Phlebography

Varicose veins, phlebothrombosis and post-thrombotic disease are frequently observed lesions of the veins of the lower extremities, leading to chronic venous insufficiency. They pose a risk of thrombotic masses transferring to the pulmonary vessels with the development of thromboembolism and pulmonary infarction.

In the examination of individuals with venous insufficiency of the extremities, impedance plethysmography and radiation methods (X-ray phlebography) play a leading role. These studies are necessary not only for diagnosis, but to an even greater extent for specifying the localization, extent, type and degree of damage, including an assessment of the venous valve apparatus.

In chronic venous insufficiency, it is necessary to examine the venous system of both extremities, since phlebothrombosis of one of them may be asymptomatic. Priority belongs to the ultrasound method due to its availability and high diagnostic value, but in some cases it does not allow to distinguish between acute and chronic venous thrombosis. X-ray phlebography is a sensitive and highly specific method for diagnosing venous insufficiency, but is contraindicated in acute thrombophlebitis, renal failure and high sensitivity to iodine drugs. Radionuclide phlebography (phleboscintigraphy) is somewhat inferior to X-ray phlebography in sensitivity and specificity, but is less traumatic, has no contraindications, does not threaten thrombus dislocation and is accompanied by a lower radiation load.

X-ray phlebography is performed in different positions of the patient - horizontal and vertical. In vertical functional-dynamic phlebography, the first image is taken after filling the veins of the lower leg, the second - after contraction of the muscles of the limb (for this, the patient is asked to rise on his toes several times), the third - immediately after the second, in the phase of muscle relaxation. Recently, magnetic resonance phlebography and computed tomographic angiography on spiral computed tomographs have been successfully used in well-equipped centers.

Unaffected veins cause a clear network of vessels on X-ray images. The vein usually runs straight, sometimes forming small bends; its lumen is uniform, slightly increasing in front of the valves. The contours of all veins are sharp and even. Intertrunk anastomoses are represented by short veins with a uniform lumen. Insufficiency of deep veins is manifested by their expansion and tortuosity with a persistent slowdown in blood flow. In case of insufficiency of communicating veins, the contrast agent is thrown from the deep veins into the superficial ones. Phlebitis leads to persistent narrowing of the vessel, and the parietal thrombus forms a marginal filling defect. When a thrombus is detected, the question of preventing pulmonary embolism arises. For this purpose, the inferior vena cava is catheterized and a special filter mesh is installed in it to capture a possible thrombus as it migrates from the veins of the lower extremities.

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