Multidetector spiral computed tomography–venography in outpatient phlebological practice

Duplex ultrasound scanning (DUS) and magnetic resonance imaging are sometimes insufficient to meet our clinical needs due to specifics of given pathology and intrinsic technical limitations of these methods. This study aims to assess the need for multispiral computed tomography–venography (CT-venography) and to evaluate its diagnostic capabilities for various disorders in primary ambulatory patients in phlebology practice.

Material and Methods. From January, 2017 to December,2019, a total of 10,112 patients sought initial consultation of a phlebologist. Upon examination, the physician assigned patients to one of the proposed categories using dedicated software. Analysis of these categories demonstrated the following pattern of morbidity: 2,167 patients (21.4%) had chronic venous disorders of class С0S-1 (CEAP classification); 4,460 patients (44.1%) had varicose veins of class C2-3 (CEAP classification); 351 patients (3.5%) had varicose veins of class C4-6; 570 patients (5.6%) had other diseases including post-thrombotic syndrome, acute thrombosis, thrombophlebitis, and venous malformations; and 2,564 patients (25.4%) were suffering from non-venous disorders. DUS was performed in all cases.

Results. The study demonstrated that 260 patients required CT-venography constituting 2.6% of the total number of patients who came to the clinic in the indicated period. The direct venography with contrast medium injection through the peripheral veins was used in 156 cases (60%). Patients did not have any significant complications, such as acute kidney injury or worsening of chronic renal failure, severe allergic reactions to the contrast agent, or problems with the puncture site of peripheral veins.

Conclusions: 1) CT-venography allowed to achieve the accurate three-dimensional imaging of the venous system, providing, in some cases, the necessary information for finding solutions on optimal management. 2) The need for CT-venography may occur in 2.6% of patients in ambulatory phlebology practice. 3) CT-venography is useful for diagnosing angiodysplasias, postthrombotic and non-thrombotic lesions, complicated varicose veins, especially in recurrence, and in some cases of acute deep vein thrombosis. 4) DUS is mandatory for hemodynamic assessment in all patients before CT-venography.

1. Russian clinical guidelines for the diagnosis and treatment of chronic venous diseases. Phlebologia. Journal of Venous Disorders.2018;12(3):146–240 (In Russ.). DOI: 10.17116/flebo20187031146.

2. Wittens C., Davies A.H., Bækgaard N., Broholm R., Cavezzi A., Chastanet S. et al. Managementof chronic venous disease: Clinical Practice Guidelines of the European Society for Vascular Surgery (ESVS). Eur. J. Vasc. Endovasc. Surg. 2015;49(6):678–737. DOI: 10.1016/j.ejvs.2015.02.007.

3. Lamba R., Tanner D.T., Sekhon S., McGahan J.P., Corwin M.T., Lall C.G. Multidetector CT of vascular compression syndromes in the abdomen and pelvis. Radiographics. 2014;34(1):93–115. DOI: 10.1148/ rg.341125010.

4. Gaweesh A.S., Kayed M.H., Gaweesh T.Y., Shalhoub J., Davies A.H., Khamis H.M. Underlying deep venous abnormalities in patients with unilateral chronic venous disease. Phlebology. 2013;28(8):426–431. DOI: 10.1258/phleb.2012.012028.

5. Liu P., Peng J., Zheng L., Lu H., Yu W., Jiang X. et al. Application of computed tomography venography in the diagnosis and severity assessment of iliac vein compression syndrome: A retrospective study. Medicine (Baltimore). 2018;97(34):e12002. DOI: 10.1097/MD.0000000000012002.

6. Kim R., Lee W., Park E.A., Yoo J.Y., Chung J.W. Anatomic variations of lower extremity venous system in varicose vein patients: demonstration by three-dimensional CT venography. Acta Radiol. 2017;58(5):542–549. DOI: 10.1177/0284185116665420.

7. Uhl J.F. Three-dimensional modelling of the venous system by direct multislice helical computed tomography venography: Technique, indications and results. Phlebology. 2012;27(6):270–288. DOI: 10.1258/ phleb.2012.012J07.

