US Evaluation of Truncal VeinsGSV, AAGSV, SSV

What to look for, measure and report.

Linda Antonucci, RPhS, RVT, RDCS

Disclosure

Linda Antonucci, RPhS, RVT, RDCS

I disclose the following financial relationship: I am a paid consultant for AngioDynamics

COMFORTABLE ENVIRONMENT WITH PROPER EQUIPMENT

• Room - warm to enhance venous dilatation

• Hydraulic table - Trendelenburg/Reverse Trendelenburg

• Chair or stool that adjusts up and down (foot rest optional)

• Adjustable ultrasound equipment is essential• if portable unit adjustable equipment stand

• Step stool with a handle to insure patient safety

• Auto inflate unit

BEFORE YOU BEGIN

• Do you have pain, aching, or heaviness in your legs?

• Does one leg bother you more than the other?

• Do your legs bother you more at the beginning or at the end of the day?

• Do you have swelling that worsens at the end of the day?

• Have you had any prior vein interventions?

• Have you ever had a DVT or SVT?

• Does anyone in your family have vein problems?

Photo courtesy of Daniella DePeri, PA

Ask a few Basic Questions Specific for SVI examDRAW visible varices while you CHAT

DETAILED PHYSICAL EXAMINATION

• Visual Inspection• Skin changes• Varicose veins• Scars from previous surgeries

or procedures• Palpation

• Temperature changes • Sub dermal varicosities

Standing & Supine

DEEP VEINS MATTER

• Perform a complete bilateral evaluation of the deep system

• Supine

• Reverse Trendelenburg >20 degrees

The calf veins, great saphenous vein and small saphenous are considered optional for a reflux evaluation, but should be included.

PATIENT POSITION FOR SUPERFICIAL VENOUS INSUFFICIENCY EVALUATION

STANDING

EXPERTS AGREESupine positionis unacceptable

Cartoon taken from www.cardstock.com

EVALUATION OF THE GSV AND SSV

Compression from origin to termination point to assess for superficial thrombosis

Overview of topography• Aplastic/Hypoplastic• Aneurysms• Tortuous segments• Large tributaries

PATIENT POSITION FOR SVI OF GSV

• Standing on floor, stool or platform

• Facing the examiner

• Open stance

• External rotation of the hip

• Knee slightly bent with heel flat

• Weight on the contralateral limb

• Holding on to the table or a stool

GSV WITH PERIPHERAL COMPRESSION RELEASE

Begin your exam at the SFJ using peripheral compression with rapid release to assess for reflux

Assess at the following levels• SFJ - Safeno-femoral junction• PT – Proximal thigh• MT – Mid-thigh• DT – Distal thigh• Knee – OFTEN aplastic/hypoplastic• PC – Proximal calf• MC – Mid-calf • Ankle – If warranted

Ankle

PATIENT POSITION FOR SSV

• Standing on floor, stool or platform

• Patient turned away from the examiner

• Open stance

• Step forward with knee slightly bent and heel flat

• Weight on the contralateral limb

• Hold on to the table or a stool

SSV WITH PERIPHERAL COMPRESSION RELEASE

Begin your exam at the SPJ using peripheral compression with rapid release to assess for reflux

Assess at the following levels• SFJ - Safeno-popliteal junction• MC – Mid-calf • Distal calf – If warranted

NORMAL GSV & SSV

Diameter• GSV 5.0 mm + 2.4mm• SSV 3 mm + 1.3mm

Competent Valve • GSV < 0.5 sec • SSV < 0.5 sec

J Korean Surg Soc. 2013 Oct; 85(4): 169–174. Published online 2013 Sep 30. doi: 10.4174/jkss.2013.85.4.169

Valve Closure

Use SAX view to obtain an anteroposterior

diameter measurement

A valve closure time of < 0.5 sec is considered

competent.

REFLUX DEFINED AND MEASURED IN THE SUPERFICIAL VEINS

PW Doppler

• GSV > 0.5 sec

• SSV > 0.5 sec REFLUX DURATION

Reflux is defined as retrograde flow of blood a vein

Color DopplerFlow reversal

REFLUX EVALUATION FOR GSV & AAGSV

• Identify the SFJ in SAX then turn to LAX

• PW Doppler examine the entire length of the vein using

peripheral compression rapid release to assess for reflux

• Measure diameter and depth and appropriately label each segment

• Measure and document the reflux duration

SFJDiam. _____Depth_____PTDiam. _____Depth_____MTDiam. _____Depth_____DTDiam. _____Depth_____KNEEDiam. _____Depth_____PCDiam. _____Depth_____MCDiam._____Depth_____DCDiam._____Depth_____

GSV reflux _______sec

AAGSV reflux _______sec

REFLUX EVALUATION FOR SSV

• Identify the SSV in SAX at the mid to distal calf then turn to LAX

• Scan from distal calf to the SPJ (above SPJ if thigh extension is present)

• PW Doppler examine the entire length of the vein using peripheral

compression rapid release to assess for reflux

• Measure diameter and depth and appropriately label each segment

• Measure and document the reflux duration SSV reflux ______sec

SPJ

Diam._____

Depth_____

PC

Diam._____

Depth_____

MC

Diam._____

Depth_____

DC

Diam._____

Depth_____

DETAILED MAPPING

• Create a detailed map• Close attention to detail is necessary for an accurate mapping.

