venography of the veins of lower limb by intra-osseous ... · veins of the lower limb can be...

437

VENOGRAPHY OF THE VEINS OFLOWER LIMB BY INTRA-OSSEOUS

TECHNIQUEBy HAROLD DODD, M.Ch., F.R.C.S.

Surgeon, St. Marys Hospital Group, King George Hospital, Ilford; Royal London Homoeopathic Hospital

and M. MISTRY, M.S., F.R.C.S.Late Surgical Registrar, Royal London Homoeopathic Hospital

The injection of radio-opaque substances intoveins was first introduced by Dos Santos in I938to investigate acute thrombo-phlebitis, but thesuggestion to inject contrast media into bones forvenograms was due to the pioneer work of Ducinget al. (I95I), who demonstrated the physiology ofcirculation in bone. Intra-osseous venography,in spite of being shown by Begg in I954 and Doddand Cockett in I956 to be safe and practicable, hasnot yet found general acceptance amongst surgeonsand radiologists on account of imaginary difficultiesand dangers.Using the intra-osseous technique, we report our

experience of 50 consecutive venograms and wehope to show that the procedure is a satisfactoryone.

Technique of Intra-osseous VenographyHalf an hour before the venogram the patient

is given distaquaine, 6oo,ooo units, with atropin,I/I00 gr. These are prophylactic and we havealways used them. The patient usually lies supineon the X-ray table, but may be on the side whenthe short saphenous vein is in question. The limbto be X-rayed lies on the cassette tunnel. The siteof injection is selected according to the position ofthe suspected pathology. Injection of the contrastmedium into the greater trochanter of the femuris chosen in order to demonstrate the internal iliac,common iliac veins and the inferior vena cava,whilst the tibial tubercle is suitable for the deepveins of the thigh. For the posterior tibial venaecomites and sometimes the popliteal vein, thelower end of tibia is good (Fig. i). The os calcishas not been used by us because Begg (I954)believes that the radiographs are not so satisfactory.The patient is made comfortable and the site of

injection is cleaned with ' Cetavlon' and spirit.The limb is draped so that only the injection areais exposed. The sterile instruments are con-veniently assembled (Fig. 2).Begg (954) used local anaesthesia in his later

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FIG. i.-Lower end of tibiapunctured for venograamof the posterior tibial venaecomites.

cases. We tried local anaesthesia in four cases,but the rapid injection of diodone was very painful.To prove that the pain was not due to the contrastmedium, normal saline was tried, and this also wasresented by the patient. Light general anaesthesiawith buthalitone sodium (' Transithal ') and gasoxygen is now used in our cases.The site for injection is selected and a puncture

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438 POSTGRADUATE MEDICAL JOURNAL August 1958

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FIG. 2.-Sterile instruments assembled.

is made down to the bone with a Bard-Parkerblade No. I5, and the periosteum is scratched.The trocar, which is a Kirshner's wire mountedon a handle, is introduced through the cortex intothe bone marrow, using a bradawl action. Thetrocar is removed and through the same hole thecannula, which is slightly bigger than the trocar,is inserted (Fig. 3). Normal saline is injected toprove that the cannula is in the marrow space.The contrast medium used is diodone (' Pyelo-

sil,' Glaxo Laboratories) 35 or 50 per cent., using20 C.C. If a second view is required, 20 C.C. moremay be given. Solutions stronger than 50 per cent.are not injected in order to avoid iodism, injury tothe marrow endothelium and deep thrombosis.

Diodone is injected steadily through the can-nula and the first plate is exposed after io c.c.have been inserted. The second plate is taken after20 c.c. and the third io seconds later. The cannulais withdrawn and the wound sealed by a steriledressing. An elastic webbing bandage is appliedfor 48 hours. Patients quickly recover and returnhome after two hours, but it has occasionally beennecessary to keep a patient overnight.We never do venography in the presence of

unhealthy skin, e.g. an ulcer, eczema or moisture.These conditions are healed first by pressurebandaging.The advantages of this intra-osseous technique

over the intravenous one of Gryspeerdt (1953) are:. (a) Tourniquets or compression bandages todeflect the contrast medium from the superficialto the deep veins are unnecessary.

