Duplex assessment of venous hemodynamics 3 oct 13th, 2011, morning 20mn2

Duplex Assessment

of Venous

Hemodynamics

Claude FRANCESCHI, Roberto DELFRATE

Paris France, Cremona Italy

Hemodynamics knowledge is the

backbone of nowadays

performance in Diagnosis and

Treatment of Arterial and Cardiac

disease

Hemodynamics ignorance is the

reason for the still raw diagnosis

and treatment of the Venous

Disease despite the advanced

technologies that cannot

compensate theoretical lacks

Venous Hemodynamics

knowledge demands a peculiar

intellectual effort because:

Not teached in most universities

Weakly promoted ( known?) by

the majority of Phlebology

Opinion Leaders and Scientific

Societies

More complex than arterial

Duplex assessment of

venous

hemodynamics is the

key point for a better

diagnosis and

appropriate treatment

strategy

IF lighted by rational

and coherent

theoretical models

Duplex aims at

assessing the

hemodynamic

changes of the

venous system

According to the

various

hemodynamic

configurations

Pressure and Flow Overloading is

responsible for TMP EXCESS

TMP Excess is Responsible for

-Veins Dilatation ( Varicose)

-Drainage impairment ( trophic changes :

edema, hypodermitis, ulcer…)

Pressure and Flow Overloading is due

to

Venous Block responsible for

-Permanent Venous Pressure Excess

-Compensatory collaterals (Open Shunts)

Valve Incompetence responsible for

-Deep Reflux ( various grades)

-Superficial Reflux

- -Closed Circuits ( Closed Shunts)

- -Deviated Flows ( Open deviated Shunts)

DUPLEX is able to assess all these

complex configurations made of

blocks and shunts

IF performed according to appropriate

data assessments

So providing accurate diagnosis and

consequently appropriate treatment

Hemodynamic Manœuvres

Are Mandatory to elicit the

hemodynamic impairments

Hemodynamic Manoeuvres

Upright Position

Squizing, Paranà , Wundsdorf:

Valvo-muscular Pump Stress Test

Valsalva: Thoraco-abdominal

Pump Stress Test

Supine Position

Venous Pressure: Hemodynamic

obstacles assessment


Upright Position




Pump Stress Test

Supine Position



Valsalva Manœuvre:

May be performed easily and properly

blowing into a blocked straw

Valsalva Manœuvre:

Increases the Toraco-abdominal venous

pressure

and reverses downwards the pressure

gradient but not the flow when blocked by

the valves closure

Valsalva Manœuvre:

Valsalva is negative when the valves are

Competent

At

rest

Systole

=

blowing

Relax

Diastole

Flow is blocked by blowing ( systole)

and appears at release (diastole)

Valsalva Manœuvre:

Valsalva is Positive when valves are

Incompetent Valve

Reverse Flow appears when blowing

( systole) and at release (diastole)

At

rest

Systole

=

blowing

Relax

Diastole

Exception!!!!!

Contrary to the majority of the veins, AT DESCENDING TRIBUTARIES OF THE

SAPHENA ARCH

Positive Valsalva flow fed by pelvic leaks

doesn’t reverse direction

o P

p P

c P

s g P

ig P

i P i P

o P

p P

c P

gs P

g s P

At

rest

Systole

=

blowing

Relax

Diastole


Upright Position




Pump Stress Test

Supine Position



Purpose:Assessing

VALVE COMPETENCE

VALVE INCOMPETENCE

Grades:

-Total, Partial, Segmental

Haemodynamic effect:

- -Closed Shunts (closed circuit )

-Open Deviated Shunt ( open circuit )

VENOUS BLOCKS AND BY-PASSING VEINS

-Open Vicarious Shunt ( open circuit )

Purpose:Assessing

VALVE COMPETENCE

VALVE INCOMPETENCE

Grades:

-Total, Partial, Segmental, Closed Shunt



-Closed Shunts (closed circuit )



Paranà:

Physiologic

Active Systole of the VMP and

plantar pump

BY

Proprioceptive reflex contraction

triggerd by a light push-pull at the

waist

Paranà:

Physiologic


plantar pump

BY



waist

Paranà:

Physiologic


plantar pump

BY



waist

Paranà:

Physiologic


plantar pump

BY



waist

Purpose:Assessing

VALVE COMPETENCE

VALVE INCOMPETENCE

Grades:




- Open Deviated Shunt ( open circuit )



