A Method of Venography

Since the first venographic studies in animals by Franck and Alwens (1) and the later work of Hirsch and Berberich (2) in man, many attempts at venography have been reported. The chief object to date has been to find a method of diagnosing acute venous thrombosis in the lower extremities (3–8). The procedure has been employed also for studies of the venous circulation in the legs (Frimann-Dahl, 9; McPheeters and Rice, 10), for evaluating the efficiency of paravertebral lumbar sympathetic blocks (Bauer, 8; Papper and Imler, 11), and for the differential diagnosis of various conditions of the veins of the lower extremities (Mark, 12; Lesser and Danelius, 13). Theoretically a method of venography should be tested on normal human beings, but the difficulties of carrying out such a procedure on an appreciable number of subjects are obvious. It is next best to pursue studies in patients with some complaints referable to the veins of the lower extremity, as has been done for this presentation. In the author's opinion venography is indicated when there are otherwise unexplained edema, skin atrophy, pigmentation, eczema, or ulcers of the lower extremity. It should not be used as a substitute for a good history or a thorough physical examination. It is probably not indicated in making a diagnosis of acute venous thrombosis of the lower extremity. When such a diagnosis is not clear, venography may be hazardous, although in the author's experience no pulmonary emboli have resulted from it. Method In order to save time in the x-ray laboratory, we start an infusion of 200 c.c. of normal saline with a 20-gauge needle into one of the veins on the dorsum of the foot in the emergency room or ward, with the patient already on a litter. The extra adapter and 1 1/2-foot length of rubber tubing shown in Figure 1 are attached to the intravenous set at its adapter to begin with. At the time of the procedure, the rubber tubing is simply detached from the intravenous set and the syringes are inserted as necessary. The 1 1/2 feet of rubber tubing enable the operator to stay at a distance from the x-ray tube while making the injection. A vein distal to the superficial venous arch or the vein draining the great toe is chosen whenever possible, because of their more direct connection and drainage to the deep veins. With the needle taped securely in place and the infusion running slowly, the patient is taken to the x-ray laboratory on the litter. In the laboratory, the patient is placed on a tilting x-ray table with Bucky diaphragm and cassette carrier. The table is then tilted some 15 degrees with the feet downward to simulate, in part at least, the upright position. The leg is placed over the center line and rotated inwardly 45 degrees, as recommended by Mark. A heavy gum rubber tourniquet is then placed snugly about the lower leg, approximately 8 cm. above the medial malleolus.