The primary imaging technique in suspected venous occlusive disease has for many years been contrast venography. Recent studies have shown ultrasound with the addition of colour Doppler imaging to be a suitable alternative method in the diagnosis of lower limb venous thrombosis. We have applied these techniques to the upper limb venous system, and have performed a prospective study of 19 patients (30 limbs) comparing colour Doppler ultrasound with venography in the diagnosis of axillary and subclavian vein thrombosis, for which colour Doppler ultrasound has a sensitivity and specificity of 100%. If vein stenosis is included, the sensitivity falls to 89%. We propose that colour Doppler ultrasound is a suitable first-line alternative to venography in the diagnosis of axillary and subclavian vein thrombosis. In addition to showing the major venous drainage of the upper limb, ultrasound routinely assesses patency of the internal jugular vein, which is, on occasion, of clinical relevance when determining possible future sites of venous access. If, however, colour Doppler ultrasound is normal then bilateral upper limb venography is indicated to exclude a more central venous problem or localized stenotic lesion.

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Adrenal venography has been carried out in 58 patients with the left adrenal vein being successfully catheterized in 91 per cent and the right in 77 per cent. Of the 30 patients with primary hyperaldosteronism, 11 adenomas (12-35 mm diameter) have been demonstrated at venography and two of 15 mm suspected, all of which were confirmed surgically. Aldosterone levels in the adrenal vein plasma were raised on the affected side. In the group of proved micronodular hyperplasia, two patients had surgically confirmed macronodules and venography demonstrated one of 12 mm diameter. Two adenomas of 11 mm and one macronodule of 15 mm have been demonstrated at venography in the remainder who have not had an operation. Ultrasound was carried out in 12 patients with primary hyperaldosteronism, ten of which had tumours at venography. Two adenomas measuring 30 and 31 mm were outlined by ultrasound and confirmed surgically. Seven adenomas, including one macronodule (10-25 mm in diameter) were not defined. Three intra-adrenal phaeochromocytomas (45-90 mm) and one extra-adrenal (80-85 mm) were demonstrated at arteriography, identified by ultrasound and confirmed surgically. Of the ten patients with Cushing's syndrome three had enlarged glands at venography, this was confirmed surgically. Cumulative experience from this analysis and published reports indicate that venography will demonstrate tumours of 10 mm or more in diameter and outline enlarged glands; aldosterone assays will lateralize tumours as small as 3 mm; ultrasound will outline tumours of 30 mm and selective adrenal arteriography will demonstrate tumours of 10 mm. One patient developed acute adrenal cortical insufficiency with intra-adrenal extravasation on one side and thrombosis of the central vein on the opposite side. A second case developed temporary adreno-cortical insufficiency. Published reports indicate that the risk of complication is about 1 per cent. The report includes an anatomical study of the efferent adrenal veins in 50 patients paying particular attention to the diameter, number of accessory hepatic veins, and the angle of entry and position of the right adrenal vein.