duplex assessment of venous hemodynamics 3 oct 13th, 2011, morning 20mn2
DESCRIPTION
Venous insufficency may be acurately assesed by DUSTRANSCRIPT
Duplex Assessment
of Venous
Hemodynamics
Claude FRANCESCHI, Roberto DELFRATE
Paris France, Cremona Italy
Hemodynamics knowledge is the
backbone of nowadays
performance in Diagnosis and
Treatment of Arterial and Cardiac
disease
Hemodynamics ignorance is the
reason for the still raw diagnosis
and treatment of the Venous
Disease despite the advanced
technologies that cannot
compensate theoretical lacks
Venous Hemodynamics
knowledge demands a peculiar
intellectual effort because:
Not teached in most universities
Weakly promoted ( known?) by
the majority of Phlebology
Opinion Leaders and Scientific
Societies
More complex than arterial
Duplex assessment of
venous
hemodynamics is the
key point for a better
diagnosis and
appropriate treatment
strategy
IF lighted by rational
and coherent
theoretical models
Duplex aims at
assessing the
hemodynamic
changes of the
venous system
According to the
various
hemodynamic
configurations
Pressure and Flow Overloading is
responsible for TMP EXCESS
TMP Excess is Responsible for
-Veins Dilatation ( Varicose)
-Drainage impairment ( trophic changes :
edema, hypodermitis, ulcer…)
Pressure and Flow Overloading is due
to
Venous Block responsible for
-Permanent Venous Pressure Excess
-Compensatory collaterals (Open Shunts)
Valve Incompetence responsible for
-Deep Reflux ( various grades)
-Superficial Reflux
- -Closed Circuits ( Closed Shunts)
- -Deviated Flows ( Open deviated Shunts)
DUPLEX is able to assess all these
complex configurations made of
blocks and shunts
IF performed according to appropriate
data assessments
So providing accurate diagnosis and
consequently appropriate treatment
Hemodynamic Manœuvres
Are Mandatory to elicit the
hemodynamic impairments
Hemodynamic Manoeuvres
Upright Position
Squizing, Paranà , Wundsdorf:
Valvo-muscular Pump Stress Test
Valsalva: Thoraco-abdominal
Pump Stress Test
Supine Position
Venous Pressure: Hemodynamic
obstacles assessment
Hemodynamic Manoeuvres
Upright Position
Squizing, Paranà , Wundsdorf:
Valvo-muscular Pump Stress Test
Valsalva: Thoraco-abdominal
Pump Stress Test
Supine Position
Venous Pressure: Hemodynamic
obstacles assessment
Valsalva Manœuvre:
May be performed easily and properly
blowing into a blocked straw
Valsalva Manœuvre:
Increases the Toraco-abdominal venous
pressure
and reverses downwards the pressure
gradient but not the flow when blocked by
the valves closure
Valsalva Manœuvre:
Valsalva is negative when the valves are
Competent
At
rest
Systole
=
blowing
Relax
Diastole
Flow is blocked by blowing ( systole)
and appears at release (diastole)
Valsalva Manœuvre:
Valsalva is Positive when valves are
Incompetent Valve
Reverse Flow appears when blowing
( systole) and at release (diastole)
At
rest
Systole
=
blowing
Relax
Diastole
Exception!!!!!