(b) Good radiographic pictures are obtained.(c) The technique can be used at any level of the

limb, depending on the part it is wished toinvestigate.

Difficulties of Intra-osseous VenographyOur chief difficulty has been that of hard, dense

bone which causes the trocar to bend. We over-come this by selecting another site for the punc-ture. This has occurred three times.The second difficulty has been the leakage of the

contrast medium by the side of the cannula. Thisis avoided by introducing the trocar with a firm,steady pressure and avoiding lateral burring of thehole.

In one case the cannula broke in the bone, dueto a sudden violent movement, but no ill effectshave followed.

Injury to a superficial vein whilst introducing thetrocar may occur. Elevation of the limb and digitalpressure with gauze stops this and the procedurecontinues. This is avoided by selecting the pointof puncture while the patient is standing.

Complications of Intra-osseous VenographyIntra-osseous venography, if carried out as

described, is practically free of complications.Bruising and Ecchymosis. The commonest com-

plication has been bruising and ecchymosis. Thishas been severe in one patient, where it was sodiffuse and painful that the patient was unable towalk for a couple of days. A pressure bandage, asalready mentioned, prevents this.

Pain. About IO per cent. of cases complained ofpain that prevented them from sleeping the nightfollowing the examination. Patients are advised totake two tablets of aspirin and to report to thecasualty department or their doctor.

Infection. If asepsis is observed, wound sepsisand acute osteomyelitis must indeed be rare. Wehave had no infection and we attribute this toaseptic precautions and not performing veno-



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Atugulst I958 DODD and MISTR Xt: Veniography of Veins of Lower Limib by Initra-Osseous Technique 439

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FIG. 3.-Showing cannula in position.

graphy in the presence of ulcerationi or moist skin;the use of penicillin is empirical.

Thrombosis. Immediate movements of the legson recovery from anaesthesia and patients return-ing home avoids thrombosis; we have had no suchtrouble.

Iodism. Dodd and Cockett (I956) mention thatthe most important complication is sensitivity oranaphylaxis to contrast medium. As a routine wehave used 35 to 50 per cent. diodone, neverstronger. We have had one patient who collapsedimmediately on injection of diodone. The pro-cedure was stopped and he recovered, but he waskept in the hospital overnight. Adrenaline i/i,ooois always kept at hand; we give 5 minims intra-muscularly, if necessary.We were unsuccessful in obtaining venograms

in four cases (8 per cent.). One already mentionedwas allergic to iodine. In two cases the opaqucmedium leaked at the bone puincture and in thcfourth case the cannula broke in the bonic; wcIIow use a solid trocar for the puncture.Of the 46 successful venograms, 23 showed ill-

competent ankle communicating veins, nine in-competent tributaries of the short saphenous veins,seven incompetent communicating veins of theHunter's canal, three incompetent communicatingveins at the upper end of tibia, three showed noabnormality and one showed a large varix of thedeep veins at the level of the knee joint. Thesediagnoses illustrate the growing field of venousdisorders of the lower limb and gone are the days

when they were limited to varicosity of the longand occasionally short saphenous veins. Intra-osseous venography has helped us to a precisediagnosis in this developing field.

Indications for Intra-osseous VenographyVenography for Chronic Ulceration of the LegThe condition and efficiency of the superficial

veins of the lower limb can be assessed by clinicalexamination, but the state of the deep veins, andleaking communicating veins, is more difficult or,sometimes, impossible to determine clinically.Intra-osseous venography has given accurate pic-tures of the condition and function of the per-forating and deep veins. It demonstrates the siteof the incompetent communicating veins betweenthe deep and superficial systems.

