Chapter 26 - Venography

Question 1

Indication for catheter directed venography

Answer 1

1) DVT with non-diagnostic US or negative US when suspicion high 2) adjunct during intervention 3) evaluation of valve prior to stripping GSV 4) venous mapping prior to surgical procedure 5) evaluate venous stenosis or venous hypertension 6) evaluate venous malformation 7) pre-op evaluate tumor involvement

Question 2

Relative contraindication of venography

Answer 2

1) cellulitis 2) iodinated ccontrast allergy 3) renal insufficiency not on dialysis (especially DM and CHF)

Question 3

Comparison of various venous imaging modalities

Answer 3

TABLE 26.1

Question 4

Grades of venous refluex

Answer 4

TABLE 26.2

Question 5

Symptoms of pelvic venous congestion syndrome

Answer 5

1) pelvic pain 2) dysmenorrhea 3) dysuria 4) dyspareunia 5) vulvar/pelvic varices in women 6) varicocele in men

Question 6

Source of pelvic congestion

Answer 6

1) ovarian vein reflux 2) pelvic varices 3) hypogastric venous insufficiency

Question 7

Ovarian veins provides drainage from

Answer 7

1) parametrium 2) cervix 3) mesosalpinx 4) pampiniform plexus

Question 8

Ovarian vein anatomy

Answer 8

2-3 trunks form single vein at L4 Right ovarian drains into IVC left ovarian drains left renal vein 3.1 mm diameter with 2-3 valves

Question 9

Pressure gradient between left renal vein and IVC

Answer 9

Nutcracker syndrome any gradient > 1 mmHg counts, normally should be zero

Question 10

Diagnostic criteria for pelvic congestion syndrome

Answer 10

1) ovarian vein > 6mm 2) retention of contrast > 20 seconds 3) congestion of pelvic venous plexus or opacification of ipsilateral/contralateral iliac veins 4) filling of vulvovaginal/thigh varicosities each variable score 1-3 total > 5 is pelvic congestion

Question 11

Causes of varicocele formation

Answer 11

1) abnormal distention of pampiniform venous plexus (drainage from testicle) 2) absence of testicular vein valves

Question 12

Testicle venous drainage anatomy

Answer 12

1) Veins of testes + epididymis –> pampiniform plexus 2) plexus from scrotum to spermatic cord –> ascend in front of ductus deferens 3) pampiniform plexus unite to form 3-4 veins –> enter abdomen through inguinal ring 4) coalesce to two gonadal veins 5) right enter IVC; left enter left renal vein

Question 13

Collaterals of venous drainage from testes

Answer 13

1) perirenal 2) retroperitoneal 3) lumbar veins

Question 14

Most common sidedness of varicocele

Answer 14

LEFT right or bilateral only accounts for 10-15% and ? tumor/adenopathy

Question 15

Diagnostic of varicocele

Answer 15

1) two prominent tortuous veins in pampiniform > 2mm on US 2) increase with valsalva 3) reflux > 2 sec on venography 4) nitroglycerin if spasm 5) internal iliac study with occlusion balloon if needed

Question 16

Treatment of varicocele

Answer 16

Occlusion of testicular vein from inguinal ligament to 5cm below convergence with left renal vein Coils 10% larger than vein

Question 17

Renal vein thrombosis causes

Answer 17

1) thrombus propagating from below to obstruct IVC and renal veins 2) caval obstruction/invasion from malignant neoplasm with compromise of renal vein 3) primary renal vein thrombosis 4) renal vein thrombosis secondary to nephritis

Question 18

How to visualize SMV

Answer 18

SMA injection then image in delayed phase

Question 19

How to visualize portal venous system

Answer 19

1) Transcutaneous transhepatic 2) transjugular intrahepatic approach

Question 20

Portal vein comes from

Answer 20

SMV + splenic vein

Question 21

Budd-chiari syndrome define

Answer 21

Thrombosis of hepatic venous outflow causes portal HTN

Question 22

Budd-chiari causes

Answer 22

1) membranous obstruction of IVC 2) pregnancy 3) oral contraceptive 4) tumors 5) infection 6) blood dyscrasias 7) idiopathic

Question 23

Characteristic of budd chiari on venography

Answer 23

1) spiderlike appearance of occluded/recanalized hepatic vein 2) distal occlusion of IVC = weblike band of stenosis

Question 24

Key in imaging of the upper extremity venous system

Answer 24

Arm at rest then arm abducted to stress the outlet provocative maneuver

Question 25

Pulmonary artery angiography key points

Answer 25

1) care with right ventricle = RBBB and cause complete HB in people with existing LBBB 2) large volume contrast contraindicated in pulmonary HTN (20 mmHg)

Question 26

Risk of venography

Answer 26

1) pain at site 2) infection 3) extravasation 4) allergy 5) thrombophlebitis 6) intraabdominal bleed via transhepatic approach 7) DVT 8) PE 9) portal vein thrombosis