Contrary to the majority of the veins, AT DESCENDING TRIBUTARIES OF THE
SAPHENA ARCH
Positive Valsalva flow fed by pelvic leaks
doesn’t reverse direction
o P
p P
c P
s g P
ig P
i P i P
o P
p P
c P
gs P
g s P
At
rest
Systole
=
blowing
Relax
Diastole
Hemodynamic Manoeuvres
Upright Position
Squizing, Paranà , Wundsdorf:
Valvo-muscular Pump Stress Test
Valsalva: Thoraco-abdominal
Pump Stress Test
Supine Position
Venous Pressure: Hemodynamic
obstacles assessment
Purpose:Assessing
VALVE COMPETENCE
VALVE INCOMPETENCE
Grades:
-Total, Partial, Segmental
Haemodynamic effect:
- -Closed Shunts (closed circuit )
-Open Deviated Shunt ( open circuit )
VENOUS BLOCKS AND BY-PASSING VEINS
-Open Vicarious Shunt ( open circuit )
Purpose:Assessing
VALVE COMPETENCE
VALVE INCOMPETENCE
Grades:
-Total, Partial, Segmental, Closed Shunt
Haemodynamic effect:
-Open Deviated Shunt ( open circuit )
-Closed Shunts (closed circuit )
VENOUS BLOCKS AND BY-PASSING VEINS
-Open Vicarious Shunt ( open circuit )
Paranà:
Physiologic
Active Systole of the VMP and
plantar pump
BY
Proprioceptive reflex contraction
triggerd by a light push-pull at the
waist
Paranà:
Physiologic
Active Systole of the VMP and
plantar pump
BY
Proprioceptive reflex contraction
triggerd by a light push-pull at the
waist
Paranà:
Physiologic
Active Systole of the VMP and
plantar pump
BY
Proprioceptive reflex contraction
triggerd by a light push-pull at the
waist
Paranà:
Physiologic
Active Systole of the VMP and
plantar pump
BY
Proprioceptive reflex contraction
triggerd by a light push-pull at the
waist
Purpose:Assessing
VALVE COMPETENCE
VALVE INCOMPETENCE
Grades:
-Total, Partial, Segmental
Haemodynamic effect:
-Closed Shunts (closed circuit )
- Open Deviated Shunt ( open circuit )
VENOUS BLOCKS AND BY-PASSING VEINS
-Open Vicarious Shunt ( open circuit )
At
rest
Diastolic
Reflux
coequal to
Systolic
Popliteal Vein
Ilio-femoro-popliteal TOTAL incompetence
S
D
coequal
At
rest
Diastole
S
D
Above Femoral Valve Closure
Decreases the Reflux
SEGMENTAL Popliteal incompetence
Diastolic
Reflux
Peak
lower than
Systolic
At
rest
S
D
Small valve leak
PARTIAL Popliteal incompetence
Low and
Lasting
Diastolic
Reflux
Purpose:Assessing
VALVE COMPETENCE
VALVE INCOMPETENCE
Grades:
-Total, Partial, Segmental
Haemodynamic effect:
- -Closed Shunts (closed circuit )
-Open Deviated Shunt ( open circuit )
VENOUS BLOCKS AND BY-PASSING VEINS
-Open Vicarious Shunt ( open circuit )
At
rest
Femoral Example
Diastolic Reflux overloaded by a competent
collateral vein flow
At
rest
Deep CLOSED SHUNT
Diastolic
Reflux Peak
and volume
Higher than
Systolic
Femoral Example
Diastolic Reflux overloaded by a competent
collateral vein flow
At
rest
Great Saphena Example
Superficial Diastolic Reflux overloaded by a deep
vein flow
At
rest
Superficial CLOSED SHUNT
Diastolic
Reflux Peak
and volume
Higher than
Systolic
S
D
Great Saphena Example
Superficial Diastolic Reflux overloaded by a deep
vein flow
At
rest
Great Saphena Example
Superficial Diastolic Reflux overloaded by a deep
vein flow
At
rest
Superficial CLOSED SHUNT
Diastolic
Reflux Peak
and volume
Higher than
Systolic
S
D
Great Saphena Example SHUNT 1
Superficial Diastolic Reflux overloaded by a deep