At

rest

Diastolic

Reflux

coequal to

Systolic

Popliteal Vein

Ilio-femoro-popliteal TOTAL incompetence

S

D

coequal

At

rest

Diastole

S

D

Above Femoral Valve Closure

Decreases the Reflux

SEGMENTAL Popliteal incompetence

Diastolic

Reflux

Peak

lower than

Systolic

At

rest

S

D

Small valve leak

PARTIAL Popliteal incompetence

Low and

Lasting

Diastolic

Reflux

Purpose:Assessing

VALVE COMPETENCE

VALVE INCOMPETENCE

Grades:







At

rest

Femoral Example

Diastolic Reflux overloaded by a competent

collateral vein flow

At

rest

Deep CLOSED SHUNT

Diastolic

Reflux Peak

and volume

Higher than

Systolic

Femoral Example

Diastolic Reflux overloaded by a competent

collateral vein flow

At

rest

Great Saphena Example

Superficial Diastolic Reflux overloaded by a deep

vein flow

At

rest

Superficial CLOSED SHUNT

Diastolic

Reflux Peak

and volume

Higher than

Systolic

S

D



vein flow

At

rest



vein flow

At

rest


Diastolic

Reflux Peak

and volume

Higher than

Systolic

S

D

Great Saphena Example SHUNT 1


vein flow

Positive (+)

Valsalva


vein flow


Other Closed Shunts have the same

hemodynamic features but are different

according to the deep leak point that

feed them their and the re-entry point

that drain them and the involved

network


vein flow

Sapheno-femoral Junction

Sapheno-popliteal Junction

Pelvis leak points

Various Perforators

Networks:

N1, N2, N3, N4

o P

p P

c P

s g P

ig P

i P i P

o P

p P

c P

gs P

g s P

Purpose:Assessing

VALVE COMPETENCE

VALVE INCOMPETENCE

Grades:







At

rest



vein flow

At

rest

Superficial OPEN DEVIATED SHUNT

Diastolic

Reflux Peak

and volume

Higher than

Systolic

S

D

Great Saphena Tributary Example

Superficial Diastolic Reflux overloaded by a

other superficial collateral veins flow

Negative (-)

Valsalva

Purpose:Assessing

VALVE COMPETENCE

VALVE INCOMPETENCE

Grades:









vein flow

At

rest

Superficial OPEN VICARIOUS SHUNT

Rest, Systolic

Peak and

Diastolic

antegrade

flow

S

Great Saphena By-Passing a popliteal

block Example

Superficial Systolic flow overloaded by deep

venous flow

D

o P

p P

c P

s g P

ig P

i P i P

o P

p P

c P

gs P

g s P

Networks and their Connections are

checked up :

Flow direction and modulation

- -at rest

- under hemodynamic stress

manœuvres

Selected according to the peculiar status of

each patient

In order to depict a taylored topo-

hemodynamic feature


Upright Position




Pump Stress Test

Supine Position



Supine Position

Venous Pressure Measurement:

Veins Patency Test

Normal ≤ 25 mm Hg

Cuff

inflation/deflation

Posterior Tibial Vein

flow

For a comprehensive information


venous

hemodynamics

Lower limbsVenous network

Dynamic Stress Manoeuvres

Hemodynamic Obstacles and Open

Vicarious Shunts

Hemodynamic Valve Incompetence

and Closed/Open Derivate Shunts

Protocole Assessment

Hemodynamic Mapping


venous

hemodynamics

Lower limbsVenous Networks (N)



Vicarious Shunts




Hemodynamic Mapping

Venous Networks ( N )

1988

Sub-Apon.

Compart.

Skin

Sub-

Cut.

Tissue

Duplicated

Apon.

fascia


1988

N3 sub-cut.

veins

N2 intra-

fasc. veins

N1 deep

veins


1988

Hierarchical draining

N1N2N3


1988

Draining Veins

N1

N2

N3

TRUNKS

Ant.Saph.

Great saph.

GiacominiV.

Small saph.

Deep veins

Saph. and Extra

Saph. tributaries


1988

Draining Veins

N4

N2 ► N2

Connecting

Veins


N2 ►N1 collectors

Sapheno-Femoral Junction

Sapheno-Popliteal Junction


N2 ►N1 main

perforators

LEGS


N3 ►N1 some

perforators

LEGS


Pelvis

6 perforators

Perineal V P Point

Rd Ligt V I Point

Clit. V C Point

Obt. V O Point

I Glut.V IG Point

S Glut. V SG Point

N3 ►N1 perforators

o P

p P

c P

s g P

ig P

i P i P

o P

p P

c P

gs P

g s P

Franceschi C, Bahnini A. (2005) Treatment of

lower extremity venous insufficiency due to pelvic

leaks points in women; Ann vasc Surg; 19; 284-88

Networks and their Connections

are checked up :

