A Simple Method for Lower Extremity Phlebography-

Pseudo-Obstruction of the Popliteal Vein!

ROBERT s. ARKOFF, M.D., RUTHERFORD S. GILFILLAN, M.D.,
and H. JOACHIM BURHENNE, M.D.

TACK OF CONSISTENT deep venous filling
L has been a shortcoming in phlebog-
raphy of the lower extremity. Certain
measures commonly adopted to improve
phlebographic examination have included
tourniquet placement about the ankle,
internal rotation of the leg, serial filming,
and biplane examination. The use of
higher doses of contrast medium has been
to a lack of mixing rather than sedimenta-
tion and found that a position 65 a from
the horizontal was as successful as the
vertical.
Phlebography in the erect or semierect
position is not without its disadvantages.
DeWeese and Rogoff (2) reported a 10
per cent incidence of syncope in their
series. Needle placement is jeopardized

Fig. 1. A 36-year-old female with clinical evidence of superticial thrombo-

phlebitis. On supine examination with the leg extended there is failure
to visualize the deep venous system below the level of the femoral condyle,
simulating deep venous occlusion (A). A patent femoropopliteal system is
readily opacified in the lateral examination with the leg flexed (B).

helpful only when the examination is
performed in the erect position (3).
Performance of the examination in the
erect position is the only maneuver which
has reportedly resulted in consistently
good visualization of the deep venous sys-
tem (4). This was pioneered by Lindblom
(5), who felt that the poor visualization
of the deep veins in the horizontal posi-
tion was due to sedimentation of the con-
trast medium since it is heavier than blood.
Greitz (3) showed that the effect was due
1 From the Departments of Radiology and General Surgery, Children's Hospital and Adult Medical Center, San
Francisco, Calif. Accepted for publication in July 1967.
RADIOLOGY 90: 66-69, January 1968.
66
by assumption of the erect position, par-
ticularly since exercise is necessary for
consistent visualization of the deep veins
in the thigh in this position. Surgical
exposure and cannulation of the vein may
then become necessary for optimum suc-
cess, and yet in some patients, especially
those with acute thrombophlebitis, both
exercise and surgical exposure may be
contraindicated.
Serial filming is of value in the phlebo-
graphic examination. Film-changing, how-
Vol. 90 SIMPLE METHOD FOR LOWER EXTREMITY PHLEBOGRAPHY 67

Fig. 2. A 19-year-old female with unilateral leg edema. Deep venous thrombosis was considered when antero-
posterior supine and attempted lateral recumbent studies, both with the leg extended, showed no filling of the deep
venous system (A and B). A third injection in the same patient in the lateral position and with slight flexion of the
knee results in good delineation of normal deep venous structures (C).

ever, especially when 14 X 36-inch cas-
settes are used, is difficult with the patient
erect or semierect.
Lastly, a biplane examination with turn-
ing of the patient is cumbersome when he is
erect. Horizontal or near-horizontal posi-
tion is more suitable for phlebography of the
lower extremity, provided adequate deep
filling can be obtained routinely.
Extrinsic myofascial and/or osseous
compression of the popliteal vein is prob-
ably responsible for poor deep venous fill-
ing and appears to be related to position-
ing. For example, in patients placed
in circular casts, edema or thrombo-
phlebitis frequently develops when the
leg is in full extension. Casting the
leg with the knee in slight flexion serves
to avoid this complication. Furthermore,
rupture of plantaris tendon or muscle
by forceful hyperextension is frequently
followed by edema and occasionally by
thrombophlebitis. It has also been noted
during surgical exposure of the popliteal
vein that after forceful extension of the
leg and dorsiflexion of the foot the pop-
liteal vein is obstructed by the soleus
bridge.
Lateral phlebograms taken with the
leg extended have shown compression of
the popliteal vein at the level of the con-
dyles of the femur. Britton (1) noted that
"hyperextension of the normal limb may
flatten the popliteal vein as it crosses the
joint line and give the roentgenographic
appearance of thrombus, stenosis, or oc-
clusion."
We have found improvement in deep
venous opacification when the knee was
slightly flexed during phlebographic ex-
amination. Since it seemed most natural
to carry out the examination in the supine
frontal position, a sponge was placed in the
popliteal space in order to flex the leg.
Lack of universal success with this ma-
neuver may have been due to compression
of the popliteal vein by the sponge itself.
The problem, then, is how to do phlebog-
raphy of the lower extremity with the leg
in flexion without supporting the knee,
68 ROBERT S. ARKOFF AND OTHERS January 1968

Fig. 3. A 35-year-old female with a past history of iliofemoral thrombophlebitis with involvement of the calf
vessels. The anteroposterior recumbent examination with the leg extended resulted in no opacification in the deep
system (A). Anteroposterior erect examination with the leg extended provided faint filling of the deep venous system
on all films (B). A third injection with the knee flexed and the patient recumbent in the lateral position (C) and
then in the anteroposterior projection (D) shows distinctly better filling than the erect examination with the leg
extended.

