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

Joseph.Zygmunt@covidien.com

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