Flow direction and modulation

- at rest

- under hemodynamic

stress manœuvres

Selected according to the

peculiar status of each patient

In order to depict a taylored

topo-hemodynamic feature


venous

hemodynamics




Vicarious Shunts




Hemodynamic Mapping


Upright Position




Pump Stress Test

Supine Position


obstacles


Upright Position




Pump Stress Test

Supine Position

Venous Pressure: Veins Patency

Test

Valsalva Manœuvre:

Systolic Block of Thoraco-abdominal Pump

increases

the Toraco-abdominal venous pressure

Valsalva Manœuvre:

Systolic Block of Thoraco-abdominal Pump

increases the Toraco-abdominal venous

pressure

So reversing downwards the pressure

gradient without flow reversal thanks to the

peripheral valves closure

Valsalva Manœuvre:

Toraco-abdominal Pump Systolic Block

increases the Toraco-abdominal venous

pressure

So reversing downwards the pressure

gradient it produces a reversal reflux flow

when the peripheral valves are incompetent

Valsalva Manœuvre:

How to achieve Valsalva Manœuvre

easily and effectively :

Blowing into a KNOTTED STRAW

Blow!

Valsalva Manœuvre:

Negative Valsalva = Competent Valve

VALVE COMPETENCE = NO SYSTOLIC REFLUX

Valsalva Manœuvre:


At

rest

At rest, Permenant and Slow Upwards

flow due to Residual Pressure


Valsalva Manœuvre:


At

rest

Systole

=

blowing

then the flow is blocked by the Valsalva

systole


Valsalva Manœuvre:


At

rest

Systole

=

blowing

then the flow is blocked by the Valsalva

systole

Valsalva Manœuvre:


At

rest

Systole

=

blowing

Relax

Diastole

Then at release, le blood flows upwards

again thanks to the thoraco-abdominal

pump diastole


Valsalva Manœuvre:

Positive Valsalva = Incompetent Valve

VALVE INCOMPETENCE = ONLY VALSLVA SYSTOLIC

REFLUX

Valsalva Manœuvre:


At

rest

VALVE INCOMPETENCE = ONLY SYSTOLIC REFLUX

Normal at rest

At

rest

Systole

=

blowing

Valsalva Manœuvre:



Systolic reflux

At

rest

Systole

=

blowing

Relax

Diastole

Valsalva Manœuvre:



Normal at Diastole

At

rest

Systole

=

blowing

Relax

Diastole

Valsalva Manœuvre:



Normal at Diasole

Valsalva Manœuvre:

Contrary to the majority of the veins, DESCENDING TRIBUTARIES OF THE

SAPHENE ARCHS flow

downwards

and its refluxes are not reverse flows

SO Valsalva is Positive when it

produces a no reverse systolic

downwards flow

The reflux is fed by one of the pelvic

leak pointso P

p P

c P

s g P

ig P

i P i P

o P

p P

c P

gs P

g s P

At

rest

Valsalva Manœuvre:


SAPHENE ARCHS flow

downwards

and are not reverse flows nor reflux when

at rest

At

rest

Systole

=

blowing

Valsalva Manœuvre:


SAPHENE ARCHS flow

downwards

and are not reverse flows nor reflux at rest .

The absence of reflux is attested by absence of

flow during the Systole

At

rest

Systole

=

blowing

Relax

Diastole

Valsalva Manœuvre:


SAPHENE ARCHS flow

downwards

and are not reverse flows nor reflux when

at rest and during the diastole

Valsalva Manœuvre:DESCENDING TRIBUTARIES OF THE

SAPHENE ARCHS

PositiveValsalva = Systolic Downwards flow

WITHOUT REVERSE FLOW

REFLUX FROM INCOMPETENT PELVIC PERFORATORS

At

rest


SAPHENE ARCHS



At

rest

Systolic

REFLUX

=

blowing


SAPHENE ARCHS



REFLUX FROM

INCOMPETENT PELVIC

PERFORATORS

At

rest


SAPHENE ARCHS



Relax

Diastole

Systolic

REFLUX

=

blowing

At

rest

Systole

=

blowing

Relax

Diastole

Valsalva Manœuvre:



Upright Position




Pump Stress Test

Supine Position


Test



Purpose:Elicit

VALVE COMPETENCE

VALVE INCOMPETENCE

Features:









Purpose:Elicit

VALVE COMPETENCE

VALVE INCOMPETENCE

Features:








Valvo-muscular Pump VMP Stress

Test

Squizing:

