Chapter 11

### INTRODUCTION

Conventional venography, also known as phlebography, refers to radiographic imaging of the veins after direct injection of the contrast material. Before the advent of cross-sectional imaging (ultrasonography, computed tomography [CT], and magnetic resonance imaging [MRI]), venography played significant role in the diagnosis of venous thrombosis. Currently, its role is limited to catheter-directed therapy of various venous disorders, venous sampling for hormonally active tumors, and dialysis access management.1,2,3 This chapter discusses the indications, techniques, and contraindications of venography and venographic appearances of normal anatomy and various pathologies affecting the veins. The subsections are divided into different regions to facilitate the discussion on technical aspects of venography.

### VENOGRAPHY OF THE UPPER EXTREMITY AND CENTRAL THORACIC VEINS

Venography of the upper extremities has regained its importance because of the increasing number of dialysis-dependent patients and the availability of new therapeutic options for deep venous thrombosis (DVT).

#### Indications

1. Venous mapping for preoperative planning of dialysis access surgery (arteriovenous fistula or graft creation)3,4

2. As a part of pharmacologic, mechanical, or combined thrombolysis of DVT affecting the upper extremity veins (e.g., Paget Schroetter syndrome) and dialysis fistula or graft5

3. As a part of treatment for central venous occlusion secondary to long-term indwelling catheters, mediastinal fibrosis, thoracic malignancy, or radiotherapy6

4. As a part of treatment for venous stenosis in patients with arteriovenous fistula or graft

5. As a part of venous catheter placements (e.g., peripherally inserted central catheter [PICC], long-term central venous catheters, ports); superior vena cava (SVC) filter placement; and catheterization of the right heart, pulmonary arteries, and other systemic veins

6. Rarely, to diagnose congenital venous anomalies and venous vascular malformations

#### Contraindications

Relative contraindications include a history of anaphylaxis with iodinated contrast materials and renal dysfunction. In patients with allergy to iodinated contrast materials, alternative contrast materials, such as carbon dioxide or gadolinium, may be used for venography.7 Patients with renal dysfunction may be prepped with renal-protective algorithms with sodium bicarbonate infusion, hydration, and Mucomyst. Carbon dioxide can be safely used in patients with renal failure. Use of carbon dioxide as a contrast material necessitates digital subtraction angiography (DSA) for imaging.8

#### Technique

The patient is placed in the supine position, and the hands are positioned in supination and abduction. This positioning is important because it is the anatomic position and it reduces the incidence of axillary vein pseudostenosis caused by pressure form the tissue bulk. A superficial vein in the dorsum of hand is accessed with 18- or 20-gauge needle. A tourniquet is applied at the upper arm. This helps fill the deep veins with contrast material. Initially, 5 to 10 mL of iodinated contrast material is injected under fluoroscopy to rule out extravasation. Then diluted iodinated contrast material (240 mgI/mL) is injected, and multiple intermittent overlapping screen ...

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