vein flow
Positive (+)
Valsalva
Superficial Diastolic Reflux overloaded by a deep
vein flow
Superficial CLOSED SHUNT
Other Closed Shunts have the same
hemodynamic features but are different
according to the deep leak point that
feed them their and the re-entry point
that drain them and the involved
network
Superficial Diastolic Reflux overloaded by a deep
vein flow
Sapheno-femoral Junction
Sapheno-popliteal Junction
Pelvis leak points
Various Perforators
Networks:
N1, N2, N3, N4
o P
p P
c P
s g P
ig P
i P i P
o P
p P
c P
gs P
g s P
Purpose:Assessing
VALVE COMPETENCE
VALVE INCOMPETENCE
Grades:
-Total, Partial, Segmental
Haemodynamic effect:
- -Closed Shunts (closed circuit )
-Open Deviated Shunt ( open circuit )
VENOUS BLOCKS AND BY-PASSING VEINS
-Open Vicarious Shunt ( open circuit )
At
rest
Great Saphena Example
Superficial Diastolic Reflux overloaded by a deep
vein flow
At
rest
Superficial OPEN DEVIATED SHUNT
Diastolic
Reflux Peak
and volume
Higher than
Systolic
S
D
Great Saphena Tributary Example
Superficial Diastolic Reflux overloaded by a
other superficial collateral veins flow
Negative (-)
Valsalva
Purpose:Assessing
VALVE COMPETENCE
VALVE INCOMPETENCE
Grades:
-Total, Partial, Segmental
Haemodynamic effect:
- -Closed Shunts (closed circuit )
-Open Deviated Shunt ( open circuit )
VENOUS BLOCKS AND BY-PASSING VEINS
-Open Vicarious Shunt ( open circuit )
Great Saphena Example
Superficial Diastolic Reflux overloaded by a deep
vein flow
At
rest
Superficial OPEN VICARIOUS SHUNT
Rest, Systolic
Peak and
Diastolic
antegrade
flow
S
Great Saphena By-Passing a popliteal
block Example
Superficial Systolic flow overloaded by deep
venous flow
D
o P
p P
c P
s g P
ig P
i P i P
o P
p P
c P
gs P
g s P
Networks and their Connections are
checked up :
Flow direction and modulation
- -at rest
- under hemodynamic stress
manœuvres
Selected according to the peculiar status of
each patient
In order to depict a taylored topo-
hemodynamic feature
Hemodynamic Manoeuvres
Upright Position
Squizing, Paranà , Wundsdorf:
Valvo-muscular Pump Stress Test
Valsalva: Thoraco-abdominal
Pump Stress Test
Supine Position
Venous Pressure: Hemodynamic
obstacles assessment
Supine Position
Venous Pressure Measurement:
Veins Patency Test
Normal ≤ 25 mm Hg
Cuff
inflation/deflation
Posterior Tibial Vein
flow
For a comprehensive information
Duplex assessment of
venous
hemodynamics
Lower limbsVenous network
Dynamic Stress Manoeuvres
Hemodynamic Obstacles and Open
Vicarious Shunts
Hemodynamic Valve Incompetence
and Closed/Open Derivate Shunts
Protocole Assessment
Hemodynamic Mapping
Duplex assessment of
venous
hemodynamics
Lower limbsVenous Networks (N)
Dynamic Stress Manoeuvres
Hemodynamic Obstacles and Open
Vicarious Shunts
Hemodynamic Valve Incompetence
and Closed/Open Derivate Shunts
Protocole Assessment
Hemodynamic Mapping
Venous Networks ( N )
1988
Sub-Apon.
Compart.
Skin
Sub-
Cut.
Tissue
Duplicated
Apon.
fascia
Venous Networks ( N )
1988
N3 sub-cut.
veins
N2 intra-
fasc. veins
N1 deep
veins
Venous Networks ( N )
1988
Hierarchical draining
N1N2N3
Venous Networks ( N )
1988
Draining Veins
N1
N2
N3
TRUNKS
Ant.Saph.
Great saph.
GiacominiV.
Small saph.