Not physiologic

Passive Systole of the VMP

+

N2 and N3 emptying



Test

Paranà:

Physiologic


plantar pump

BY



waist



Test



Test



Test



Test



Test



Test

At rest, very low upwards flow

At

rest



Test

Pull 2 cms back but quickly

In order to trigger a Systole by

Proprioceptive reflex contraction of

the calf

At

rest



Test

Then Push ahead 2 cms but quickly

In order to relax the

Proprioceptive reflex contraction of

the calf (Diastole)

At

rest



Purpose:Elicit

VALVE COMPETENCE

VALVE INCOMPETENCE

Features:







At

rest



Test

Popliteal Vein


At rest



Test

Systole

At

rest

Popliteal Vein


At

rest



Test

Diastole

Popliteal Vein


S

D

coequal

At

rest



Test

Popliteal Vein

SEGMENTAL Popliteal Incompetence

At rest



Test

Systole

At

rest

Popliteal Vein


At

rest



Test

Diastole

Popliteal Vein

S

D

D peak

<S peak


Femoral Valve

Closure

Decreases the

Reflux

At

rest



Test

Popliteal Vein

PARTIAL Popliteal Incompetence

At rest



Test

Systole

At

rest

Popliteal Vein




Test

At

rest

Popliteal Vein


Diastole

Popliteal Vein

S

D

D peak

<S peak

D time

>S time

At

rest



Test

Popliteal Vein

Deep Closed Shunt Example

Diastole

Incompetent Fem-Popliteal V

+ Competent Collat.V ( may be Deep Fem.)

At

rest

D peak

>

S peak

At

rest



Test

Great Saphenous vein


At rest



Test

Systole

At

rest

Popliteal Vein


At

rest



Test

Diastole

Popliteal Vein


S

D

coequal


Upright Position




Pump Stress Test

Supine Position


Test

Supine Position

Venous Pressure Measurement:

Veins Patency Test

Normal ≤ 25 mm Hg

Cuff

inflation/deflation

Posterior Tibial Vein

flow


venous

hemodynamics




Vicarious Shunts




Hemodynamic Mapping

Hemodynamic Obstacles

The hemodynamic significance of a

block in terms of drainage quality is

inversely proportional to the collateral

compensatory veins developing

N1

N2

N3

N4L

N4T

Collectors: N2 -N1: SFJ, SPJ

N3 -N1: Perineal V P Point

Rd Ligt V I Point

Clit. V C Point

Obt. V O Point

I Glut.V IG Point

S Glut. V SG Point

Internetworks connections

Perforators:

N2 -N1: saphenous truncks→deep Veins

N3 -N1:Saphenous tributaries and

others→deep Veins

Connectors:

N2 –N2: saphenous truncks

N3 -N1:Saphenous tributaries and others

N1

N2

N3

N4L

N4T



Rd Ligt V I Point

Clit. V C Point

Obt. V O Point

I Glut.V IG Point

S Glut. V SG Point


Perforators:



others→deep Veins

Connectors:



Great Saphenous Trunk

Small Sahenous Arch

Giacomini Vein

Anterior Saphena

Great Saphenous Arch

Small Sahenous Trunk

N2

N3

N4L

N4T

Common Femoral Vein

Superficial Femoral Vein

Popliteal Vein

Deep Femoral Vein

1988

Draining network from skin to suprafascial veins (Network 3) then intrafascial veins

(Network 2) then deep subfascial veins (Network 1)

N2

N3

N4L

N4T

N1

Dynamic manœuvres

Valsalva manœuvres

Active calf pump test

Passive calf pump test

Obstacle assessments

Dynamic Obstacle assessments

Demodulatlion

collateral by-pass

doppler ankle pressure

Anatomic Obstacle assessments

Color

Compression

Networks N1,N2,N3,N4

Assessment protocole

Mapping

Strategies

Tactics

Valve competence

assessment

SHUNTS: venous segment

overloaded by extra

volume/pressure fed by Escape

points and redirected into Re-

entry points :

Sapheno-femoral junction

Sapheno-Popliteal junction

Pelvic leak points

Perforators

Valve incompetence

assessment : value

Open vicarious shunts

Open derivating shunts

Closed shunts

superficial : type

1 to 6

deepMixt shunts

N1

N2

N3

N4L

N4T



Rd Ligt V I Point

Clit. V C Point

Obt. V O Point

I Glut.V IG Point

S Glut. V SG Point


Perforators:



others→deep Veins

Connectors:



Science

Duplex assessment of venous hemodynamics 3 oct 13th, 2011, morning 20mn2