). A precise etiology has not yet been determined, but dehydration has been felt to playa possible role in thrombosis of the inferior vena cava (1, 2). Linear calcification of the ilio-femoral venous system appears to be associated with relatively longstanding occlusion of these major venous pathways. Dehydration may have played a significant role in CASE III where the patient had been exercising vigorously immediately prior
to the onset of leg edema and apparent phlebothrombosis. The linear configuration fits the usually straight pathway of these major venous channels. The slight nodularity may conform to the presence of calcified deformed valves. Arterial calcification on the other hand is often curvilinear, presenting as two nearly parallel calcific densities. This is particularly true in the iliac arterial system. The presence of a well-defined linear calcification in the region of the external iliac vein in a person with chronic leg edema, leg varicosities, or a history of pulmonary embolization should suggest the possibility of chronic iliac vein thrombosis . Lower extremity and iliac venography should corroborate this impression. The substantial number of patients with venous disease of the lower extremities suggests that this combination of findings may be frequently encountered in the daily practice of diagnostic radiology . ACKNOWLEDGMENT: The author would like to thank Dr . John T. Underberg for the use of CASE III and all of his associates for their considerate advice.
314
VINCENT
P.
November 1975
BANKER
Ai Fig. 3 . CASE III. A. Plain radiograph of the soft tissues of the pelvic area demonstrating a linear calcification in the right external iliac ve in. B. Filling of numerous collaterals in the right thigh without filling of the superficial femoral vein is evident, suggesting occlusion of the superficial femoral vein . C. Occasional pelvic coflateral veins (arrows) are filled following right leg venography.
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Diagnostic Radiology
Thrombosis 1
Vincent P. Banker, M.D. Linear calcification in the soft tissues of the pelvis in the region of the external iliac vein should suggest the possibility of calcified external iliac vein thrombosis, particularly in patients with a suspicious clinical history or physical findings. Extremity and pelvic venography corroborate the plain film findings. INDEX TERMS:
Thrombosis, iliac vein. Veins, iliac. Venography, indications
Radiology 117:311-314, November 1975
• puncture of the right common femoral vein. A preliminary radiograph (Fig. 2, B) showed linear calcification in the region of the right external iliac vein. Following injection of contrast material, an irregular group of collateral veins was filled, suggesting that the iliac system was partially occluded (Fig. 2, C). Inferior venacavography showed a patent left-sided inferior vena cava that crossed to the right as it received the left renal vein. Because of the extensive deep vein occlusive disease in the lower extremities, vein stripping was contraindicated. The patient was discharged with supportive therapy and anticoagulation.
are seen daily in the form of pelvic phleboliths and frequently as phleboliths in the spleen and lower extremities. Other forms of venous calcifications are much less frequent, but have been reported in the inferior vena cava in children (1, 2), in the portal venous system (3, 4), and in arteriovenous malformations and vein of Galen aneurysm (5). Iliac vein calcification, however, has not been described previously. Four cases of calcified external iliac vein thrombosis are presented.
V
ENOUS CALCIFICATIONS
CASE III: C. S., a 23-year-old woman, was admitted for evaluation of persistent swelling of the right leg. Deep phlebitis of the right leg had developed in 1966, following vigorous physical exercise. At that time she was temporarily placed on anticoagulants and has had intermittent swelling of the right leg since that initial episode. Her father also has a history of venous insufficiency. Physical examination showed the right calf to be about 5 cm larger than the left calf, as well as mild pitting edema of the right ankle. A preliminary radiograph disclosed a linear calcific density in the region of the external iliac vein in the pelvic area on the right side (Fig. 3, A). The venogram demonstrated patent superficial and deep right calf veins, but total occlusion of the superficial femoral vein and external iliac vein (Fig. 3, B and C) was suggested by filling of scattered collateral channels. The patient was discharged with supportive therapy.
CASE REPORTS CASE I: A. S., a 67-year-old man, was admitted with pain and swelling of the left leg of four days duration. He had been hospitalized with recurrent episodes of thrombophlebitis and pulmonary infarction for the previous six years. Preliminary radiographs for leg venography (Fig. 1, A and B) demonstrated linear and nodular calcification extending from the region of the left common iliac vein to the femoral vein at the upper thigh level. Venography of the left lower extremity (Fig. 1, C) showed evidence of complete occlusion of the left femoral and saphenous system with filling of numerous anastomoses in the thigh. A right iliac venogram (Fig. 1, D) showed retrograde filling of the left common mac vein down to the level of the calcified linear density as well as filling of numerous dilated collateral branches of the internal iliac venous system. The impression was that the long calcification represented a calcified thrombus and the nodules were perhaps calcified deformed valves. The patient was discharged on anticoagulant therapy.
