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A leg venogram is a radiographic study of the deep veins of the legs and Inferior vena cava following the administration of a contrast medium.
NB:This procedure, once commonly performed in radiology departments, has now been completely replaced by ultrasound imaging.(compression technique and colour Doppler flow) . Duplex sonography (US) has become the imaging modality of choice, because of its simplicity and high sensitivity and specificity, especially in the femoropopliteal region.
Ultrasound should always be the imaging modality of choice, as there are no needles, no radiation, no IV contrast and when performed by a Sonographer is a highly sensitive test. There may be limitations in visulalising the calf veins due to oedema and obesity.
- Deep vein thrombosis (DVT) is a common medical condition with a wide range of manifestations that range from an asymptomatic state to a classic symptomatic DVT, with important sequelae of pulmonary embolism, chronic venous insufficiency, and postphlebitic syndrome.
- (DVT) is a common clinical problem that complicates many medical and surgical disorders It can cause morbidity in itself due to acute pain and swelling of the affected limb, and it may also cause structural damage to the valves of the deep veins that results in the postphlebitic syndrome.
- If not recognized, deep venous thrombi can extend and embolize to the pulmonary arterial circulation. Pulmonary embolism can cause sudden death or, if nonfatal, result in shortness of breath and chest discomfort
- Clinical examination is insensitive, and objective tests are required for the diagnosis
- Leg venography is performed almost exclusively to exclude deep vein thrombosis (DVT)
- DVT is a difficult Diagnosis to make on the basis of clinical findings alone
• Up to half of patients with signs and symptoms suggestive of DVT do not actually have DVT
• Conversly, many patients who do have DVT will not manifest the typical symptoms of leg swelling and calf pain
- DVT is a difficult Diagnosis to make on the basis of clinical findings alone
- Symptoms of lower extremity DVT will usually present in one of two ways.
- The first is with symptoms of calf-popliteal vein DVT. Most patients with acute DVT will initially develop symptoms of pain and swelling in the calf of one leg
- The symptoms tend to increase with ambulation and improve with rest. There may be associated increased warmth, redness, and tenderness of the calf area.
- On average, a patient's symptoms will persist for about 7 days during that time, symptoms usually worsen.
- The pain and swelling may become more severe and progress proximally up the leg to the popliteal fossa and medial thigh
- non-consent by patient to procedure
- contrast or iodine allergy
- pregnancy (pregnancy test compulsory for women of child-bearing age in some centres)
- impaired renal function (check creatinine if recent test available). A creatanine level greater than 180 micromols/litre is a contraindication
- bleeding disorders, blood thinning medications , anticoagulants (heparin, warfrin, aspirin)[ check INR if available]
- morbid obesity can mitigate against successful foot vein access
- diabetic patients on metformin
- severe asthma
The superficial veins consist of the long and short saphenous trunks and their tributaries. Multiple arcades (commonly three) join the greater and lesser saphenous systems. Other superficial veins may bypass the saphenous veins to drain more proximallly into the gluteal veins or the veins of the lower abdomen. The perforating veins penetrate through the deep fascia to connect the deep veins with the superficial veins. They are present from foot to groin.( more common in the calf)
- Lower extremity venous anatomy can be broadly divided into three components:
- Superficial veins
- Deep veins
- Perforating veins
- The superficial system includes the small (SSV) & greater saphenous veins (GSV)
- The greater saphenous vein continues along the medial aspect of the thigh and drains into the common femoral vein (CFV) at the saphenofemoral junction (SFJ).
- The deep system is more complex that the superficial system
- Common femoral vein
- Femoral vein (prevoiusly known as Superficial femoral vein often duplicated)
- Deep femoral vein( drains thigh previously known as profunda femoris vein)
- Popliteal vein
- Three paired veins drain the calf
- – The anterior tibial veins ATV (lateral)
- – The peroneal veins PV(medial and deep)
- – And the posterior tibial veins PTV(Medial)These veins run parallel to the tibial arteries of the same names
The muscular veins (venous sinuses of the calf muscles which dont have valves)
- Medial and lateral gastrocnemius veins
- Medial and lateral soleal veins
- The tibial veins drain into the popliteal vein which inturn forms the femoral vein (FV) at the adductor canal.
- The deep femoral vein (DFV) drains the thigh muscles and joins with the FV to form the CFV
- The superficial and deep systems are joined by a series of perforating veins
- Venous blood flows from the superficial to the deep system, aided by the presence of bicuspid valves in the veins of both systems, in a normal competent system.
quoted from •SCVIR Syllabus “Venous Interventions” in
Chap:Diagnosis of Deep Venous Thrombosis (p190)
by Jeanne M. Laberg, M.D. & Peter W. Callen, M.D.
- patient identification (3 Cs- correct patient, correct side, correct procedure)
- Patient should be wearing a hospital gown; pants,socks and shoes removed
- consent form
- no diet restrictions (some centres suggest fast from solids for 4 - 6 hours prior to procedure)
- collect relevant previous imaging for ease of access prior to procedure
- Radiologist may require a bucket of hot water to place patient foot in to encourage dilation of peripheral foot veins
- low level sedation may be required for extremely anxious patients
- If the patient's lower limb is very oedematus/swollen, elevation of the limb prior to the procedure for 8 hours may assist in needle access to the leg veins
- 'Emla' local anaesthetic cream can be applied to the dorsum of the patient's foot 90 minutes prior to the procedure to reduce the pain associated with the needle insertion.
1 21 guage 3/4 inch butterfly needle 3 25 ml syringes 1 drawing up canula 1 swab 1 tape 1 20 ml normal saline in 25 ml syringe 2 tourniquet
|Vein Cannulation|| || |
- All adjacent images should overlap (no missed anatomy)
- It is very easy to image too quickly when using a plain film technique- don't change cassettes so quickly that you beat the contrast bolus up the leg
- repeat injection and imaging may be required (ie a second run)
- Don't use too low a kVp- you want to be able to penetrate the contrast-filled veins
- If the patient is unsteady, it may be prudent to apply a buckyband or other support around the patients chest/abdomen
- If the patient is post hip surgery, examine the affected leg first
- some radiologists prefer 50 mls of non-ionic contrast (370 mg/ml) diluted with 25 mls to make a total of 75 mls. This is injected through three 25ml syringes.
- In an adult patient with normal renal function, total contrast media injected should be less that 200 mls of 370 mg/ml.
Note the flow void simulating a narrowing of the femoral vein
- A vein containing thrombus will either appear as an occluded vein or may have a 'train track' appearance cause by the contrast running around the thrombus
source: Mosby 2003 in www.elcamino.edu/faculty/mcolunga/RT%20255/Venography%20&%20Lymphography.ppt
This venogram image demonstrates extensive DVT of the deep veins. Note numerous filling defects.
- Patient should be observed for 1 hour to ensure no adverse reaction to contrast media or bleeding from injection site
- increase fluid intake
- Venogram induced DVT
- contrast allergic reaction (anaphylaxis)
- extravisation of contrast media
- pulmonary embolus
- injection site local infection
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, Feb 7 2010, 8:37 PM EST
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