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Venous investigations

Dr Ravul jindal MS FRCS DNB FVSI

Director vascular surgery

Vice President Venous Association of India

Fortis Hospital

Mohali

www.indianvascularsurgery.com

Is pre-op duplex

assessment

important for

varicose vein

surgery?

Ultrasonic assessment

Explanation

Information provided by DS will have significant

impact on the selection of appropriate treatment

Failure to identify all sources of venous filling is

likely to result in early recurrence

Indications for Duplex Scan

Recommendation: both limbs should be studied

Primary uncomplicated GSV VVs

Debated whether all pts – if not 30% of important connections between deep

and superficial veins will be missed

Primary uncomplicated LSV VVs Essential

Non-saphenous & Recurrent VVs Essential

CVD with complications Essential

Surveillance after treatment the only way to obtain level I

evidence as to outcome in the future

Venous malformations

anatomical information about the extent of the malformation and its

relationship to other vessels

may be used to guide treatment by sclerotherapy

Position of the patient

Greater saphenous

Position of the patient Lesser saphenous

Anatomy of superficial veins of the

lower limb

Anatomical structures on B-mode

Images courtesy of Olivier Pichot, MD

Fascial layers creating “saphenous eye”

GSV

Bound anteriorly by superficial fascia &

posteriorly by deep fascia

Often called “saphenous eye”

Tortuosity Side branches

GSV Variables

Images courtesy of Olivier Pichot, MD

SFJ Tributary Veins

SCI: Superficial Circumflex Iliac

SE: Superficial Epigastric

SEP: Superficial External Pudendal

AASV: Anterior Accessory

Saphenous

PASV: Posterior Accessory

Saphenous

Image adapted from: Chandler JG et al. Defining the role of extended saphenofemoral junction ligation: A

prospective comparative study. JVS 2000;32:941-53

Final Tip Position Verification

◦ In both transverse and

longitudinal imaging planes

◦ Use measurement calipers to

confirm distance to SFJ

Important step to avoid

misaligning catheter

relative to deep venous

system

Recommendation is 2.0 cm distal to SFJ

Confirm tip position with ultrasound:

Image courtesy of Pranay Ramdev, MD

GSV Before Treatment

Image courtesy of Olivier Pichot, MD, CHU de Grenoble, France.

Image courtesy of Olivier Pichot, MD, CHU de Grenoble, France.

GSV After Treatment

Small Saphenous Vein (SSV)

Courses from lateral ankle up

posterior calf

Terminates in popliteal fossa at

Saphenopopliteal Junction (SPJ)

◦ Variable confluence with Popliteal Vein

(PV)

◦ Proximal portion lies between superficial

& deep fascial layers

SSV

SPJ

Pop V

Figure adapted from: Weiss RA, et al eds. Vein diagnosis and treatment: A comprehensive approach. McGraw-Hill Companies, Inc.; 2001.

Detection of reflux on colour facility

The aim of ablation procedures is to damage the inner

vein wall without causing a full-thickness burn, which

could lead to perforation of the vein resulting in bruising

or haematoma formation

If vein lies superficially, close to skin the ablation

may cause burn

Vein depth from the skin: Why is so

important?

Vein Mapping Make indentions in skin using a straw

Remove US gel from leg

Connect marks on leg with marker to identify

pathway of vein and important anatomy

Image courtesy of Nick Morrison, MD

Selective descending ovarian and hypogastric venogram

Significant ovarian vein reflux but

No hypogastric vein reflux was detected

Hypogastric vein reflux Ovarian vein reflux

Descending Ovarian Venogram 4 weeks after

embolisation

CT venography

Chronic Venous Obstruction

DP=22 mmHg DP=8 mmHg

DP=2 mmHg

Thank you for your attention