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

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