Who Needs More Testing Beyond Venous Duplex?

Who needs more testing beyond venous duplex?

IVC 2014 Miami Beach FL

William Marston MDProfessor and Chief, Division of

Vascular SurgeryUniversity of N. Carolina Hospitals

Disclosures

• Scientific Consultant– Veniti– Volcano– Organogenesis

• Clinical Trial Investigator– Smith and Nephew/Healthpoint

Deriving maximum information from duplex ultrasound

• Venous duplex report– No acute DVT– Reflux in GSV– No deep reflux

Duplex information

• Pathway of venous abnormality to symptoms– VV, edema, ulceration

• Reflux to symptom site

• Size of refluxing veins to symptom site

• Obstruction proximal to symptom site

Informative venous duplex report

• Abnormal pathways– SSV to pop and/or vein of Giacomini– Duplicate GSV

– Hypoplastic femoral system– Pelvic or other collaterals to labia

• Sites of reflux and size of refluxing segments– Deep, superficial, perforator

• Obstruction in all segments including iliac and IVC

Duplex limitations - anatomic

• Operator dependent – Nicos vs the rest of

the world

Duplex limitations - physiologic

• Duplex can provide:– Direction of flow– Velocity of flow– Caliber of conduit

– Cannot directly infer venous hypertension or other measure of severity of venous insufficiency

Clinical situations requiring additional testing

• 38 YO former collegiate volleyball player

• h/o meniscus repair on left• Right leg pain, aching with

activity - no edema or skin changes

• Most severe in knee area

• GSV reflux at knee 4-5 mm diameter

Plethysmography

Venous Filling Index (VFI, normal < 2 cc/sec), the value determined by 90% of VV divided the time required to reach 90% of VV

Additional Testing

• 47 YO female with h/o leg pain, aching after walking

• Mild/moderate edema late in day

• s/p GSV ablation, 5 sessions of scleroRx

• Continued leg aching w minimal improvement

CT venogram and APG

Additional testing: Deep and superf disease post-proc

• 52 YO male w Class 4 CVI left leg

• Deep and superficial reflux on exam

• No evidence of venous obstruction

• Reflux times– CFV 2.1 secs– FV 0.4 secs

– Pop 3.3 secs– GSV at SFJ

4.5 secs– GSV at knee

6.2 secs– SSV 0.2 secs

S/p GSV ablation

• How much will symptoms improve with superficial correction alone?

• Does patient still need to use compression?

• Repeat duplex to see if deep reflux corrects

• VFI improvement to normal range suggests correction of primary cause of CVI

Additional testing: pelvic symptoms, groin VV

• Labial VV• Pelvic congestion

symptoms• Nutcracker syndrome

VLU and h/o DVT

• 63 YO female w right leg ulcer and h/o DVT 7 years ago

• Compression and topical therapies with some improvement for 3 months, but still large persistent wound

Venous duplex findings

• GSV reflux throughout with vein size 7-10 mm

• CFV waveform with reduced phasicity

• Reflux in SFV and pop v with changes c/w old DVT (partially compressible)

CT/MR venogram

• Determine presence and severity of ilio-caval outflow obstruction– Could you stent at same

setting as GSV ablation?– Further evaluate severity of

pop and fem v obstruction• Femoral venoplasty?

Or go straight to venous intervention - IVUS

When are further diagnostic tests necessary?

• Not often for infrainguinal questions– If symptoms don’t match duplex

findings– If patients don’t improve after

appropriate intervention

• Venous outflow obstruction• Abd/Pelvic symptoms or source• At the time of therapeutic venous

intervention600-0003.42/001

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