Combined CT Venography and Pulmonary Angiography: A Comprehensive Review1
Douglas S. Katz, MD,
Peter A. Loud, MD,
Dennis Bruce, MD,
Adam M. Gittleman, MD,
Richard Mueller, LRT,
Donald L. Klippenstein, MD and
Zachary D. Grossman, MD
1 From the Department of Radiology, Winthrop-University Hospital, 259 First St, Mineola, NY 11501 (D.S.K., D.B., A.M.G., R.M.); and the Department of Radiology, Roswell Park Cancer Institute, Buffalo, NY (P.A.L., D.L.K., Z.D.G.). Presented as an education exhibit at the 2001 RSNA scientific assembly. Received February 6, 2002; revision requested March 26 and received May 7; accepted May 15. Address correspondence to D.S.K. (e-mail: dsk2928@pol.net).
View larger version (96K):
[in a new window]
|
Figure 1a. Representative normal CT venographic portion of a combined CTVPA study (hereafter, CT venogram) in a 19-year-old woman with chest pain. CT venograms of the pelvis (a) and legs (b) demonstrate patent bilateral external iliac (arrows in a) and distal superficial femoral (large arrows in b) veins. The superficial femoral veins are posterolateral to the superficial femoral arteries (small arrows in b) at this level. Findings from CT pulmonary angiography were also normal (not shown).
|
|
View larger version (76K):
[in a new window]
|
Figure 1b. Representative normal CT venographic portion of a combined CTVPA study (hereafter, CT venogram) in a 19-year-old woman with chest pain. CT venograms of the pelvis (a) and legs (b) demonstrate patent bilateral external iliac (arrows in a) and distal superficial femoral (large arrows in b) veins. The superficial femoral veins are posterolateral to the superficial femoral arteries (small arrows in b) at this level. Findings from CT pulmonary angiography were also normal (not shown).
|
|
View larger version (98K):
[in a new window]
|
Figure 2a. Increasing shortness of breath in a 62-year-old woman with a history of lung cancer. (a) CT pulmonary angiographic portion of the CTVPA study (hereafter, CT pulmonary angiogram) shows a saddle pulmonary arterial embolus. A right peripheral pulmonary infarction (arrow) is evident even at this mediastinal window. (b) CT venogram obtained at the level of the pubic symphysis shows acute left common femoral venous thrombosis (arrow) and edema in the anterior fat (arrowheads). The clot extended from the left external iliac vein to the left calf.
|
|
View larger version (96K):
[in a new window]
|
Figure 2b. Increasing shortness of breath in a 62-year-old woman with a history of lung cancer. (a) CT pulmonary angiographic portion of the CTVPA study (hereafter, CT pulmonary angiogram) shows a saddle pulmonary arterial embolus. A right peripheral pulmonary infarction (arrow) is evident even at this mediastinal window. (b) CT venogram obtained at the level of the pubic symphysis shows acute left common femoral venous thrombosis (arrow) and edema in the anterior fat (arrowheads). The clot extended from the left external iliac vein to the left calf.
|
|
View larger version (66K):
[in a new window]
|
Figure 3. Shortness of breath in a 53-year-old man with acute myelogenous leukemia. A right lower lobe PE was identified on the CT pulmonary angiogram (not shown). CT venogram shows acute right popliteal venous thrombosis. Localized edema is extensive, and enhancement of the venous wall (long arrow) is prominent, as are edema and subtle peripheral enhancement of the adjacent arterial wall (short arrow).
|
|
View larger version (92K):
[in a new window]
|
Figure 4 Chest pain and shortness of breath in a 39-year-old woman. CT venogram shows acute left common femoral venous thrombosis. Expansion of the vein (arrow) is significant compared with the normal right side, the venous wall is markedly thickened and enhanced, and the adjacent fat is edematous. PE was also present (not shown).
|
|
View larger version (62K):
[in a new window]
|
Figure 5. Increasing shortness of breath and edema and erythema of the left leg in a 67-year-old woman with stage IV non-small-cell lung cancer who was hospitalized for dehydration and pneumonia. CT venogram shows acute left superficial femoral DVT (arrow), along with leg swelling and edema. PE was also identified (not shown).
|
|
View larger version (70K):
[in a new window]
|
Figure 6. CT venogram shows DVT in the right superficial femoral vein (long arrow) and partial thrombosis of the right deep femoral vein (short arrow) in an 82-year-old woman. The findings were acute by clinical history; the right thigh exhibits relatively subtle swelling compared with the left.
