Veins of the Neck :

The catheter has been introduced into the left brachiocephalic vein from the femoral vein. The catheter is advanced from the femoral vein into the inferior vena cava, through the right atrium into the superior vena cava and then into the left brachiocephalic. The veins of the neck are divided into two sets, one lying superficial to the deep fascia and the other lying deep to it. The external jugular vein is formed by the union of the posterior division of the retromandibular vein and the posterior auricular vein, and originates at the angle of the mandible. It terminates by draining into the subclavian vein about 4 cm above the clavicle. The internal jugular vein begins in the base of the skull and is continuous with the sigmoid sinus. The vein passes inferiorly through the neck within the carotid sheath to unite with the subclavian vein, thus forming the brachiocephalic vein. Note the position of the thyroid veins, the superior and middle being shown. The inferior thyroid veins arise in the thyroid gland, after a free anastomosis with the middle and superior veins, to drain into the brachiocephalic veins. This technique of superselective catherization of thyroid veins is of particular use when assaying blood for increased parathormone levels due to a parathyroid tumour (parathyroid venous sampling).

   Axillary and Subclavian Venogram :

The cephalic vein tuns upwards along the lateral border of the biceps muscle and lies in the deltopectoral groove before entering the infraclavicular fossa. It pierces the clavipectoral fascia, crosses the axillary artery and joins the axillary vein below the clavicle. The basilic vein runs upwards from the elbow along the medial border of the biceps muscle to perforate the deep fascia in the middle of the arm, and ascends beside the brachial artery to the lower border of teres major where it becomes the axillary vein. The axillary vein extends from this point to become the subclavian vein at the outer border of the first rib.

   Inferior Vena Cavogram :

The inferior vena cava is demonstrated by catheterization of both femoral veins with simultaneous injection of contrast medium. The vein is formed from the junction of the two common iliac veins at the level of L5 and ascends, terminating in the lower posterior part of the right atrium. The inferior vena cava receives the following veins: lumbar, right testicular or ovarian, renal, right suprarenal, inferior phrenic and hepatic. The main indication for performing this technique is to check for evidence of venous thrombosis. The entrance of the renal and hepatic veins can be seen. It is possible, however, to get some retrograde flow of contrast medium into the origins of these veins by performing a Valsalva manoeuvre at the time of injection.

   Iliac Venogram :

The catheters lie in the external iliac veins and simultaneous injection has again been performed. Compression has been applied to cause retrograde filling of the pelvic vessels. The usual indication for pelvic venography is to demonstrate obstruction of the iliac or pelvic veins and to look for evidence of fresh thrombosis.

   Veins of the Lower Limb :

These three films demonstrate the deep veins of the lower limb from ankle to hip. A superficial vein on the dorsum of the foot was injected by direct needle technique with constrictive bands placed above the ankle and below the knee. These bands cause the deep venous system to fill by occluding the superficial veins. There is a wide variation in the distribution of calf veins, but they are mainly grouped into the anterior and posterior tibial veins. These veins join to form the popliteal vein at the lower border of the popliteus muscle. The femoral vein accompanies the femoral artery and begins at the hiatus in the adductor magnus muscle. The termination of the superficial long saphenous vein can be seen in the saphenous opening, about 4 cm below and lateral to the pubic tubercle. A lateral film of the calf veins is often useful to show recent thrombosis, which can be missed on a single anteroposterior view. A perforating vein can be seen going from the superficial to the deep venous system in the calf and these can become considerably enlarged and varicose.

   Splenoportogram :

The portal circulation can be visualized by three techniques: percutaneous splenic puncture, operative mesenteric venogram and selective splenic arteriogram. The majority of splenic venograms are performed for the investigation of portal hypertension. The tributaries of the portal vein are the splenic, superior mesenteric, left gastric, right gastric, paraumbilical and cystic veins. The portal system includes all the veins which drain blood from the intestine and from the spleen, pancreas and gall bladder. The portal vein and its tributaries have no valves in the adult, but this is not so in the fetus.

   Left Suprarenal Venogram :

The right suprarenal vein is very short and drains directly into the inferior vena cava just above the upper pole of the right kidney. It may occasionally drain via the hepatic vein. The left suprarenal vein is longer and drains into the left renal vein. This vein may occasionally have some drainage via the inferior phrenic vein. Considerable care must be taken in the amount of contrast injected because of the risk of suprarenal infarction. On the left side, approximately 5 ml and, on the right side, 2 ml are usually sufficient. With selective catheterization, it is possible to take blood samples for hormone analysis.

   Lymphangiograms :

Lymphangiography is performed in the upper and lower limb by the cannulation of lymph vessels that have been rendered visible by the subcutaneous injection of patent blue dye. The contrast used is iodized oil fluid injection (Lipiodol Ultra-Fluid). This accumulates in the glands and shows their internal structure. If injection is too rapid or too forceful, extravasation can occur, particularly in the upper limb. There are normally one to four channels in the lower leg, following the course of the long saphenous vein. The beaded appearance is due to valves. The lymphatic system of the pelvis and abdomen is demonstrated by bilateral injections of contrast medium into the lymphatics of the feet. The importance of the first day or immediate films is to show the position of the afferent and efferent vessels as they enter and leave the nodes, respectively. This is important if one is to avoid making false positive diagnoses of metastases in later films. Once the contrast medium has reached the thoracic duct, the injection should be stopped, because any more contrast given will go straight to the thoracic duct and hence into the left subclavian vein to end up as oil emboli in the lungs. One of the contraindications of this technique is when the patient has severe respiratory disease with a decreased transfer factor. The indications include investigation of lymphoedema, the detection of metastases (e.g. from kidney, cervix, testicle and bladder), and in the diagnosis and staging of the reticuloses. The lumbar crossover of iliac vessels can be seen clearly on this film. Numerous crossflow channels exist between the two sides and, if there is obstruction, these channels increase significantly. There are four sets of nodes around the aorta: the right and left para-aortic, the retro-aortic and the pre-aortic. The cisterna chyli is situated in front of the bodies of L1 and L2 and it receives vessels from the para-aortic group of glands and the intestinal lymphatic trunks. It gives off the thoracic duct, which ascends on the posterior thoracic wall to open into the left subclavian vein. As the nodes of the pelvis lie along the lateral borders, near the iliac vessels, oblique views of the pelvis are required to see these nodes clearly. Signs of lymphatic obstruction include: stasis, dermal backflow, the filling of abnormal collateral channels and the opening of lymphaticovenous channels. The AP film of the abdomen shows the normal position of the para-aortic lymph nodes. Note that the normal para-aortic nodes should not lie outside a line formed by the tips of the transverse processes. Signs of metastases in the nodes include: filling defects, failure of severely involved nodes to fill, obstruction of a normal lymphatic pathway, and distortion and displacement by a nodal mass. As contrast medium remains in the lymphatic nodes for up to 18 months, it is a useful technique to x-ray again following treatment to show remission or recurrence of disease.