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4:00 pm

Peripheral ArteriographyErnest j. Ring, MD

4:30 pm

Venous and Pulmonary Arterial Imaging

Steven C. Rose, MD

Learning objectives: From this presentation, attendeesshould be able to: (1) list the different sonographic tech­niques used to evaluate each of the three major venoussegments of the lower extremity (iliocaval, femoropopli­teal, and infrapopliteal) for deep venous thrombosis(DVT); (2) list the four fundamental items to evaluatesonographically in patients with lower extremity venousinsufficiency; (3) list the sonographic criteria to diag­nose occlusion of(a) the sonographically accessible tho­racic veins (aXillary and internal jugular veins), and(b) the sonographically inaccessible conduit veins (cen­tral subclavian, innominate veins and superior venacava [SVC)); (4) list six important anatomic variants ofthe inferior vena cava (IVC)/renal venous system, andthree variants of the SVc,· and (5) list three sonographicimaging alternatives to pulmonary angiography for di­agnoses ofpulmonary embolism.

BLOOD flow in normal lower extremity veins coursesfrom the periphery toward the right atrium and from thesubcutaneous superficial veins toward the deep venoussystem via perforating branches. Blood flow is largelyunidirectional because of the bicuspid valves locatedprincipally distal to the inguinal ligament. Because oflow intraluminal pressure (typically less than 15 mm Hgwhen supine), venous blood in the central portions ofboth the normal lower and upper extremity veins (eg,common femoral, axillary, or internal jugular veins) var­ies considerably with changes in intrathoracic and intra­abdominal pressure during respiration and right atrialpressure changes during the cardiac cycle. The pliantvenous walls and relatively low intraluminal pressurepermit ready distention with dependency or volumeoverload ("capacitance function") and compression with

external pressure.Important anatomic variants include duplication of

the popliteal, superficial femoral, and greater saphenousveins, and compression of the left common iliac vein bythe overlying right common iliac artery. The latter con­dition may lead to synechiae formation and/or thrombo­sis (May-Thurner Syndrome).

The most common indication for evaluation of lowerextremity veins is diagnosis of suspected acute DVT. His­torically, the diagnostic gold standard is ascending con­trast venography that was assumed to have an accuracyapproaching 100%. However, contrast venography en­

tails patient discomfort, has risks associated with contrastinjection (notably skin slough, induced thrombophlebi-