ISNVD Abstract Book

The 2 nd Annual ISNVD Scientific Meeting
February 18–22 th 2012 Orlando, Florida, USA
Catheter venography for the assessment of internal jugular veins and
azygous vein – consensus document
Contrary to some well-recognized venous territories, relatively little is known about anatomy,
physiological flow and hemodynamics in the internal jugular veins. Even less is known about the
azygous vein. Consequently, catheter angiography and interpretation is currently performed according
to the rules governing examination of other veins. Still, differences exist between techniques and
interpretation amongst centers. Since our knowledge about anatomy and physiology of veins that may
play a role in pathophysiology of neurological disorders (especially: multiple sclerosis) in the setting
of the so-called chronic cerebrospinal venous insufficiency (CCSVI) is at its infancy, there are many
problems that should be addressed.
1. Vascular access.
Most venographies are currently performed through femoral access. Access through an upper
extremity vein is a theoretical option in the case of agenesis of inferior vena cava. A direct puncture of
the internal jugular vein can also be used, but can be technically challenging if such a vein is
hypoplastic or collapsed. Thus, femoral access is the preferred route. However, there are some issues,
which need to be considered when using femoral access.
Firstly, the pressure measurement in the internal jugular vein may not be reliable (jugular valve is
potentially kept open by the diagnostic catheter – hypothetically reducing or eliminating any crossvalve
pressure differential). Options may include using a smaller caliber device such as a pressuresensing
wire, which is less disruptive to valves or for accurate pressure measurement direct jugular
access could be considered.
Secondly, there is discussion about which femoral vein (right or left), should be punctured. Insertion
of the catheter through the left femoral vein allows a much easier assessment of left iliac vein (May-
Thurner syndrome), the ascending lumbar veins and the left renal vein (Nutcracker syndrome). On the
other hand, access through right femoral vein makes access and angioplasty of the left internal jugular
and azygous veins much easier particularly in the case of tortuous iliac and left brachiocephalic veins.
In addition, there is currently no evidence to support angioplasty of asymptomatic stenosis of the left
iliac or left renal vein, thus a potential benefit from left femoral access is not clear. We therefore
recommend right femoral vein access for routine assessment of the internal jugular and azygous veins
and possible consideration of angioplasty. Left femoral vein access may be an option if the screening
of additional veins, such as left iliac vein is planned.
2. Angiographic contrast.
Angiographic contrast may be used diluted (1:1) or non-diluted. Diluted contrast allows better
visualization of endoluminal structures (valve leaflets, webs, etc.). However, non-diluted contrast
allows better opacification of epidural and other collaterals as well as better estimation of overall
features of veins particularly stenosis.
There is no clear consensus on whether contrast should be hand or pressure injected. Hand injections
are performed using smaller volumes of contrast under lower pressure. Pressure injectors are higher