|
|
View larger version (56K):
[in a new window]
|
Figure 7a. Shortness of breath in an 89-year-old woman. (a) CT venogram shows partial thrombosis of the left deep femoral vein (arrow). The chronicity of this finding is unclear from examination of this image alone. (b) CT pulmonary angiogram shows multiple segmental PEs (arrows), and the patient was acutely symptomatic.
|
|
View larger version (113K):
[in a new window]
|
Figure 7b. Shortness of breath in an 89-year-old woman. (a) CT venogram shows partial thrombosis of the left deep femoral vein (arrow). The chronicity of this finding is unclear from examination of this image alone. (b) CT pulmonary angiogram shows multiple segmental PEs (arrows), and the patient was acutely symptomatic.
|
|
View larger version (83K):
[in a new window]
|
Figure 8a. Pneumonia and history of chronic right lower extremity DVT in a 77-year-old woman. (a) CT venogram shows chronic DVT (arrow) in a shrunken right common femoral vein. (b) CT venogram obtained immediately below a shows continued chronic right common femoral venous thrombosis (long arrow) and chronic superficial venous thrombosis in the saphenous veins bilaterally (short arrows).
|
|
View larger version (83K):
[in a new window]
|
Figure 8b. Pneumonia and history of chronic right lower extremity DVT in a 77-year-old woman. (a) CT venogram shows chronic DVT (arrow) in a shrunken right common femoral vein. (b) CT venogram obtained immediately below a shows continued chronic right common femoral venous thrombosis (long arrow) and chronic superficial venous thrombosis in the saphenous veins bilaterally (short arrows).
|
|
View larger version (91K):
[in a new window]
|
Figure 9a. Pleuritic chest pain and shortness of breath in a 30-year-old woman. The patient had a history of prior pacemaker placement but no definitive history of DVT. (a, b) CT venograms reveal marked hypoplasia of the right external iliac vein (arrow in a) and atresia of the right common femoral vein associated with several tiny collateral veins (arrows in b). The right common femoral and superficial femoral veins were not visualized 4 years earlier at sonography (not shown). It is unclear whether this finding is an acquired or congenital abnormality in this patient.
|
|
View larger version (84K):
[in a new window]
|
Figure 9b. Pleuritic chest pain and shortness of breath in a 30-year-old woman. The patient had a history of prior pacemaker placement but no definitive history of DVT. (a, b) CT venograms reveal marked hypoplasia of the right external iliac vein (arrow in a) and atresia of the right common femoral vein associated with several tiny collateral veins (arrows in b). The right common femoral and superficial femoral veins were not visualized 4 years earlier at sonography (not shown). It is unclear whether this finding is an acquired or congenital abnormality in this patient.
|
|
View larger version (117K):
[in a new window]
|
Figure 10a. Myeloma, chest pain, and leg swelling in a 72-year-old woman. (a) CT venogram shows partial thrombosis of the inferior vena cava (arrow). The chronicity of this nonocclusive thrombus cannot be determined at this specific level. (b) CT venogram shows acute thrombosis of the left common femoral vein (arrow), which is expanded by the clot. (c) CT venogram shows both acute and chronic thrombosis in the distal left superficial femoral vein (arrow); subtle central venous calcification indicates chronic DVT, and expansion of the vein and soft-tissue edema indicates the acute component of the process. Thrombosis was also present in the left iliac, popliteal, and calf veins. The CT venographic findings led to the placement of an inferior vena cava filter via the right internal jugular vein.
|
|
View larger version (88K):
[in a new window]
|
Figure 10b. Myeloma, chest pain, and leg swelling in a 72-year-old woman. (a) CT venogram shows partial thrombosis of the inferior vena cava (arrow). The chronicity of this nonocclusive thrombus cannot be determined at this specific level. (b) CT venogram shows acute thrombosis of the left common femoral vein (arrow), which is expanded by the clot. (c) CT venogram shows both acute and chronic thrombosis in the distal left superficial femoral vein (arrow); subtle central venous calcification indicates chronic DVT, and expansion of the vein and soft-tissue edema indicates the acute component of the process. Thrombosis was also present in the left iliac, popliteal, and calf veins. The CT venographic findings led to the placement of an inferior vena cava filter via the right internal jugular vein.
