Renal Vein Thrombosis Demonstrated by Selective Renal Phlebography

Abstract

Selective renal phlebography is a relatively new procedure, with few reports in the literature of its technic or applications. Recently, the authors encountered a case of renal trauma with subsequent renal vein thrombosis. The thrombus was demonstrated by selective renal vein catheterization and phlebography. The purpose of this paper is to report the case, to review the radiographic diagnosis of renal vein thrombosis, and to discuss the technic and applications of selective renal phlebography. Method Radiographic demonstration of the renal veins has been accomplished by several methods. Delayed films following renal arteriography often disclose filling of the main renal veins. Inconsistency of opacification and lack of detail, however, render this method unreliable for diagnosis. The renal veins may, at times, be visualized during inferior vena cavography. Helander and Lindbom (1) have described the findings in the normal cavogram. Because of the large volume of blood diluting the contrast agent, streaming or blurring of the contour of the vena cava occurs for a short distance above the renal vein orifices (Fig. 1). Increasing the intracaval pressure by a Valsalva maneuver is said to result in filling of the caval tributaries, including the renal veins (2). In our experience, however, voluntary performance of this maneuver rarely results in satisfactory vein opacification. The procedure of choice for radiographic demonstration of the renal veins is selective catheter phlebography. This is performed by the Seldinger replacement method using preformed catheters, but with puncture of the femoral vein rather than the femoral artery (3). The technic of selective renal angiography and the preparation of suitable curved catheters have been described in detail by Tillotson and Halpern (4). A curved yellow ÖOdman catheter (E.D. 2.85 mm., I.D. 1.5 mm.) is preferred for this study in our department. When the catheter is in the renal vein, filming is accomplished with a mechanical film changer of the Schönander type programmed for two films per second for four seconds. A Gidlund apparatus is used to inject 15 to 20 c.c. of 75 per cent Hypaque under 2.5 to 3 kg./sq. cm. of pressure. With pressures of this order, filling of the interlobar renal veins can frequently be accomplished, and occasionally of the left gonadal vein as well; the main renal veins are consistently well visualized. Case Report J. V., an 18-year-old white male, was admitted on Sept. 10, 1962, three weeks after an auto accident resulting in trauma to the left flank. He had experienced aching left mid back pain for one week, but this had disappeared subsequently. Three days prior to admission, sharp right posterior chest and flank pain developed. The past history was negative.