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Role of CT venography in the diagnosis and treatment of benign thoracic central venous obstruction.

Kim H, Chung JW, Park JH, Yin YH, Park SH, Yoon CJ, Choi YH - Korean J Radiol (2003 Jul-Sep)

Bottom Line: The following features were analyzed by two observers: the cause, degree, and extent of venous obstruction; associated thrombosis; and implications for the planning of treatment.In all patients, CT venography depicted the causes of obstruction, including extrinsic compression of the left brachiocephalic vein, and mediastinal inflammatory pseudotumor.In evaluating the status of central veins proximal to long segmental obstruction, and associated thrombosis, CT venography was superior to digital subtraction venography.

View Article: PubMed Central - PubMed

Affiliation: Department of Radiology, Seoul National University College of Medicine, Seoul, Korea. chungjw@radcom.snu.ac.kr

ABSTRACT

Objective: To evaluate the role of CT venography in the diagnosis and treatment of benign thoracic central venous obstruction.

Materials and methods: Eighteen patients who had undergone both CT venography and digital subtraction venography were prospectively enrolled in this study. The following features were analyzed by two observers: the cause, degree, and extent of venous obstruction; associated thrombosis; and implications for the planning of treatment. CT venography and digital subtraction venography were compared in defined venous segments, and the degree of obstruction, and correlation was expressed using Spearman's rank correlation coefficient.

Results: In all patients, CT venography depicted the causes of obstruction, including extrinsic compression of the left brachiocephalic vein, and mediastinal inflammatory pseudotumor. Interobserver agreement regarding classification of the degree of obstruction was judged as good for CT venography (K=0.864), and in evaluating this, there was significant correlation between CT venography and digital subtraction venography (reader 1: Rs = 0.58, p < 0.01; reader 2: Rs = 0.56, p < 0.01). In evaluating the status of central veins proximal to long segmental obstruction, and associated thrombosis, CT venography was superior to digital subtraction venography. In half of all patients, the findings of CT venography led to changes in the treatment plan.

Conclusion: The findings of CT venography correlated closely with those of digital subtraction venography, and the former accurately depicted the degree and extent of benign venous obstruction.

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Complete occlusion of the left subclavian vein occurring at ipsilateral contrast material injection.A. Curved planar reformation image demonstrates membranous obstruction of the proximal portion of the left subclavian vein (arrow). Reader 1 interpreted this as severe stenosis, and reader 2 as occlusion. The brachial vein, thoracoepigastric vein (arrowheads), and left brachiocephalic vein (curved arrow) are clearly enhanced, whereas the subclavian vein and axillary vein show only slight enhancement. Because the collateral circulation bypassed the occluded subclavian vein, no obstructive lesion was seen in the left axillary vein at the abrupt transition in contrast enhancement (open arrow).B. Oblique coronal thin-slab maximum-intensity-projection image obtained after segmentation of the left clavicle and first rib reveals membranous obstruction (arrow) of the proximal portion of the left subclavian vein and faint enhancement of this vein (S). The injected contrast material drained into the left brachiocephalic vein through the lateral thoracic and thoracoepigastric vein (open arrow), and this explains the lesser degree of contrast enhancement of the left subclavian vein.C. Digital subtraction venography performed with the catheter tip in the left axillary vein depicts the thoracoepigastric vein (arrowheads), lateral thoracic vein (curved arrow), posterior intercostal vein (arrow), and left brachiocephalic vein. The left subclavian vein and proximal axillary vein are not opacified, so the level of stenosis can be mistaken for the mid-portion of the axillary vein.D. Digital subtraction venography with the catheter tip placed just before the obstructing membrane in the left subclavian vein demonstrates complete occlusion (arrow) of the left subclavian vein. The left brachiocephalic vein beyond the obstruction is opacified by collateral circulation via the left external jugular vein. The left axillary vein is widely patent.
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Figure 1: Complete occlusion of the left subclavian vein occurring at ipsilateral contrast material injection.A. Curved planar reformation image demonstrates membranous obstruction of the proximal portion of the left subclavian vein (arrow). Reader 1 interpreted this as severe stenosis, and reader 2 as occlusion. The brachial vein, thoracoepigastric vein (arrowheads), and left brachiocephalic vein (curved arrow) are clearly enhanced, whereas the subclavian vein and axillary vein show only slight enhancement. Because the collateral circulation bypassed the occluded subclavian vein, no obstructive lesion was seen in the left axillary vein at the abrupt transition in contrast enhancement (open arrow).B. Oblique coronal thin-slab maximum-intensity-projection image obtained after segmentation of the left clavicle and first rib reveals membranous obstruction (arrow) of the proximal portion of the left subclavian vein and faint enhancement of this vein (S). The injected contrast material drained into the left brachiocephalic vein through the lateral thoracic and thoracoepigastric vein (open arrow), and this explains the lesser degree of contrast enhancement of the left subclavian vein.C. Digital subtraction venography performed with the catheter tip in the left axillary vein depicts the thoracoepigastric vein (arrowheads), lateral thoracic vein (curved arrow), posterior intercostal vein (arrow), and left brachiocephalic vein. The left subclavian vein and proximal axillary vein are not opacified, so the level of stenosis can be mistaken for the mid-portion of the axillary vein.D. Digital subtraction venography with the catheter tip placed just before the obstructing membrane in the left subclavian vein demonstrates complete occlusion (arrow) of the left subclavian vein. The left brachiocephalic vein beyond the obstruction is opacified by collateral circulation via the left external jugular vein. The left axillary vein is widely patent.

