Overview Introduction to Chronic Venous

1

Introduction to Chronic Venous Insufficiency

1

Greg Curry

Vascular Ultrasound

Monash Health

Overview

• Background

– Normal anatomy

– Not just varicose veins…. Manifestations of CVI

• Incompetence / Reflux ?

– What is it?

– Criteria

– Where does it come from?

• Superficial

• Deep

• The big picture

– Why ultrasound?

– Treatment options

• The Ultrasound Examination

– Questions ?

– Examination technique ?

Paired SystemsFemoral 70%

Popliteal 25%

Proximal/ DistalUse Inferior/ Superior

Gastroc/ Soleal

Foot Venous Drainage

Anatomy- Deep System

Common Femoral

Femoral Vein

Deep Femoral VeinJVS 2005

Sup. Epigastric V.

Ext Pudendal V.

SPJ

Multiple Accessory V

Anterior Accessory GSV

Great saphenous vein

Superficial circumflex iliac vein

Posterior thigh circumflex vein

Ascending Small Saphanous V

Anterior Thigh Circumflex

Anatomy- Superficial

Anatomy- Superficial

Anterior thigh circumflex vein

Anterior Acc Great Saph V

Anterior Accessory GSV

Great saphenous vein


Posterior thigh circumflex vein

Ascending Small

Saphanous V

Anterior Thigh Circumflex

Sup. Epigastric V.

Ext Pudendal V.

CVI…..Not Just Varicose Veins

• Incidence – 7% (Casarone et al Angiology)

• Presents– Reticular

– Varicose Veins

– Pain, Swelling

– Hyperpigmentation,

– Fibrosis

– Ulcers

• Imposte– Well being

– Health budget

2

An important test!

• Not all just ugly veins

• Long term suffering

• Complex - Failed treatments

• We can really impact patient’s quality of life

The Magic word… Incompetence

• Valve failure

– Incompetency

• Flow Deep- Superficial

Competent Incompetent What criteria?: The Bottom line

• Time based

• Velocity criteria Neglen 2004

• Efficiency/ Reflux Index Beckwith

– TAV* Time = Area

– Clinical reflux < 70 %

Reflux > 0.5 secsNicholaidis Circulation 2000

Consensus Statement

AA = augment area AR= reflux area

Sites of Incompetence / Reflux

• Major junctions

– SFJ

– SPJ

• Incompetent perforators


• Major junctions

– SFJ

– SPJ

• Incompetent perforators

• Importance

– Documenting

• Size/ Variations

3


• Major Junction

• Incompetent perforator

• Pelvic contribution

– 25%

– Ovarian V/ Abdominal

Deep system: Deep Reflux

• Important Dx.

– Decision making

• > 0.5sec (1.0sec)

• Segmental

– Clinical significance?

Deep Reflux

• Non-ascending column

• Single container

• Valvular failure

– Substantive

• Low Velocity

– 100% reflux

• Undercalled

Role of Ultrasound in the Assessment of Chronic Venous Insufficiency

Allen, PL Ultrasound Quarterly 2001 Vol. 17, No. 1, pp. 3–10

Deep System

• Myriad of Variations

– Aplasia, Hypoplasia

– Multiple Veins (eg. 5 PT’s)

– Changes 2° to pathology

16

Chronic Venous Insufficiency: Why ?

• Ultrasound : Best test

• Manifestations of CVI– Location: Where are they

• Are they related to– Deep source?

– Atypical venous pathways

• The Endgame – Plan treatment → Improve Outcome

The next questions

• How do we test for reflux?

– Position

– Augmentation

• Is there reflux?

– Factors affecting “reflux”

• Severity?

4

How do we test for reflux?

Aim: Create physiological reflux ?

Reproduce Gravity

How do we test for reflux?

• Primary

– Augment,

• Secondary• Valsalva,

– Dorsi flexion

• Patient Position

How do we test? Creating physiological reflux

• Augment

– Various techniques

• Valsalva

– Strain down

• Toe/ Foot Movement

• Reproducible/ Physiologic

How do we test for reflux? Positions

Multiple positions/ Multiple testing methods

How do we test for reflux? Augmentation

• Manual squeeze

– Create significant void

• Thigh

• Calf

• Foot

Is there Reflux?

Valve closure time

Venous bed

Venous outflow

Testing technique

Location of cursor

Weather, time of day, etc

0.5 sec… 1.0 sec…2.0 sec

5

Grading Incompetence - Severity

• Qualitative- Subjective (experience)

1. SIGNIFICANT - (Moderate -> Gross)

2. MILD

3. V. mild/trickle flow ? Clinical Significance

• Time > 0.5 sec.

• Efficiency Index (Qualitative)

• Clinical Presentation

• Tool for communication

The examination

• Take a minute to ponder how you do this exam?

• First…. What are the key questions to be

answered?