|
|
View larger version (61K):
[in a new window]
|
Figure 10c. Myeloma, chest pain, and leg swelling in a 72-year-old woman. (a) CT venogram shows partial thrombosis of the inferior vena cava (arrow). The chronicity of this nonocclusive thrombus cannot be determined at this specific level. (b) CT venogram shows acute thrombosis of the left common femoral vein (arrow), which is expanded by the clot. (c) CT venogram shows both acute and chronic thrombosis in the distal left superficial femoral vein (arrow); subtle central venous calcification indicates chronic DVT, and expansion of the vein and soft-tissue edema indicates the acute component of the process. Thrombosis was also present in the left iliac, popliteal, and calf veins. The CT venographic findings led to the placement of an inferior vena cava filter via the right internal jugular vein.
|
|
View larger version (121K):
[in a new window]
|
Figure 11. Right-sided chest pain in a 50-year-old man with acute myelogenous leukemia. CT venogram shows an isolated left iliac venous thrombosis (arrow). This finding, plus those of PE (not shown) and left external iliac venous thrombosis (not shown), led to inferior vena cava filter placement by means of a right inguinal approach. Although the nonocclusive left iliac venous thrombosis is not accompanied by findings of acute venous thrombosis such as wall enhancement, significant venous enlargement, or edema in the adjacent soft tissues, the PE and DVT were presumed to be acute on the basis of the patient’s history.
|
|
View larger version (117K):
[in a new window]
|
Figure 12a. Repeated complaints of syncope over the previous few months in a 30-year-old man. Left-sided chest pain and swelling of the right leg developed 9 days prior to imaging. Findings from sonography of the lower extremities, which included the usual survey of both common femoral, superficial femoral, and popliteal veins, were normal. CT pulmonary angiogram (a) shows a left PE (arrow), and CT venogram (b) reveals a right external iliac thrombosis (arrow). There was also right calf DVT, and the thighs were found not to have DVT.
|
|
View larger version (107K):
[in a new window]
|
Figure 12b. Repeated complaints of syncope over the previous few months in a 30-year-old man. Left-sided chest pain and swelling of the right leg developed 9 days prior to imaging. Findings from sonography of the lower extremities, which included the usual survey of both common femoral, superficial femoral, and popliteal veins, were normal. CT pulmonary angiogram (a) shows a left PE (arrow), and CT venogram (b) reveals a right external iliac thrombosis (arrow). There was also right calf DVT, and the thighs were found not to have DVT.
|
|
View larger version (60K):
[in a new window]
|
Figure 13. Six days of shortness of breath after abdominal surgery in a 55-year-old woman. CT venogram shows multiple thrombosed veins in the right calf (arrows). Both calves are edematous. DVT was isolated to the right calf, and PE was identified at the CT pulmonary angiographic phase of the study (not shown).
|
|
View larger version (69K):
[in a new window]
|
Figure 14. Acute shortness of breath after liver surgery in a 66-year-old man. CT venogram shows large but patent proximal deep femoral veins (solid arrows) bilaterally (with smaller deep femoral arteries immediately anterior to the veins), posterior to the superficial femoral veins (open arrows) and arteries. In this case, results of CTVPA were negative for both PE and DVT.
|
|
View larger version (71K):
[in a new window]
|
Figure 15. CT venogram of a 69-year-old man shows DVT in the right superficial (solid arrow) and deep femoral (open arrow) veins.
|
|
View larger version (79K):
[in a new window]
|
Figure 16. Decreased oxygen saturation in an 80-year-old man. CT venogram shows bilateral superficial femoral (solid arrows) and deep femoral venous thrombosis (open arrows). CT pulmonary angiograms revealed PEs (not shown). Correct diagnosis of DVT is relatively difficult in this patient because the findings are bilateral, but the veins are expanded and decreased in attenuation compared with what is normally expected. In this case, sonography performed immediately after the CT study helped confirm bilateral DVT. Sonography is complementary in the small percentage of equivocal CT venographic studies.
|
|
View larger version (110K):
[in a new window]
|
Figure 17a. Shortness of breath after sigmoid colonic resection in an 81-year-old woman. (a) CT pulmonary angiogram shows a right interlobar PE (arrow). (b) CT venogram reveals subtle left deep femoral venous thrombosis (solid arrow) and asymmetry with the normal right side (open arrow).
