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Varicose Veins Chronic Venous Insufficiency

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Varicose Veins Chronic Venous Insufficiency Sonocartography: Don’t be a technician!! Marcus Stanbro, DO, FSVM Center for Venous & Lymphatic Medicine Saturday, March 24, 2018 Standing venous reflux exam Disclosures No pertinent disclosures Standing Venous Duplex Objectives 1. Quickly review indications for obtaining a standing venous exam 2. Introduce basic methodology for performing the standing reflux exam 3. Highlight a few examples and diagnostic pearls Limitations 1. Today’s discussion will focus on the duplex exam, but this information must be combined with patient history and physical exam. 2. Other tools used include the clinical, etiologic, anatomic and pathophysiologic scoring (CEAP score), Venous Clinical Severity Score (VCSS), and different QOL assessments. 3. Will not discuss ultrasound guided access Abbreviations DUS = Duplex Ultrasound FV = Femoral Vein (replaces superficial femoral vein) GSV = Great saphenous vein (replaces Greater or Long) SSV = Small saphenous vein (replaces Short or Lesser) AASV = Anterior accessory saphenous vein (replaces lateral) PASV = Posterior accessory saphenous vein SFJ = Saphenofemoral Junction SPJ = Saphenopopliteal Junction Supine basics 1. Four components: 1. B-Mode – Appearance 2. Color 3. Doppler 4. Compression Reflux Definition Flow = wrong direction 1. Reflux = pathologic retrograde flow 1. Deep system = >1.0 second 2. Superficial system = >0.5 seconds 2. How do you elicit reflux? Needs standardization 1. For flow: you have to create a pressure gradient 1. Valsalva 2. Compression – Release (calf squeeze) Indications 1. Evaluation of leg discomfort and/or swelling 2. Pre-operative (VV/CVI +/- ulcers) 3. Post-operative (VV/CVI +/- ulcers) 4. Surveillance* *Not proven Varicose Veins Chronic Venous Insufficiency Importance & Impact Presentation Diagnosis Treatment Etc. (special circumstances, complications, etc) Importance & Impact IMPORTANCE OF VENOUS DISEASE It is estimated that 20% of American women and 7% of American men suffer from venous disease Venous disease results in symptoms such as aching, fatigue, swelling, and pain in the legs that can interfere with daily living Cosmetic issues may affect quality of life At least 20% of patients with venous disease (namely GSV reflux) will develop leg ulcers Venous Ulcers Many take > 9 months to heal Up to 66% last > 5 years Affect 1% general population w/ annual healthcare cost of $3 billion Presentation: Spectrum of venous disease C4b lipodermatosclerosis C1 telangiectasia C2 varicose veins C6 venous ulceration C1 reticular veins C3 Swelling Terms to describe Varicose Vein Saphenofemoral Junction (SFJ) Deep/superficial vein junction Great Saphenous Vein (GSV) Trunk vein, usually straight Reflux Retrograde flow in the leg Varicosities Superficial tributaries beneath the skin Typically below the knee Duplex Testing Patient History Duplex Testing-History Absolutely essential components: Previous DVT or superficial thrombophlebitis Previous intervention Vein “stripping”, true ligation, division, and removal of saphenous vein Phlebectomy Catheter-based ablations (length of treated vein), etc Injection sclerotherapy Duplex Testing-History Detailed (working with vein center/phlebologist) Previous DVT or superficial thrombophlebitis Previous intervention Treatment of the junction None Flush ligation Distal ligation preserving terminal valve and superficial epigastric Repeat for recurrence, foam sclerotherapy, etc. Treatment of the main trunk None Ablation (length) Stripping (length) Duplex Testing-History Detailed cont’d Treatment of tributaries (concomitant vs delayed) None phlebectomies Sclerotherapy (foam or liquid) Catheter ablations Treatment of perforating veins None Ablation Ligation (epifascial vs subfascial i.e. SEPS) Sclerotherapy (foam or liquid) Duplex Testing-Exam Duplex Testing-Exam Lipodermatosclerosis – Severe Venous Hypertension Duplex Testing Methodology Venous Duplex-Deep Supine Duplex Assess for patency of deep system CFV FV Popliteal vein Standing Duplex Reflux of CFV Pop V Venous Duplex-Superficial Standing Duplex Assess size and function of superficial system Determine source of reflux Determine status of perforating veins Standing Reflux Exam Eliciting the Reflux Essential to create adequate pressure gradient!! Valsalva Attempts at standardizing involve devise using forced expiration Compression and release Hand squeeze Rapid cuff deflator Eliciting the Reflux Essential to create adequate pressure gradient!! Rapid cuff deflator Typically placed on the proximal calf, BUT ideally should be placed over the “reservoir” A Comparison of the Cuff Deflation Method With Valsalva's Maneuver and Limb Compression in Detecting Venous Valvular Reflux Arie Markel, MD; Mark H. Meissner, MD; Richard A. Manzo, CCVT; Robert O. Bergelin, MS; D. Eugene Strandness, Jr, MD Arch Surg. 1994;129(7):701-705 ←Reservoir The “Reservoir” Standing venous exam Areas of concern or sources of errors 1. Position of body (Standing if possible) 2. Position of cuff 3. Time of day? 4. Use of stockings? 5. Patterns of veins and likely suspects Terms to describe Varicose Vein Saphenofemoral Junction (SFJ) Deep/superficial vein junction Great Saphenous Vein (GSV) Trunk vein, usually straight Reflux Retrograde flow in the leg Varicosities Superficial tributaries beneath the skin Typically below the knee Standing venous exam Sources of reflux Name the 4 sources of reflux. Standing venous exam Sources of reflux 1. Junctional (GSV, SSV) 2. Pudendal/pelvic 3. Perforators 4. “Siphon” 5. “Re-entry” (original source is 1-4 above) Examples Potential sources of reflux: AASV Pudendal Hach’s perforator Pudendal/ Vulvar Varices Hach’s Perforator Profunda Femoral Vein Patterns of Reflux Big vein – big reservoir Smaller vein- big reservoir Patterns of Reflux Big vein – small reservoir Examples Examples Examples Examples Examples Examples Examples WW Examples Examples Examples Examples Pearls Significant findings- Asymmetry Significant Findings - STP Significant Findings – Pulsatile Flow Significant Findings-Perforators Duplex Testing-Exam Lipodermatosclerosis – Severe Venous Hypertension Significant Findings-Perforator Venous duplex Supine Standing Reflux “Post-op” Endovenous Heat Induced Thrombosis (EHIT) EHIT Conclusion It’s all about reflux Look at the leg first, making note of VV location Pay attention to placement of cuff, area of compression/rapid deflation Be aware of sources of error Be suspicious of VV or large axial vein without reflux (usually means you missed it!) Before and After Pictures GSV Distribution .
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