and the simple answer is to make the in-
jection with the patient in the lateral posi-
tion.
We have successfully demonstrated the
deep venous system in the recumbent posi-
tion even in the face of partial popliteal
occlusion. Our method yields a biplane
examination with a single injection.
METHOD OF PHLEBOGRAPHIC
EXAMINATION
The patient is placed in the supine posi-
tion, for preliminary radiography, on a
special tunnel containing two abutting 14
X 17-inch stationary grids with 8: 1 ratio.
Films are taken at 55 inches distance in
order to accommodate a 14 X 36-inch
field. A wedge filter is used to offset the
smaller diameter of the lower leg relative
to the thigh. The average factors are 90
kV, 500 mA, and 1/20 second. No vari-
ation in the technic for the anteroposterior
and lateral projections has been found
necessary. The foot is wrapped in hot,
moist towels to provide venous dilata-
tion. A tourniquet is placed about the
malleoli. A No. 20 or No. 21 needle of a
pediatric scalp vein transfusion set is in-
serted into a superficial vein on the dorsum
of the foot or ankle and taped in place.
The patient is then turned into the lateral
position with the leg flexed and relaxed.
The opposite leg is placed forward of the
leg being examined. Thirty to fifty cubic
centimeters of contrast medium is then
injected over a thirty to forty-five second
interval, and the initial 14 X 36-inch film
is exposed, followed in ten seconds by a
second film. The patient then turns as
soon as possible into the supine position,
and a third film is obtained which serves
as a mate to film No.2. A fourth film is
taken ten seconds later. Additional films
may be obtained and/or a greater time
interval may be used if appropriate.
DISCUSSION
The exact mechanism causing positional
obstruction of the popliteal vein has not
been determined. Similar findings in Fig-
ures 1 and 2 cast suspicion on the stretching
of the popliteal vein over the femoral con-
dyles in extension, with perhaps additional
compression by those muscles which cross
the popliteal vein dorsally. The plantaris
muscle, in particular, is in a position to
cause such compression. The soleus mus-
cle bridge is also dorsal to the vein, but it
Vol. 90 SIMPLE METHOD FOR LOWER EXTREMITY PHLEBOGRAPHY
is further distal than the site of the obstruc-
tion seen in these cases.
Regardless of the exact mechanism, ex-
tension of the leg appears to cause compres-
sion of the popliteal vein, which varies with
individuals but operates in both horizontal
and erect positions.
Optimal filling of the deep venous system
can be obtained with the patient horizontal,
if the leg is flexed (Figs. 1 and 2). The
advantage gained is due to flexion of the
leg, rather than assumption of the lateral
position (Fig. 2). Extension of the leg to
some degree interferes with filling, even in
the erect position, and for this reason re-
cumbent studies with the leg flexed may
approach if not surpass erect studies (Fig.
3).
SUMMARY
A method for phlebography of the lower
extremity in the recumbent position is
described. It results routinely in satis-
factory opacification of the deep venous
system and provides a biplane examination
with a single injection and one x-ray tube.
The consistent deep venous filling appears
to be afforded by injection with the leg in
69
flexion. Previous studies in extension have
been misinterpreted as deep venous ob-
struction.
Determination of the exact mechanism
of compression of the popliteal vein when
the leg is extended must await further
study. However, pressure by the femoral
condyles and/or the plantaris muscle must
be considered.
ACKNOWLEDGMENT: The authors thank Drs.
Vietor Richards, William Dubilier, Jr., and William
L. Anderson for the use of Figure 2.
Department of Radiology
Children's Hospital and Adult Medical Center
3700 California Street
San Francisco, Calif. 94119
REFERENCES
1. BRITTON, R. C.: [In] Vascular Roentgenology,
ed. by R. A. Schobinger and F. F. Ruzicka, Jr. New
York, Macmillan, 1964, pp. 658-661.
2. DEWEESE, J. A., AND ROGOFF, S. M.: Func-
tional Ascending Phlebography of the Lower Extremity
by Serial Long Film Technique: Evaluation of Ana-
tomic and Functional Detail in 62 Extremities. Am. J.
Roentgenol, 81: 841-854, May 1959.
3. GREITZ, T.: The Technique of Ascending
Phlebography of the Lower Extremity. Acta radiol.
42: 421-441, December 1954.
4. GREITZ, T.: Phlebography of the Normal Leg.
Acta radiol. 44: 1-20, July 1955.
5. LINDBLOM, K.: Phlebographische Untersuchung
des Unterschenkels bei Kontrastinjektion in eine sub-
kutane Vene. Acta radiol. 22: 288-296, 1941.