Deep veins
Saph. and Extra
Saph. tributaries
Venous Networks ( N )
1988
Draining Veins
N4
N2 ► N2
Connecting
Veins
Venous Networks ( N )
N2 ►N1 collectors
Sapheno-Femoral Junction
Sapheno-Popliteal Junction
Venous Networks ( N )
N2 ►N1 main
perforators
LEGS
Venous Networks ( N )
N3 ►N1 some
perforators
LEGS
Venous Networks ( N )
Pelvis
6 perforators
Perineal V P Point
Rd Ligt V I Point
Clit. V C Point
Obt. V O Point
I Glut.V IG Point
S Glut. V SG Point
N3 ►N1 perforators
o P
p P
c P
s g P
ig P
i P i P
o P
p P
c P
gs P
g s P
Franceschi C, Bahnini A. (2005) Treatment of
lower extremity venous insufficiency due to pelvic
leaks points in women; Ann vasc Surg; 19; 284-88
Networks and their Connections
are checked up :
Flow direction and modulation
- at rest
- under hemodynamic
stress manœuvres
Selected according to the
peculiar status of each patient
In order to depict a taylored
topo-hemodynamic feature
Duplex assessment of
venous
hemodynamics
Lower limbsVenous Networks (N)
Dynamic Stress Manoeuvres
Hemodynamic Obstacles and Open
Vicarious Shunts
Hemodynamic Valve Incompetence
and Closed/Open Derivate Shunts
Protocole Assessment
Hemodynamic Mapping
Hemodynamic Manoeuvres
Upright Position
Squizing, Paranà , Wundsdorf:
Valvo-muscular Pump Stress Test
Valsalva: Thoraco-abdominal
Pump Stress Test
Supine Position
Venous Pressure: Hemodynamic
obstacles
Hemodynamic Manoeuvres
Upright Position
Squizing, Paranà , Wundsdorf:
Valvo-muscular Pump Stress Test
Valsalva: Thoraco-abdominal
Pump Stress Test
Supine Position
Venous Pressure: Veins Patency
Test
Valsalva Manœuvre:
Systolic Block of Thoraco-abdominal Pump
increases
the Toraco-abdominal venous pressure
Valsalva Manœuvre:
Systolic Block of Thoraco-abdominal Pump
increases the Toraco-abdominal venous
pressure
So reversing downwards the pressure
gradient without flow reversal thanks to the
peripheral valves closure
Valsalva Manœuvre:
Toraco-abdominal Pump Systolic Block
increases the Toraco-abdominal venous
pressure
So reversing downwards the pressure
gradient it produces a reversal reflux flow
when the peripheral valves are incompetent
Valsalva Manœuvre:
How to achieve Valsalva Manœuvre
easily and effectively :
Blowing into a KNOTTED STRAW
Blow!
Valsalva Manœuvre:
Negative Valsalva = Competent Valve
VALVE COMPETENCE = NO SYSTOLIC REFLUX
Valsalva Manœuvre:
Negative Valsalva = Competent Valve
At
rest
At rest, Permenant and Slow Upwards
flow due to Residual Pressure
VALVE COMPETENCE = NO SYSTOLIC REFLUX
Valsalva Manœuvre:
Negative Valsalva = Competent Valve
At
rest
Systole
=
blowing
then the flow is blocked by the Valsalva
systole
VALVE COMPETENCE = NO SYSTOLIC REFLUX
Valsalva Manœuvre:
Negative Valsalva = Competent Valve
At
rest
Systole
=
blowing
then the flow is blocked by the Valsalva
systole
Valsalva Manœuvre:
Negative Valsalva = Competent Valve
At
rest
Systole
=
blowing
Relax
Diastole
Then at release, le blood flows upwards
again thanks to the thoraco-abdominal
pump diastole
VALVE COMPETENCE = NO SYSTOLIC REFLUX
Valsalva Manœuvre:
Positive Valsalva = Incompetent Valve
VALVE INCOMPETENCE = ONLY VALSLVA SYSTOLIC
REFLUX
Valsalva Manœuvre:
Positive Valsalva = Incompetent Valve
At
rest
VALVE INCOMPETENCE = ONLY SYSTOLIC REFLUX
Normal at rest
At
rest
Systole
=
blowing
Valsalva Manœuvre:
Positive Valsalva = Incompetent Valve
VALVE INCOMPETENCE = ONLY SYSTOLIC REFLUX
Systolic reflux
At
rest
Systole
=
blowing
Relax
Diastole
Valsalva Manœuvre:
Positive Valsalva = Incompetent Valve
VALVE INCOMPETENCE = ONLY SYSTOLIC REFLUX
Normal at Diastole
At
rest
Systole
=
blowing
Relax
Diastole
Valsalva Manœuvre:
Positive Valsalva = Incompetent Valve
VALVE INCOMPETENCE = ONLY SYSTOLIC REFLUX
Normal at Diasole
Valsalva Manœuvre:
Contrary to the majority of the veins, DESCENDING TRIBUTARIES OF THE
SAPHENE ARCHS flow
downwards
and its refluxes are not reverse flows
SO Valsalva is Positive when it
produces a no reverse systolic
downwards flow
The reflux is fed by one of the pelvic
leak pointso P
p P
c P
s g P
ig P
i P i P
o P
p P
c P
gs P
g s P
At
rest
Valsalva Manœuvre:
Contrary to the majority of the veins, DESCENDING TRIBUTARIES OF THE
SAPHENE ARCHS flow
downwards
and are not reverse flows nor reflux when
at rest
At
rest
Systole
=
blowing
Valsalva Manœuvre:
Contrary to the majority of the veins, DESCENDING TRIBUTARIES OF THE
SAPHENE ARCHS flow
downwards
and are not reverse flows nor reflux at rest .