8. Stehling M.K., Rosen M.P., Weintraub J., Kim D., Raptopoulos V. Spiral CT venography of the lower extremity. AJR Am. J. Roentgenol. 1994;163(2):451–453.

9. Baldt M.M., Zontsich T., Stümpflen A., Fleischmann D., Schneider B., Minar E. et al. Deep venous thrombosis of the lower extremity: efficacy of spiral CT venography compared with conventional venography in diagnosis. Radiology. 1996;200(2):423–428. DOI: 10.1148/radiology.200.2.8685336.

10. Karande G.Y., Hedgire S.S., Sanchez Y., Baliyan V., Mishra V., Ganguli S. et al. Advanced imaging in acute and chronic deep vein thrombosis. Cardiovasc. Diagn. Ther. 2016;6(6):493–507. DOI: 10.21037/cdt.2016.12.06.

11. Shi W.Y., Wang L.W., Wang S.J., Yin X.D., Gu J.P. Combined direct and indirect CT venography (Combined CTV) in detecting lower extremity deep vein thrombosis. Medicine (Baltimore). 2016;95(11):e3010. DOI: 10.1097/MD.0000000000003010.

12. Coelho A., O’Sullivan G. Evaluation of incidence and clinical significance of obturator hook sign as a marker of chronic iliofemoral venous outflow obstruction in computed tomography venography. J. Vasc. Surg. Venous Lymphat. Disord. 2020;8(2):237–243. DOI: 10.1016/j.jvsv.2019.07.011.

13. Lee B.B., Nicolaides A.N., Myers K., Meissner M., Kalodiki E., Allegra C. et al. Venous hemodynamic changes in lower limb venous disease: the UIP consensus according to scientific evidence. Int. Angiol. 2016;35(3):236–352.

14. Coelho A., O’Sullivan G. Usefulness of direct computed tomography venography in predicting inflow for venous reconstruction in chronic post-thrombotic syndrome. Cardiovasc. Intervent. Radiol. 2019;42(5):677–684. DOI: 10.1007/s00270-019-02161-5.

15. Mavili E., Ozturk M., Akcali Y., Donmez H., Yikilmaz A., Tokmak T.T. et al. Direct CT venography for evaluation of the lower extremity venous anomalies of Klippel–Trenaunay Syndrome. AJR Am. J. Roentgenol. 2009;192(6):311–316. DOI: 10.2214/AJR.08.1151.

16. Bastarrika G., Redondo P. Indirect MR venography for evaluation and therapy planning of patients with Klippel – Trenaunay Syndrome. AJR Am. J. Roentgenol. 2010;194(2):244–245. DOI: 10.2214/AJR.09.3417.

17. Bastarrika G., Redondo P., Sierra A., Cano D., Martínez-Cuesta A., López-Gutiérrez J.C. et al. New techniques for the evaluation and therapeutic planning of patients with Klippel – Trénaunay Syndrome. J. Am. Acad. Dermatol. 2007;56(2):242–249.DOI: 10.1016/j.jaad.2006.08.057.

18. Park E.A., Chung J.W., Lee W., Yin Y.H., Ha J., Kim S.J. et al. Three-dimensional evaluation of the anatomic variations of the femoral vein and popliteal vein in relation to the accompanying artery by using CT venography. Korean J. Radiol. 2011;12(3):327–340. DOI: 10.3348/kjr.2011.12.3.327.

19. Harris R.W., Andros G., Dulawa L.B., Oblath R.W., Horowitz R. Iliofemoral venous obstruction without thrombosis. J. Vasc. Surg. 1987;6(6):594–599.

20. Sato K., Orihashi K., Takahashi S., Takasaki T., Kurosaki T., Imai K. et al. Three-dimensional CT venography: A diagnostic modality for the preoperative assessment of patients with varicose veins. Ann. Vasc. Dis. 2011;4(3):229–234. DOI: 10.3400/avd.oa.11.00021.

21. Krishan S., Panditaratne N., Verma R., Robertson R. Incremental Value of CT Venography Combined with Pulmonary CT Angiography for the Detection of Thromboembolic Disease: Systematic Review and Meta-analysis. Am. J. Roentgenol. 2011;196(5):1065–1072. DOI: 10.2214/AJR.10.4745.