Mentions: At CT venography, both readers identified all the 24 stenotic sites demonstrated at digital subtraction venography. Fourteen patients had one stenotic site, three patients had two, and one patient had four; the degree of obstruction was grade I at three sites, grade II at ten, grade III at nine, and grade IV at two. Interobserver agreement was good (κ=0.864). Regarding the degree of stenosis, there was significant correlation between CT venography and digital subtraction venography (reader 1: Rs =0.58, p < 0.01; reader 2: Rs = 0.56, p < 0.01). Reader 1 underestimated two cases of complete occlusion as severe stenosis (Fig. 1), and reader 2 underestimated one such case as severe stenosis and overestimated one case of severe stenosis as complete occlusion. In two patients with dynamic obstruction due to extrinsic compression of the left brachiocephalic vein, both readers reported moderate or severe stenosis at CT venography (Fig. 2).


Role of CT venography in the diagnosis and treatment of benign thoracic central venous obstruction.

Kim H, Chung JW, Park JH, Yin YH, Park SH, Yoon CJ, Choi YH - Korean J Radiol (2003 Jul-Sep)

Complete occlusion of the left subclavian vein occurring at ipsilateral contrast material injection.A. Curved planar reformation image demonstrates membranous obstruction of the proximal portion of the left subclavian vein (arrow). Reader 1 interpreted this as severe stenosis, and reader 2 as occlusion. The brachial vein, thoracoepigastric vein (arrowheads), and left brachiocephalic vein (curved arrow) are clearly enhanced, whereas the subclavian vein and axillary vein show only slight enhancement. Because the collateral circulation bypassed the occluded subclavian vein, no obstructive lesion was seen in the left axillary vein at the abrupt transition in contrast enhancement (open arrow).B. Oblique coronal thin-slab maximum-intensity-projection image obtained after segmentation of the left clavicle and first rib reveals membranous obstruction (arrow) of the proximal portion of the left subclavian vein and faint enhancement of this vein (S). The injected contrast material drained into the left brachiocephalic vein through the lateral thoracic and thoracoepigastric vein (open arrow), and this explains the lesser degree of contrast enhancement of the left subclavian vein.C. Digital subtraction venography performed with the catheter tip in the left axillary vein depicts the thoracoepigastric vein (arrowheads), lateral thoracic vein (curved arrow), posterior intercostal vein (arrow), and left brachiocephalic vein. The left subclavian vein and proximal axillary vein are not opacified, so the level of stenosis can be mistaken for the mid-portion of the axillary vein.D. Digital subtraction venography with the catheter tip placed just before the obstructing membrane in the left subclavian vein demonstrates complete occlusion (arrow) of the left subclavian vein. The left brachiocephalic vein beyond the obstruction is opacified by collateral circulation via the left external jugular vein. The left axillary vein is widely patent.
© Copyright Policy - open-access
Related In: Results  -  Collection

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Show All Figures
getmorefigures.php?uid=PMC2698080&req=5