According to Anning, only iI per cent. of chronictulceration of the leg is due to varicose veins. There-fore 8o per cent. of chronic ulcers of the leg maybe due to former deep thrombosis. Linton andHardy (1948) showed by surgical explorations, andLockhart-Mummery and Smitham ( 95 I) by veno-graphy, that in phlebitic legs the clot in deep veinsbecomes canalized, but the valves of the deep andcommunicating veins are destroyed. Thereforeretrograde flow via the communicating veins leadsto superficial venous hypertension, causing ulcera-tion (Fig. 4, A, B, C). Cockett and Jones fromtheir studies showed that the venous drainage ofthe ulcer area of the leg is by three or four per-forating veins direct to the deep system.



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440 POS'T'GRADUA'TE MEDICAL JOURNAL August 1958

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A iFIG. 4.-A, 13, C: ShowNing inconmpetent ankle pcerforating veins.

'T'hus, in cases of post deep venous thrombosisintra-osseous venography localizes the level of thedamage by the thrombosis, the presence and thelevel of leakage through the perforating veinsleading to superficial venous hypertension. Wehave found unsuspected faulty perforating veins atthe ankle, knee and mid-thigh.

Venography in Recurrent Superficial VaricositiesDodd and Cockett (1956) mention five causes for

persistence or recurrence of varicose veins. Ofthese incorrect and incomplete diagnoses arcimportant.When an attempt to diagnosc clinically the

source of filling of recurrent varices fails, or theresults of the tests are conflicting, a venogram isinvaluable. For example, incompetence of theexternal saphenous veins is more common than weformerly believed, and therefore persistence ofsuperficial varices. At present, in our opinion, theratio of incompetence of external saphenous veinsto internal saphenous veins is around I: 6; pre-viously it was i: IO.

Quite frequently incompetent communicatingvein or veins are present above the ankle, in the

calf, or in the thigh. Our venograms have shownus that an incompetent vein passing into Hunter'scanal is associated with some incompetence of thedeep veins and we now suspect that it, too, is apost-thrombotic feature (Fig. 5). An appreciablenumber of our persisting varicose veins afteroperation are due to this faulty perforating vein.A long oblique incompetent perforating vein

passing from the middle of the calf to the poplitealvein may mimic incompetence of the shortsaphenous vein; Dow (195I) also showed this.Ainother possibility is varicosity of the vein draini-inlg the inner head of gastrocnemius. Venographyin such cases may avoid the error of tying the shortsapheinous vein only. We aipply the term' pseudo-short saphenous veiti ' to incornpeteilt tributariesof the popliteal vein.

Venography for other Symptoms of Post-thromboticSyndrome(a) Oedema. Patients with uncomplicated in-

competence of the superficial varicose veins seldomdevelop oedema of the legs and ankle, but wherethe deep veins are faulty it is a frequent symptom.Venographic studies in these patients have shown



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Au,gust 1958 DODnD and MISTR Y: VenQqrapliv of Vensi. of Lower Limblb,i [nira-Osseous Techniiqute 44I

Fic. 5.-Showing incompetentperforating vein of Hunter'sCanal.

us that the ankle communicating veins of the legare frequently incompetent and occasionally thatpassing into Hunter's canal.

(b) Bursting Pain in the Calf and Leg. Bauerdrew attention to the ' bursting pains' in deepvenous thrombosis. Cockett (1956) is of theopinion that the cause of this lies in the destructionof the valves in the deep calf veins. He furthersuggests that one indication for Bauer's poplitealvein ligation is for the ' bursting pains.' We havefound in our venograms that in some of thesecases there is incompetence of veins in the legs andof muscular tributaries of the popliteal vein. Webelieve that this is the real pathology, for it hasbeen relieved by the ligation of these incompetentperforating veins.

Venography for Acute Deep Phlebo-thrombosisWe have not used venography in diagnosis and

we think that it is contraindicated, because it isunnecessary, may precipitate an embolism, andthat by irritation of the endothelium it may causean extension of the thrombosis.

