Duplex for Superficial Venous Disease
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Transcript of Duplex for Superficial Venous Disease
Disclosure Joseph Zygmunt, Jr., RVT, RPhS
I disclose the following financial relationship(s):
•Employment: Covidien Inc.
DUPLEX FOR SUPERFICIAL VENOUS DISEASE
Joseph A. Zygmunt, Jr., RVT, RPhS
IVC 2011
Clinical to Duplex Map
Key Technique References – Duplex Meissner M, et al: The Hemodynamics and diagnosis of venous disease. J
Vasc Surg 2007; 46:4S-24S.
Coleridge-Smith P, et al Duplex Investigation of the Veins in Chronic Venous
Disease of the Lower Limbs-UIP Consensus Document Part I Basic Principles.
Eur J Vasc Endovasc Surg 2006;31:83-92
Cavezzi, A et al: Duplex Investigation of the Veins in Chronic Venous Disease
of the Lower Limbs-UIP Consensus Document. Part II Anatomy. Eur J Vasc
Endovasc Surg 2006; 31:288-299
Labropoulos, N, et al: Definition of venous reflux in lower extremity veins. J
Vasc Surg 2003; 38:793-8
Labropoulos, N, et al: Study of venous reflux progression. J Vasc Surg 2005;
41:291-5
Foldes, M et al: Standing Versus Supine Positioning in Venous Reflux
Evaluation:Journal of Vasc Tech 1991;15(6):321-24. * 70%
Zygmunt, J : What’s New in Duplex Scanning of the Venous System.
Perspectives in Vasc Surg and Endovasc Therapy 21(2):2009 94-104
Superficial vein reflux is the most
common abnormality in patients
with chronic venous disease (CVD).
Reflux in the saphenous veins and their
tributaries has the highest prevalence.
Labropoulos et al. Am J Surg 1995;169:572-4
Labropoulos et al. J Vasc Surg 1996;23:504-10
Prevalence of saphenous and non-
saphenous tributary reflux n %
GSV 111* 65
SSV 33 19
GSV+SSV 12 7
Non-saphenous veins 15 9
Total 171 100
*p<0.0001 for all comparisons
Reflux Vein Mapping
RPhS – Registered Phlebology Sonographer
(recognized**) www.cci-online.org
Reflux Values - Pathologic
Labropoulos, N et al. Definition of Venous Reflux,
J Vasc Surg 2003;38:793-8
Cut Off Values for reflux
Fem – pop >1000ms
Calf +DFV > 500ms
Superficial > 500ms
*Perforators > 350ms
*size >3.5mm
reflux : measured during muscular diastole
GSV is medial and slightly posterior to the deep system Sheath Landmark “key”
Where is the GSV located on the leg?
SVU LE Venous Insufficiency
Guideline #3 a…. – veins to check for reflux
CFV
SFJ and the GSV @ multiple (5) sites
FV
Pop V –above and below SPJ **
SSV (2)
Perfs as needed
Examine prox, mid and distal vein segment and at major
tributaries or perforators
-To ensure sufficient data is provided to the physician to direct patient
Management and render a final diagnosis
-focused physical exam – observation of signs, symptoms etc…
Diameter of a saphenous vein may decrease distal to a major incompetent tributary
Sourcing Reflux : Clues
Scan in Transverse – The Alignment Sign
AAGSV GSV
FA FV
Geometric Relationships & Patterns
GSV Variations – Sheath and Tributaries
Ricci and Georgiev - Journal of Vascular Technology
“h” vein
Anterior Saph
Multi-level investigation
Mapping of a GSV Tributary leaving the sheath
GSV
Trib
GSV in “eye”
US image
to diagram
Diameter of a saphenous
vein may decrease
distal to a major incompetent tributary
Location of Probe and Augmentation Site Van Bemmelen et al JVS 1989
Evaluated technique and position: Valsalva, prox compression, release of distal compression Manual compression of the supine limb proximal to the transducer site did not result in closure of the valve but rather in reflux during the entire compression followed by cessation of flow The deflation of a cuff distal to the transducer is the
most reliable maneuver to obtain sustained
closure of the valve with physiologic transvalvular pressure gradients. The correct and consistent translation of reflux into valve incompetence is a prerequisite for the understanding of patho-physiologic characteristics of veins
Foldes, M et al: Standing Versus Supine Positioning in Venous
Reflux Evaluation:Jour of Vasc Tech 1991;15(6):321-24. * 70%
Neuhardt, D et al – Differences in Saphenous Vein Reflux
Detection According to Patient Positioning – Abstract UIP Monaco
2009 26-49%
Temporal Effects on reflux how to interpret the data?
Tarrant G, Clark, J et al; Differences in Venous Function of the Lower Limb by Time of Day: A Comparison of Chronic Venous Insufficiency Between and Afternoon and Morning Appointment by Duplex Ultrasound. The Journal for Vascular Ultrasound 2008;32(4):187-192.
Zamboni, P, Cisno, C et al; Reflux Elimination without and Ablation of Disconnection of the Saphenous Vein. A Haemodynamic Model for Venous Surgery: Eur J Vasc Endovasc Surg 2001; 21: 261-369
Meissner,M, Moneta, G,et al; The hemodynamics and diagnosis of venous Disease. J Vasc Surg 2007; 46:4S-24S
Shape of the reflux curve….
0.5 sec = pathologic VCTs poor correlation to CEAP Varicose Reservoir Capacitance
Rodriguez JVS 1996 – VCTs do not accurately reflect the magnitude of refluxed volume Iafarati JVS 1994 - Reflux time does not discriminate severity [C0-C6] Vasdekis 1989 – Peak flow volume – non discriminatory
Large refluxing vein empties into small capacitor
– peak velocity is high and duration short
Small refluxing vein empties into a large
capacitor – velocity is low and duration long
Keys to Proper Documentation ICAVL, ACR and SVU standards:
Transverse with and without
compressions (patency)
long Axis Image
Spectral Doppler tracing
required
60 degree angle
Color – optional
standing position for reflux
determinations
Separate US report
Archived Images
~2.5 seconds of reflux
Color Information Display
What does that FLASH of color
REALLY mean?
Compartments – change in compartment
3 Compartments
N3
N2
N1
EXIT
RE ENTRY
Images and drawings courtesy of
Olivier Pichot, MD
Competent SFJ w/
Incompetent sub-termainal
Valve and distal reflux
Anterior Saph (AAGSV) Incompetence
with distal GSV reflux
**transverse view for orientation
Summary:Does your test match the clinical picture?
Information will impact
treatment options
Failure to identify and treat all sources of reflux is likely to
result in early recurrence
Exam is very operator and technique dependent
Reflux is not STATIC1
1Labropoulos, N, et al: Study of venous reflux
progression. J Vasc Surg 2005; 41:291-5
CONCLUSIONS Color duplex ultrasound should be performed
to understand the pathology and plan
treatment for CVI patients.
This will tailor the treatment to the patients’
needs and misdirected treatment can be
prevented.
Be Curious - look for the source - does it
match the clinical picture
SFJ Anatomy – what do we know?
Saphenous Arch
Region includes superior
branches, SFJ including
the TV and Pre-TV
Terminal Valve *femoral side of TV
Pre Terminal Valve
*competence of saph arch
Femoral Vein Valves
Suprasaphenic valve (SSV)
Infrasaphenic valve (ISV)
Gillot – Phlebology 2009
ISV