Figure 1: Complete occlusion of the left subclavian vein occurring at ipsilateral contrast material injection.A. Curved planar reformation image demonstrates membranous obstruction of the proximal portion of the left subclavian vein (arrow). Reader 1 interpreted this as severe stenosis, and reader 2 as occlusion. The brachial vein, thoracoepigastric vein (arrowheads), and left brachiocephalic vein (curved arrow) are clearly enhanced, whereas the subclavian vein and axillary vein show only slight enhancement. Because the collateral circulation bypassed the occluded subclavian vein, no obstructive lesion was seen in the left axillary vein at the abrupt transition in contrast enhancement (open arrow).B. Oblique coronal thin-slab maximum-intensity-projection image obtained after segmentation of the left clavicle and first rib reveals membranous obstruction (arrow) of the proximal portion of the left subclavian vein and faint enhancement of this vein (S). The injected contrast material drained into the left brachiocephalic vein through the lateral thoracic and thoracoepigastric vein (open arrow), and this explains the lesser degree of contrast enhancement of the left subclavian vein.C. Digital subtraction venography performed with the catheter tip in the left axillary vein depicts the thoracoepigastric vein (arrowheads), lateral thoracic vein (curved arrow), posterior intercostal vein (arrow), and left brachiocephalic vein. The left subclavian vein and proximal axillary vein are not opacified, so the level of stenosis can be mistaken for the mid-portion of the axillary vein.D. Digital subtraction venography with the catheter tip placed just before the obstructing membrane in the left subclavian vein demonstrates complete occlusion (arrow) of the left subclavian vein. The left brachiocephalic vein beyond the obstruction is opacified by collateral circulation via the left external jugular vein. The left axillary vein is widely patent.
Mentions: At CT venography, both readers identified all the 24 stenotic sites demonstrated at digital subtraction venography. Fourteen patients had one stenotic site, three patients had two, and one patient had four; the degree of obstruction was grade I at three sites, grade II at ten, grade III at nine, and grade IV at two. Interobserver agreement was good (κ=0.864). Regarding the degree of stenosis, there was significant correlation between CT venography and digital subtraction venography (reader 1: Rs =0.58, p < 0.01; reader 2: Rs = 0.56, p < 0.01). Reader 1 underestimated two cases of complete occlusion as severe stenosis (Fig. 1), and reader 2 underestimated one such case as severe stenosis and overestimated one case of severe stenosis as complete occlusion. In two patients with dynamic obstruction due to extrinsic compression of the left brachiocephalic vein, both readers reported moderate or severe stenosis at CT venography (Fig. 2).

Bottom Line: The following features were analyzed by two observers: the cause, degree, and extent of venous obstruction; associated thrombosis; and implications for the planning of treatment.In all patients, CT venography depicted the causes of obstruction, including extrinsic compression of the left brachiocephalic vein, and mediastinal inflammatory pseudotumor.In evaluating the status of central veins proximal to long segmental obstruction, and associated thrombosis, CT venography was superior to digital subtraction venography.

View Article: PubMed Central - PubMed

Affiliation: Department of Radiology, Seoul National University College of Medicine, Seoul, Korea. chungjw@radcom.snu.ac.kr

ABSTRACT

Objective: To evaluate the role of CT venography in the diagnosis and treatment of benign thoracic central venous obstruction.

Materials and methods: Eighteen patients who had undergone both CT venography and digital subtraction venography were prospectively enrolled in this study. The following features were analyzed by two observers: the cause, degree, and extent of venous obstruction; associated thrombosis; and implications for the planning of treatment. CT venography and digital subtraction venography were compared in defined venous segments, and the degree of obstruction, and correlation was expressed using Spearman's rank correlation coefficient.

Results: In all patients, CT venography depicted the causes of obstruction, including extrinsic compression of the left brachiocephalic vein, and mediastinal inflammatory pseudotumor. Interobserver agreement regarding classification of the degree of obstruction was judged as good for CT venography (K=0.864), and in evaluating this, there was significant correlation between CT venography and digital subtraction venography (reader 1: Rs = 0.58, p < 0.01; reader 2: Rs = 0.56, p < 0.01). In evaluating the status of central veins proximal to long segmental obstruction, and associated thrombosis, CT venography was superior to digital subtraction venography. In half of all patients, the findings of CT venography led to changes in the treatment plan.

Conclusion: The findings of CT venography correlated closely with those of digital subtraction venography, and the former accurately depicted the degree and extent of benign venous obstruction.

Show MeSH
Related in: MedlinePlus