Venography for Skin DiseasesIn pigmentation, eczema and induration due to

post-thrombotic syndrome, when the skin con-dition is quiescent venographic studies are usefulin showing incompetent perforating veins.

Interpretation of VenogramsIt is easy to interpret a venogram of a normal

leg, but after the deep veins have been thrombosedand re-canalized and communicating veins renderedincompetent it may be difficult. It is necessary to-have an open mind with regard to the findings andto have clinical assessment of the possibilities also.We recently diagnosed an incompetent tributaryof the popliteal vein and a faulty communicatingvein passing into Hunter's canal. The venogramconfirmed the latter and operation proved bothwere present.Knowledge of the variations of veins and their

tributaries is essential in interpreting the veno-grams. The studies of Kosinski (1926) and Cockett(I956) are helpful in diagnosing the findings. Deepveins may be absent or replaced by collaterals;this is rare.

Venographic studies sometimes show no valves;this may be due to their congenital absence or,more commonly, to their destruction by deepvenous thrombosis. In this case the somewhatlarge irregular channel unbroken by valves lendssupport to this. The channel may show a moth-eaten appearance due to an old thrombus within itswalls. We have not found it necessary to useValsalva's manoeuvre to demonstrate the valvesduring venography. We can discern them withthe patient supine under general anaesthesia. Begg(I9S4) also showed this.

Extension of Knowledge of Venous DisordersOur venograms have widened our conception of

the possible venous disorders. First in connectionwith the perforating veins passing into Hunter'scanal. They have shown us that the resultingvarices may be above or below the perforator andalso that this vessel itself may run an irregularcourse. We now diagnose the varicosity of thisvessel oftener and are exposing the femoral vein inHunter's canal to tie it. Similarly, the ankle per-forating veins may cause varices in the upper legor about the ankle. Further, we now recognize as aclinical entity incompetent tributaries of thepopliteal vein.

ConclusionsWe are reporting our experience with intra-

osseous venography and have found that it is asafe and valuable procedure. Its technique, in-dications, complications and usefulness are dis-cussed. It has extended our knowledge of diagnosis

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442 POSTGRADUATE MEDICAL JOURNAL August I958

and operations on venous disorders of the lowerlimbs. We do not wish to convey that this shouldbe adopted as a routine. It is exacting and time-consuming, but it is an invaluable auxiliary indifficult presentations.

AcknowledgmentWe wish to warmly thank Dr. R. Paul and his

staff of the X-Ray Department at the Royal LondonHomoeopathic Hospital for their enthusiasticco-operation and help in solving the radiologicaldifficulties; without them we could not havedeveloped this valuable assistance to our vein work.

BIBLIOGRAPHY

ANNING, S. T. (1949), Brit. med. J7., ii, 458.BEGG, A. C. (I954), Brit..j. Radiol., 27, I38.COCKETT, F. B. (I953), 'Pathology and Treatment of V'enious

Ulcers of the Leg,' M.S. Thesis, London.COCKETT, F. B., and JONES, D. E. E. (1953), Lancet, i, 17.DODD, H., and COCKETT, F. B. (1956), ' Pathology and Surgery

of the Veins of the Lower Limb,' E. & S. Livingstone Ltd.DOS SANTOS (1938), J. int. Chir., 3, 625.DOW, J. D. (195i), Brit.3r. Radiol., 24, I82; (I951), Y. Fac. Radiol.

(Lond.), 2, i8o.DUCING, MARQUS, BAUX, PAILLE and VOISIN (195i),

Y. de Radiol. et d'-Electral., 32, 189.KOSINSKI, C. (1926), J. Anat. (Lond.), 60, 131.1,INTON, R. R., and HARDY, C. B. (1948), .S'argery, 24, 452.LOCKHART-MUMMERY, H. E., and sMITHAM, J. H. (I951),

Brit. J. Surg., 40, 442.

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