CASE IV: P. S., a 69-year-old man, was admitted for prostatism characterized primarily by frequency and a diminished stream. Pertinent history revealed that he had suffered some type of major injury to the left lower extremity many years earlier that had left him with persistent swelling and discomfort for many years thereafter. Excretory urography revealed a linear calcification in the soft tissues of the pelvis in the area of the external iliac vein, which was presumed to represent calcified external iliac vein thrombosis (Fig. 4). Venography was not performed. Absence of any arterial calcification in the pelvic area and the straight configuration suggested that the calcification was venous in nature. The patient was discharged following prostatectomy without further evaluation of the left lower extremity.
CASE II: D. M., a 34-year-old man, was admitted for vein stripping with a history of bilateral leg varicosities of sixteen years duration. He had had recent episodes of apparent superficial phlebitis of the left leg. Leg and thigh venography demonstrated numerous leg varicosities as well as bilateral occlusion of the femoral veins except for the most superior portion of the right femoral vein which appeared to be partially patent (Fig. 2, A). Right iliac venography was attempted via 1
From the Department of Radiology, Waukesha Memorial Hospital, Waukesha, Wis. Accepted for publication in June 1975.
311
dk
Fig. 1. CASE r. A. Plain radiograph of the soft tissues of the left side of the pelvis showing the linear calcification in the left external iliac vein area (arrows). B. Plain radiograph of the left hip showing the continuous linear calcification extending into the common and superficial femoral veins (arrows). Minimal nodularity along the calcification suggests deformed calcified venous valves. C. Lower extremity venogram demonstrates filling of extensive collateral channels in the left thigh, but no filling of the superficial or common femoral veins . D. Right iliac venogram via a right common femoral vein puncture demonstrates retrograde filling of the left common internal and external iliac veins. The latter vein fills down to its junction with the calcified external iliac vein (closed arrows). Note also the thrombus adherent to the wall of the left common iliac vein and inferior vena cava (open arrows).
312
CALCIFIED EXTERNAL ILIAC VEIN THROMBOSIS
Vol. 117
313
Diagnostic Radiology
,, "
Fig. 2. CASE II. A. Lower leg venogram shows filling of numerous collateral channels with probable reconstitution of the superficial femoral vein (arrow). B. Plain radiograph of the soft tissues of the right side of the pelvis showing the linear calcification in the right external iliac vein (arrows). C. Iliac venogram shows filling of numerous collateral channels in the region of the external iliac vein and perhaps partial filling of the external iliac vein itself.
DISCUSSION
Soft-tissue calcification is ubiquitous, having been described with arterial and venous disease, hypercalcemia, collagen disorders, myositis ossificans, calcinosis universalis, parasitic infestation, Ehlers-Danlos syndrome and cretinism (6). Calcification of the venous system in the form of phleboliths is known in the pelvis, spleen, and lower extremities, but has been described much less frequently in other forms. Calcification of the inferior vena cava as an amorphous calcified mass has been described in children (1, 2) as well as calcified thrombosis of the portal system (3, 4). A precise etiology has not yet been determined, but dehydration has been felt to playa possible role in thrombosis of the inferior vena cava (1, 2). Linear calcification of the ilio-femoral venous system appears to be associated with relatively longstanding occlusion of these major venous pathways. Dehydration may have played a significant role in CASE III where the patient had been exercising vigorously immediately prior
to the onset of leg edema and apparent phlebothrombosis. The linear configuration fits the usually straight pathway of these major venous channels. The slight nodularity may conform to the presence of calcified deformed valves. Arterial calcification on the other hand is often curvilinear, presenting as two nearly parallel calcific densities. This is particularly true in the iliac arterial system. The presence of a well-defined linear calcification in the region of the external iliac vein in a person with chronic leg edema, leg varicosities, or a history of pulmonary embolization should suggest the possibility of chronic iliac vein thrombosis . Lower extremity and iliac venography should corroborate this impression. The substantial number of patients with venous disease of the lower extremities suggests that this combination of findings may be frequently encountered in the daily practice of diagnostic radiology . ACKNOWLEDGMENT: The author would like to thank Dr . John T. Underberg for the use of CASE III and all of his associates for their considerate advice.
314
VINCENT
P.
November 1975
BANKER
Ai Fig. 3 . CASE III. A. Plain radiograph of the soft tissues of the pelvic area demonstrating a linear calcification in the right external iliac ve in. B. Filling of numerous collaterals in the right thigh without filling of the superficial femoral vein is evident, suggesting occlusion of the superficial femoral vein . C. Occasional pelvic coflateral veins (arrows) are filled following right leg venography.
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