You must identify the highest source of reflux to insure successful treatment.

• Reflux• Be persistent

• Peripheral augmentation• Valsalva maneuver*• Provocative maneuvers

* Valsalva will not detect reflux unless there is a connection with a pelvic source.

GSV ORIGIN AND TERMINATION

ORIGIN anterior to the medial

malleolus

TERMINATESatSFJ

Images taken from “Venous Ultrasound A Comprehensive Approach” used with permission from Dr. Miguel LoVuolo

The great saphenous vein dramatically changes direction at the white dot which is referred to as Boyd’s point and deviates toward the posterior aspect of the knee.

GSV

AASV __

INCLUDE MAJOR ACCESSORY VEINS

All major accessory veinswhen present should

be evaluated

GSV VARIANTS

Taken from UIP consensus Document. Part II. Anatomy

1 2 3 4

1. ClassicGreatSaphenous Vein Pattern

2. GSV with large paralleling tributary

3. GSV is present to a variable level then either aplastic or hypoplastic for a variable length.

4. A small portion of the GSV is absent for across the knee line

* The missing GSV is usuallybypassed by a bridge vein

GSV “E” POINT

Images taken from Phlebology 2017 Vol. 32 (2) 120-124 The E point: a new echographic great saphenous identification sign in specific anatomical variants and applications Stefano Ricci, Leo Moro, Alessandro Ferrini, Isaura Rossi Bartoli and Raffaele Antonelli Incalzi

ANTERIOR ACCESSORY GREAT SAPHENOUS VEIN

Aligned with the Femoral Artery

Courses more anteriorly than the

Great Saphenous Vein

AAGSV

GSV

FA

Image courtesy of Jeannie Melendez

COMMON AAGSV PATTERNS

1 2 3 4

1. AAGSV coursesanteriorly then it is joined by a large tributary at a the mid-thigh

2. AAGSV coursesanteriorly then it is joined by a large tributary at the distal thigh or knee level

3. AAGSV coursesmedially and joins the GSV at a variable level

4. AAGSV coursesmedially and joins the GSV at the knee. The GSV is aplastic from theSFJ until the level at which the AAGSV joins it.

APLASTIC OR HYPOLASTIC GSV Dominant AAGSV at PROXIMAL THIGH

Images taken from Phlebology 2017 Vol. 32 (2) 120-124 The E point: a new echographic great saphenous identification sign in specific anatomical variants and applications Stefano Ricci, Leo Moro, Alessandro Ferrini, Isaura Rossi Bartoli and Raffaele Antonelli Incalzi

STANDARD SFJ

Image taken from www.phlebologia.org

Common TrunkIndependent Junctions

SFJ VARIANT - ECTASIA

Image taken from www.phlebologia.org

AREAS OF AWARENESS

Structure that may hinder navigation • Tortuous vessel• Valves• Chronic webbing

AREAS OF AWARENESS CON’T

Regions that may lead to post procedure problems or treatment failure

• Large tributaries • Large perforators (mid thigh)• Aneurysmal segments

GSV ANEURYSM

Image courtesy of New Jersey Vein Center

Any vein segment thatis 2x the size of the

connecting vein should be classified as a

aneurysmal and reported on your worksheet.

MEDIAL MID-THIGH PERFORATOR

GSV

Femoral Vein

GSV tributary

Images taken from “Venous Ultrasound A Comprehensive Approach” used with permission from Dr. Miguel LoVuolo

SSV ORIGIN AND TERMINATION

Termination Point Absent SPJ

Image taken from UIP consensus Document. Part II. Anatomy

SAPHENO-POPLITEAL JUNCTION ANATOMICAL ARCHITECTURE

Image taken from “Venous Ultrasound A Comprehensive Approach” used with permission from Dr. Miguel LoVuolo

1. Small Saphenous Vein

2. Intergemellar vein draininginto the small saphenous vein

3. Gastrocnemius veins draining into the popliteal vein

4. Popliteal Vein

“BECAUSE OF” OR THE “CAUSE OF”

Image taken from researchgate.org

Linda Antonucci, RPhS, RVT, RDCS Email - laveins@gmail.com