The absence of reflux is attested by absence of
flow during the Systole
At
rest
Systole
=
blowing
Relax
Diastole
Valsalva Manœuvre:
Contrary to the majority of the veins, DESCENDING TRIBUTARIES OF THE
SAPHENE ARCHS flow
downwards
and are not reverse flows nor reflux when
at rest and during the diastole
Valsalva Manœuvre:DESCENDING TRIBUTARIES OF THE
SAPHENE ARCHS
PositiveValsalva = Systolic Downwards flow
WITHOUT REVERSE FLOW
REFLUX FROM INCOMPETENT PELVIC PERFORATORS
At
rest
Valsalva Manœuvre:DESCENDING TRIBUTARIES OF THE
SAPHENE ARCHS
PositiveValsalva = Systolic Downwards flow
WITHOUT REVERSE FLOW
At
rest
Systolic
REFLUX
=
blowing
Valsalva Manœuvre:DESCENDING TRIBUTARIES OF THE
SAPHENE ARCHS
PositiveValsalva = Systolic Downwards flow
WITHOUT REVERSE FLOW
REFLUX FROM
INCOMPETENT PELVIC
PERFORATORS
At
rest
Valsalva Manœuvre:DESCENDING TRIBUTARIES OF THE
SAPHENE ARCHS
PositiveValsalva = Systolic Downwards flow
WITHOUT REVERSE FLOW
Relax
Diastole
Systolic
REFLUX
=
blowing
At
rest
Systole
=
blowing
Relax
Diastole
Valsalva Manœuvre:
Positive Valsalva = Incompetent Valve
Hemodynamic Manoeuvres
Upright Position
Squizing, Paranà , Wundsdorf:
Valvo-muscular Pump Stress Test
Valsalva: Thoraco-abdominal
Pump Stress Test
Supine Position
Venous Pressure: Veins Patency
Test
Squizing, Paranà , Wundsdorf:
Valvo-muscular Pump Stress Test
Purpose:Elicit
VALVE COMPETENCE
VALVE INCOMPETENCE
Features:
-Total, Partial, Segmental, Closed Shunt
Haemodynamic effect:
-Open Deviated Shunt ( open circuit )
-Closed Shunts (closed circuit )
VENOUS BLOCKS AND BY-PASSING VEINS
-Open Vicarious Shunt ( open circuit )
Squizing, Paranà , Wundsdorf:
Valvo-muscular Pump Stress Test
Purpose:Elicit
VALVE COMPETENCE
VALVE INCOMPETENCE
Features:
-Total, Partial, Segmental, Closed Shunt
Haemodynamic effect:
-Open Deviated Shunt ( open circuit )
-Closed Shunts (closed circuit )
VENOUS BLOCKS AND BY-PASSING VEINS
-Open Vicarious Shunt ( open circuit )
Squizing, Paranà , Wundsdorf:
Valvo-muscular Pump VMP Stress
Test
Squizing:
Not physiologic
Passive Systole of the VMP
+
N2 and N3 emptying
Squizing, Paranà , Wundsdorf:
Valvo-muscular Pump VMP Stress
Test
Paranà:
Physiologic
Active Systole of the VMP and
plantar pump
BY
Proprioceptive reflex contraction
triggerd by a light push-pull at the
waist
Squizing, Paranà , Wundsdorf:
Valvo-muscular Pump VMP Stress
Test
Squizing, Paranà , Wundsdorf:
Valvo-muscular Pump VMP Stress
Test
Squizing, Paranà , Wundsdorf:
