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Ultrasound Diagnosis of Lower Extremity Venous Insufficiency
S. Lakhanpal MDPresident & CEO
Center for Vein Restoration
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Diagnostic Evaluation for Venous Disease:Assumes that a good clinical evaluation gas been completed.
Suspected Chronic Ambulatory Venous Hypertension –lower extremity
AVH (can be documented by But usually not needed) US examination.
Reflux Disease
Infra inguinal
Deep venous reflux
US
Superficial Venous Reflux
U.S
Obstructive disease
Supra inguinal
Surface US
Venogram/ IVUS
CTV/MRV
Infra inguinal
US
Phlebography
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Essential Components of Duplex Scanning
• Visualization
• Compressibility
• Venous flow
• Augmentation
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US Equipment & Basic Settings
• Examination room conditions: Warm and comfortable, prevents spasm• Higher frequency probes(6-7MHz) are used for superficial structures
and lower frequency probes(3MHz) for deeper structures. All veins can be interrogated by probes between 3-7 MHz.
• Curvilinear probes provide better depth.• Other basic settings
– Pulse repetition frequency (PRF): 1500Hz(Low flow frequency).– Focus: Posterior wall(allows better lateral resolution in the field of
imaging).– Time gain compensation(TGC): Set to perfect the imaging of the
target vessel– Gain: Dark background to avoid overestimation of velocities– Angle of insonation: Set at 0 degrees, angle may have to be
corrected to be parallel to the flow channel.
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What to look for?
Venous reflux: reversal of flow in the veins
Physiologic(the time it takes for the valve leaflets to appose)
CFV, FV, PV: <1sec
Superficial Veins: <0.5sec.
Pathological
Congenital 1-2%
Primary -24%
Secondary(post thrombotic) – 75%
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Technique
• Augmentation:– Valsalva; evaluation of the valves in the groin– Compression and release; distal to the point of evaluation
» Automated an standardized(size, duration & inflation) pneumatic cuffs used 5 cm below the probe site.
– Additional dorsi/plantar flexion in patients with significant edema• Patient position:
– Starts with patient standing, with weight on the contralateral limb. Limb being evaluated flexed and externally rotated. Tilt table with a back rest.
• Sequence:– Starts at the CFV, above the junction of the FV and the Deep FV– SFJ with the terminal and pre terminal valves– Pop.V, and the deep calf veins– The GSV(surrounded by two layers of fascia – saphenous eye), SSV
(triangular fascia), their tributaries, non saphenous veins are examined next.
– Perforating veins: Course perpendicular to the deep veins and pierce the fascia. Normal flow is superficial to deep.
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Recurrent Varices after Surgery (REVAS)
• Incidence– 20-80%
• Causes:– True recurrence
• Technical failure to ligate SFJ (19%)• Neovascularization in cases of SFJ disease(20%)
– Residual disease• Failure to recognize perforator disease
– Progression of original disease• Most common in patients with strong family
histories
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Theories of Reflux – Origination and Extension
• In cases of primary(non thrombotic) reflux of the superficial and deep system:– The reflux circuit theory; The reflux in the superficial system and
consequently the perforators will overload the deep system and lead to dilatation and reflux of the deep system. This kind of reflux involved the proximal vessels and valves(SFJ, SPJ, Gastro popliteal jn.)
– Walsh SH and Sales CM in two independent studies have suggested that treating the superficial system here will fix the deep reflux.
• In Primary CVD reflux in PV’s develops– In an ascending manner through the adjoining
incompetent superficial vein, – In a descending manner from the reentry flow of
refluxing superficial veins. In such cases treating the superficial veins treats the refluxing perforators.
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Other Pathologies
Other Pathologies Identified by US
Aneurysms Tumors Phlebosclerosis
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Further Evaluation of the pelvic & abdominal veins
• Indications:– Symptomatic non saphenous varicosities– Recurrent Varicose veins of the legs– Leg Disease out of proportion for documented venous insufficiency in the legs– Symptoms suggestive of pelvic venous congestion
• Evaluations:– US– Inferior veno cavography
– US guided B/L Femoral venous access 6fr sheath on the Rt side with a 4F sheath on the left.
– B/L injections– LIMA catheter with a glide through the right to gain access to the
renal vein– IVUS
– Change sheath to 11 Fr.– Criterion
– CTV;• May Thurner syndrome ( normal size of the CIV 10-12 mm)
– MRV
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Ultrasound Diagnosis of Venous Disease
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Normal GSV Within the Fascial Plane
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Competent Superficial Doppler
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Valvular Competence
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Evaluation of Deep Vein Reflux
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Sapheno-femoral Junction
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Dilated - GSV Within the Fascial Plane
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Vessel Diameter
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VI in Superficial Vessel
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Documented Venous Insufficiency in SSV
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Catheter to Deep Junction Measurement
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Perforator with Measurement
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Chronic, Non-Occlusive Deep Vein Thrombosis
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Deep Vein Thrombosis
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Superficial Venous Thrombosis
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Baker’s Cyst in the Popliteal Fossa
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US Findings and Their Clinical Correlation
• Duplex US and its correlation with symptoms:– Up to 4/5th of the patients presenting with CVD are
symptomatic with achiness heaviness, tiredness, restless limb, burning and ulceration.
• Duplex US and its correlation with signs: – Varicose veins and telengectasias are present in 4/5th .– Skin changes of some sort are present in up to 1/4th – Active or healed ulcerations in up to 1/9th .
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US Findings and Their Clinical Correlation
• Duplex US and severity of disease:
– C1-2: Reflux limited to the superficial system– C3-6: Prevalence of deep vein reflux and perforator
reflux increases.– C4-6: Higher incidence of combined obstruction and
reflux.
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US Findings and Their Clinical Correlation
• Presence of Reflux by Location:
– Superficial Veins in 90% of the Patients• GSV 70-80%• SSV 15-25%• Non Saphenous Veins -10%
– Deep System in 30%• Perforator Veins 20%
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US Findings and Their Clinical Correlation
• Ulcers and reflux:
– Superficial system alone: up to 50% but Superficial reflux is present in up to 95%
– Isolated deep vein reflux<10%. Popliteal vein has strongest correlation.
– Veins in the ulcer bed and 2 cms around it, reflux in upto 90%
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It is essential that all patients who complain of pelvic symptoms or associated non saphenous varicosities have their pelvic veins evaluated;
• Sonographic Evidence of Pelvic Venous Congestion
– The visualization of dilated ovarian veins greater than 4 mm in diameter.
– Dilated tortuous arcuate veins in the myometrium that communicate with bilateral pelvic varicose veins.
– Slow blood flow (less than 3 cm/s), and reversed caudal or retrograde venous blood flow particularly in the left ovarian vein.
– Interestingly, more than 50% of women with PCS have associated cystic ovaries as well. The US appearance may range from classic polycystic ovarian syndrome to clusters of cysts in bilaterally enlarged ovaries (4 to 6 cysts of 5 to 15 mm in diameter).
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Thank You