26

Chronic Venous Insufficiency: The Questions

1. Superficial venous reflux

– Is there reflux?

– Where does it come from?

– Where does it distribute to?

– Severity

– R’ship to clinical presentation...

2. Is there deep venous reflux

3. Deep vein patency (?old/recent DVT)

Now its time to do the examination…

• Clinical examination

• Explanation

• Set – up

• Scanning

28

Clinical Examination

Look !!

Ensure your worksheet explains all manifestations of

CVI

29

Do you have a good opening spiel…

“Today we are doing a scan on the veins on your leg.

Your referrer can see where the veins are but can’t see where

they come from. This is why we do the test.

I need to start at the groin where there is a main valve

and then work my way down”

30

6

The Beginning

• Erect

• High Frequency transducer

• Approach

• Awareness : Clinical setting

• Transducer technique– Varied pressure, 360°

Start at the SFJ

• Important Question!

• Is the SFJ incompetent?

32

1. Sapheno-Femoral Junction

• Anatomy-Trans.

– Scan superiorly

• Size- (? dilated)

• Is there SFJ reflux

– SFJ – Sagittal

– Valsalva

– Augment

Ext pudendal V

Sup Epigastric

Superficial circumflex iliac V

2. Great Saphenous V / Accessory V

• Evaluate the GSV

• Document size

– Intrafascial

– Extrafascial


• Main GSV

• Posterior Thigh Circumflex V

• Saphenous “eye”

• Rare

• Saphenous ligament


7

3. Pelvic Contribution?

• Established understanding


– 8% (Jung 2009)

– Can be higher • Patient demographics

– Sometimes• Pelvic congestion syndrome

• Not always ovarian V

• Source

– Vulvo-perineal

– Round ligament

• Communicate via…


Sup. Epigastric V.

Ext Pudendal V.


• Insert

– Between terminal/ preterminal


Sup. Epigastric V.

Ext Pudendal V.

Sup. Epigastric V / SFJ


• Segmental reflux

• Tracking small VV’s

Flow from ext pudendal



– Tiny- small varices

• Communication with

– Posterior accessory GSV

– Vein of Giacomini

– Ascending SS

– Any veins !

• Present as

– Small thigh varices

The Common…

• Junctional

– SFJ, SPJ

• Incompetent Perforator

• Pelvic

– Numerous sources

41

The Procedure : The Deep System

• CFV - Inferior to SFJ

• Deep Femoral V

– Superior

– Reflect atypical anatomy

• Femoral V - Mid

– Predictor of SSV

– Above inf thigh perforator

8

The question to ask at this point….

• Have I resolved the upper leg?

Now the popliteal fossa…

44

The Procedure : Small Saphenous Vein

• Anatomical variants– Insertion

• Via GV• Direct• FV• Internal Iliac V

• Size - ? Dilated

• Insertion – Meas. from knee crease

• Reflux

• LSV reflux → SSV “syphon”

Intersaphenous connection

Sites of interrogation- Small Saphenous

V of Giac.

Add canal

SPJ

SSV- Pop fossa

SSV - Mid calf

The Procedure : Popliteal Fossa

• Gastrocnemius Vein

• Incompetent perforator

• Baker’s cystGV

Perforator

The Procedure : Deep System: Lower leg

• Popliteal

• Gastrocnemius V

• Posterior Tibial, Peroneal

– Only if inf. popliteal reflux

Peroneal

PT

Tibio-per. trunk

9

Next…..Incompetent Perforators

• Size

• Location - (fascia)

• Dist. from Med. malleolus

• MARKING -No Black/Blue texta

• ALL OF LEG MUST BE EXAMINED

Testing of Perforators (Below line → Deep- Superficial)

Inferior calf augment Valsalva

The toe wiggle Tourniquet: Upper calf

Perforator Testing

• Time based Negle´n JVS 2004

– 0.5 sec (3 consecutive augments) Delis JVS 2004, Delis Radiology 2004

• Size Negle´n JVS 2004

– > 4.0 mm

• Describe

– Location

– Presence of reflux

– Relationship to VV’s

• DON’T Overcall / Note if dilated but is just inflow

Perforators

Nomenclature of the veins of the lower limbs: An

international interdisciplinary consensus statement

Alberto Caggiati, et al 2002 JVS

The Procedure : DVT Study

• Limited

• Full study

– Hx of DVT

– Leg swelling

– Significant deep venous reflux

Communication

• Quality worksheet

• Structured reporting

• Liaise Vascular consultant

– Feedback

– Detail

• Vein Sizes

SSV

GSV

AAGSV

10

The worksheet

55

Take home messages

• Important test

• CVI US is challenging and

rewarding

– Clinical question

– Know your anatomy

– Technique is important

– “Contextual reporting”

56

Documents

Overview Introduction to Chronic Venous