Valvo-muscular Pump VMP Stress
Test
Squizing, Paranà , Wundsdorf:
Valvo-muscular Pump VMP Stress
Test
Squizing, Paranà , Wundsdorf:
Valvo-muscular Pump VMP Stress
Test
Squizing, Paranà , Wundsdorf:
Valvo-muscular Pump VMP Stress
Test
At rest, very low upwards flow
At
rest
Squizing, Paranà , Wundsdorf:
Valvo-muscular Pump VMP Stress
Test
Pull 2 cms back but quickly
In order to trigger a Systole by
Proprioceptive reflex contraction of
the calf
At
rest
Squizing, Paranà , Wundsdorf:
Valvo-muscular Pump VMP Stress
Test
Then Push ahead 2 cms but quickly
In order to relax the
Proprioceptive reflex contraction of
the calf (Diastole)
At
rest
Squizing, Paranà , Wundsdorf:
Valvo-muscular Pump Stress Test
Purpose:Elicit
VALVE COMPETENCE
VALVE INCOMPETENCE
Features:
-Total, Partial, Segmental, Closed Shunt
Haemodynamic effect:
-Open Deviated Shunt ( open circuit )
-Closed Shunts (closed circuit )
VENOUS BLOCKS AND BY-PASSING VEINS
-Open Vicarious Shunt ( open circuit )
At
rest
Squizing, Paranà , Wundsdorf:
Valvo-muscular Pump VMP Stress
Test
Popliteal Vein
Ilio-femoro-popliteal TOTAL incompetence
At rest
Squizing, Paranà , Wundsdorf:
Valvo-muscular Pump VMP Stress
Test
Systole
At
rest
Popliteal Vein
Ilio-femoro-popliteal TOTAL incompetence
At
rest
Squizing, Paranà , Wundsdorf:
Valvo-muscular Pump VMP Stress
Test
Diastole
Popliteal Vein
Ilio-femoro-popliteal TOTAL incompetence
S
D
coequal
At
rest
Squizing, Paranà , Wundsdorf:
Valvo-muscular Pump VMP Stress
Test
Popliteal Vein
SEGMENTAL Popliteal Incompetence
At rest
Squizing, Paranà , Wundsdorf:
Valvo-muscular Pump VMP Stress
Test
Systole
At
rest
Popliteal Vein
SEGMENTAL Popliteal Incompetence
At
rest
Squizing, Paranà , Wundsdorf:
Valvo-muscular Pump VMP Stress
Test
Diastole
Popliteal Vein
S
D
D peak
<S peak
SEGMENTAL Popliteal Incompetence
Femoral Valve
Closure
Decreases the
Reflux
At
rest
Squizing, Paranà , Wundsdorf:
Valvo-muscular Pump VMP Stress
Test
Popliteal Vein
PARTIAL Popliteal Incompetence
At rest
Squizing, Paranà , Wundsdorf:
Valvo-muscular Pump VMP Stress
Test
Systole
At
rest
Popliteal Vein
PARTIAL Popliteal Incompetence
Squizing, Paranà , Wundsdorf:
Valvo-muscular Pump VMP Stress
Test
At
rest
Popliteal Vein
PARTIAL Popliteal Incompetence
Diastole
Popliteal Vein
S
D
D peak
<S peak
D time
>S time
At
rest
Squizing, Paranà , Wundsdorf:
Valvo-muscular Pump VMP Stress
Test
Popliteal Vein
Deep Closed Shunt Example
Diastole
Incompetent Fem-Popliteal V
+ Competent Collat.V ( may be Deep Fem.)