|
|
View larger version (77K):
[in a new window]
|
Figure 17b. Shortness of breath after sigmoid colonic resection in an 81-year-old woman. (a) CT pulmonary angiogram shows a right interlobar PE (arrow). (b) CT venogram reveals subtle left deep femoral venous thrombosis (solid arrow) and asymmetry with the normal right side (open arrow).
|
|
View larger version (68K):
[in a new window]
|
Figure 18a. Shortness of breath and atrial fibrillation in an 81-year-old woman. (a) CT venogram shows a large acute left common femoral venous thrombus (solid arrow) and superficial thrombosis in the right saphenous vein (open arrow). (b) CT venogram shows DVT in a duplicated left distal superficial femoral vein (solid arrows) and in the medially located right saphenous vein (open arrow). Diagnosis of these complex venous thromboses is easy at CT venography but would be difficult at sonography.
|
|
View larger version (68K):
[in a new window]
|
Figure 18b. Shortness of breath and atrial fibrillation in an 81-year-old woman. (a) CT venogram shows a large acute left common femoral venous thrombus (solid arrow) and superficial thrombosis in the right saphenous vein (open arrow). (b) CT venogram shows DVT in a duplicated left distal superficial femoral vein (solid arrows) and in the medially located right saphenous vein (open arrow). Diagnosis of these complex venous thromboses is easy at CT venography but would be difficult at sonography.
|
|
View larger version (58K):
[in a new window]
|
Figure 19a. Left-sided chest pain in a 78-year-old woman. CT venograms show DVT in the right popliteal vein (arrow in a) and right calf (ie, peroneal) vein (solid arrow in b). Patent superficial varices in the right calf are also seen (open arrows in b).
|
|
View larger version (56K):
[in a new window]
|
Figure 19b. Left-sided chest pain in a 78-year-old woman. CT venograms show DVT in the right popliteal vein (arrow in a) and right calf (ie, peroneal) vein (solid arrow in b). Patent superficial varices in the right calf are also seen (open arrows in b).
|
|
View larger version (87K):
[in a new window]
|
Figure 20a. Shortness of breath and right leg pain in a 43-year-old man. CT venograms show prominent but patent left medial thigh (a) and calf (b) superficial varices. A relatively subtle right calf DVT is also present (arrow in b). The patient had associated PE (not shown) and no evidence of DVT in the thighs. Analysis of complex venous anatomy in these types of cases is readily and rapidly accomplished with the CT venographic portion of the study.
|
|
View larger version (58K):
[in a new window]
|
Figure 20b. Shortness of breath and right leg pain in a 43-year-old man. CT venograms show prominent but patent left medial thigh (a) and calf (b) superficial varices. A relatively subtle right calf DVT is also present (arrow in b). The patient had associated PE (not shown) and no evidence of DVT in the thighs. Analysis of complex venous anatomy in these types of cases is readily and rapidly accomplished with the CT venographic portion of the study.
|
|
View larger version (88K):
[in a new window]
|
Figure 21. Shortness of breath after low anterior rectal resection in an 80-year-old woman. CT venogram shows significant streak artifacts caused by a right total hip prosthesis. Clot in the left common femoral vein is identified (arrow).
|
|
View larger version (77K):
[in a new window]
|
Figure 22. Shortness of breath in a 97-year-old woman. CT venogram shows a prominent popliteal fossa region cyst on the left (arrow) and osteoarthritic changes in both knees.
|
|
View larger version (71K):
[in a new window]
|
Figure 23a. Shortness of breath in a 74-year-old woman with a history of malignancy. CT venograms show acute right proximal popliteal DVT (arrow in a), continuation of the clot in the more distal right popliteal vein (long arrow in b), and small bilateral popliteal arterial aneurysms (short arrows in b).
|
|
View larger version (68K):
[in a new window]
|
Figure 23b. Shortness of breath in a 74-year-old woman with a history of malignancy. CT venograms show acute right proximal popliteal DVT (arrow in a), continuation of the clot in the more distal right popliteal vein (long arrow in b), and small bilateral popliteal arterial aneurysms (short arrows in b).
|
|
View larger version (62K):
[in a new window]
|
Figure 24. Chest pain and shortness of breath in a 45-year-old man. CT venogram shows a well-demonstrated complex abscess in the left thigh but no DVT.
|
|
Copyright © 2002 by the Radiological Society of North America.
