Simplified Phlebography of the Inferior Vena Cava in Urologic Diagnosis

Abstract

Although numerous methods of evaluating retroperitoneal disease are available to the urologie surgeon, visualization of the inferior vena cava is seldom used. Since the procedure was first suggested by Dos Santos in 1935 (4), the radiographic contrast technics described in the literature have been varied but cumbersome and therefore poorly accepted. This is emphasized by an extensive review of radiologic aids in the diagnosis of retroperitoneal tumors (7), listing thirteen procedures but making no mention of contrast filling of the inferior vena cava. The complicated technic described, requiring venous cut down (8), catheters, (10), bilateral injections (11), serial filming (3), transosseous injections (20), and translumbar vena caval puncture (11) are probably responsible to a large extent for the poor acceptance of this procedure. We have used a simpler, safer, and equally diagnostic technic in 85 studies and believe this method to be generally applicable even in the investigation of outpatients. Technic No premedication is necessary, omission of the previous meal being the only preparation routinely employed. The patient lies supine on the radiographic table in a 10° Fowler's position and scout films are obtained. These include an anteroposterior projection with a Bucky grid and a lateral view with a horizontal beam and grid cassette. The roentgenograms thus obtained obviate positional changes by the patient. While the preliminary films are being developed, the right femoral area is cleansed with an antiseptic solution. The femoral arterial pulse is palpated 1 cm. below the inguinal ligament and a local anesthetic infiltrated into the skin and deeper tissues medial to the artery. The scout films are viewed and any adjustment in technic is made at this time. A 3-inch, 17-gauge, 45°-beveled needle is inserted percutaneously into the femoral vein. While blood is continuously with-drawn into a syringe, the needle is advanced 2 cm. within the lumen of the vein. This secure placement of the needle diminishes the possibility of extravasation. The posterior course of the external iliac vein immediately superior to the inguinal ligament must be borne in mind as the needle is advanced. A plastic tube is connected to the needle and both are taped to the thigh of the patient. The patency of the needle is maintained by a normal saline infusion. A test dose of 1 c.c. of contrast material is injected in an attempt to determine iodine sensitivity and possible extravasation, which is manifested by local pain. A sphygmomanometer cuff is placed on the opposite thigh as cephalad as possible and the pressure raised to 200 mm. Hg prior to the injection. This diminishes distortion and dilution of the contrast column by blood from the opposite extremity.