At
rest
D peak
>
S peak
At
rest
Squizing, Paranà , Wundsdorf:
Valvo-muscular Pump VMP Stress
Test
Great Saphenous vein
Ilio-femoro-popliteal TOTAL incompetence
At rest
Squizing, Paranà , Wundsdorf:
Valvo-muscular Pump VMP Stress
Test
Systole
At
rest
Popliteal Vein
Ilio-femoro-popliteal TOTAL incompetence
At
rest
Squizing, Paranà , Wundsdorf:
Valvo-muscular Pump VMP Stress
Test
Diastole
Popliteal Vein
Ilio-femoro-popliteal TOTAL incompetence
S
D
coequal
Hemodynamic Manoeuvres
Upright Position
Squizing, Paranà , Wundsdorf:
Valvo-muscular Pump Stress Test
Valsalva: Thoraco-abdominal
Pump Stress Test
Supine Position
Venous Pressure: Veins Patency
Test
Supine Position
Venous Pressure Measurement:
Veins Patency Test
Normal ≤ 25 mm Hg
Cuff
inflation/deflation
Posterior Tibial Vein
flow
Duplex assessment of
venous
hemodynamics
Lower limbsVenous Networks (N)
Dynamic Stress Manoeuvres
Hemodynamic Obstacles and Open
Vicarious Shunts
Hemodynamic Valve Incompetence
and Closed/Open Derivate Shunts
Protocole Assessment
Hemodynamic Mapping
Hemodynamic Obstacles
The hemodynamic significance of a
block in terms of drainage quality is
inversely proportional to the collateral
compensatory veins developing
N1
N2
N3
N4L
N4T
Collectors: N2 -N1: SFJ, SPJ
N3 -N1: Perineal V P Point
Rd Ligt V I Point
Clit. V C Point
Obt. V O Point
I Glut.V IG Point
S Glut. V SG Point
Internetworks connections
Perforators:
N2 -N1: saphenous truncks→deep Veins
N3 -N1:Saphenous tributaries and
others→deep Veins
Connectors:
N2 –N2: saphenous truncks
N3 -N1:Saphenous tributaries and others
N1
N2
N3
N4L
N4T
Collectors: N2 -N1: SFJ, SPJ
N3 -N1: Perineal V P Point
Rd Ligt V I Point
Clit. V C Point
Obt. V O Point
I Glut.V IG Point
S Glut. V SG Point
Internetworks connections
Perforators:
N2 -N1: saphenous truncks→deep Veins
N3 -N1:Saphenous tributaries and
others→deep Veins
Connectors:
N2 –N2: saphenous truncks
N3 -N1:Saphenous tributaries and others
Great Saphenous Trunk
Small Sahenous Arch
Giacomini Vein
Anterior Saphena
Great Saphenous Arch
Small Sahenous Trunk
N2
N3
N4L
N4T
Common Femoral Vein
Superficial Femoral Vein
Popliteal Vein
Deep Femoral Vein
1988
Draining network from skin to suprafascial veins (Network 3) then intrafascial veins
(Network 2) then deep subfascial veins (Network 1)
N2
N3
N4L
N4T
N1
Dynamic manœuvres
Valsalva manœuvres
Active calf pump test
Passive calf pump test
Obstacle assessments
Dynamic Obstacle assessments
Demodulatlion
collateral by-pass
doppler ankle pressure
Anatomic Obstacle assessments
Color
Compression
Networks N1,N2,N3,N4
Assessment protocole
Mapping
Strategies
Tactics
Valve competence
assessment
SHUNTS: venous segment
overloaded by extra
volume/pressure fed by Escape
points and redirected into Re-
entry points :
Sapheno-femoral junction
Sapheno-Popliteal junction
Pelvic leak points
Perforators
Valve incompetence
assessment : value
Open vicarious shunts
Open derivating shunts
Closed shunts
superficial : type
1 to 6
deepMixt shunts
N1
N2
N3
N4L
N4T
Collectors: N2 -N1: SFJ, SPJ
N3 -N1: Perineal V P Point
Rd Ligt V I Point
Clit. V C Point
Obt. V O Point
I Glut.V IG Point
S Glut. V SG Point
Internetworks connections
Perforators:
N2 -N1: saphenous truncks→deep Veins
N3 -N1:Saphenous tributaries and
others→deep Veins
Connectors:
N2 –N2: saphenous truncks
N3 -N1:Saphenous tributaries and others