Lower Extremity Venous Sonography Harry H. Holdorf PhD, MPA, RDMS (Ob/Gyn, Ab, BR), RVT, LRT(AS)

Hholdorf.com October, 2015

Hholdorf.com October, 2015

Hholdorf.com October, 2015

Hholdorf.com October, 2015

Factors Affecting Venous Flow Venous-Skeletal muscle pump ‘Venous heart’ The GREAT MUSCLE PUMP = Calf muscle Muscle contraction squeezes vein propelling blood upward-forward Hholdorf.com October, 2015

Effective Calf Muscle Pump Blood moves from superficial system (s) to deep system (D) Competent valves prevent reflux Venous volume and pressure decreases Venous return to heart increases Hholdorf.com October, 2015

Ineffective Calf Muscle Pump Incompetent valves cause reflux Venous volume and pressure increases Results in venous pooling and ambulatory venous hypertension. Hholdorf.com October, 2015

Respiration Inspiration (Phasic) Decrease in intra-thoracic pressure Increases blood flow from upper extremities Increase in intra-abdominal pressure Decreases blood flow from lower extremities Hholdorf.com October, 2015

Respiration Exhalation Increase in intra-thoracic pressure Decreases blood flow from upper extremities Decrease in intra-abdominal pressure Increases blood from lower extremities Hholdorf.com October, 2015

Valsalva Maneuver Patient takes in deep breath & holds it, then bears down (as if having a bowel movement) Intra-thoracic and intra-abdominal pressure increases significantly All venous return halted Veins will enlarge Hholdorf.com October, 2015

Hholdorf.com October, 2015 Vein Valves

Hholdorf.com October 2015 Superficial Veins - GSV

Importance of the Greater Saphenous Vein The great saphenous vein (GSV), previously also called the long saphenous vein, is a large, subcutaneous, superficial vein of the leg. It is the longest vein in the body running along the medial length of the leg. Clinical significance Pathology of the great saphenous vein is relatively common, but in isolation typically not life-threatening. Varicose veins: The great saphenous vein, like other superficial veins, can become varicose; swollen, twisted and lengthened, and generally considered to be unsightly. Thrombophlebitis The GSV can thrombose. This type of phlebitis of the GSV is usually not life-threatening in isolation; however, if the blood clot is located near the sapheno-femoral junction or near a perforator vein, a clot fragment can migrate to the deep venous system and to the pulmonary circulation. Also it can be associated with, or progress to a deep vein thrombosis which must be treated. The vein is often removed by cardiac surgeons and used for auto transplantation in coronary artery bypass operations, when arterial grafts are not available or many grafts are required, such as in a triple bypass or quadruple bypass. Hholdorf.com October 2015

Vein Mapping for Coronary Artery bypass graft surgery A tourniquet is placed around the upper thigh or the patient is placed in reverse Trendelenberg to aid in venous filling. The LSV is carefully traced onto the exterior of the leg using a surgical marker. Beginning distally at the medial malleolus, a generous amount of ultrasound gel is applied to the donor leg. The focus is set to a depth of 2.8 cm to the scan area below the knee and may be adjusted to greater depths as the thigh is reached. The vein is identified and confirmed on the ultrasound screen as a tubular, compressible structure. The LSV is accurately followed up the medial aspect of the leg and marked for the entire length of its course. The caliber of the vein is assessed and measured at multiple sites and adjustment is made for distension. Hholdorf.com October 2015

Hholdorf.com October, 2015 Superficial Veins - GSV Images courtesy of Phillips - ATL

Hholdorf.com October, 2015 Superficial Veins - GSV Sheath Greater saphenous sheath

Hholdorf.com October, 2015 Superficial Veins – Groin Tributaries

Hholdorf.com October, 2015 Superficial Veins

Hholdorf.com October, 2015 Superficial Veins - Giacomini Vein

Hholdorf.com October, 2015 Deep Veins – Full Length

Hholdorf.com October, 2015 Deep Veins – Gastrocnemius Veins

Hholdorf.com October, 2015 Deep Veins – Popliteal Vein

Hholdorf.com October, 2015 Deep Veins – Sural Tributaries Image courtesy of Phillips - ATL Thrombosed soleal veins With compression Normal gastrocnemius veins No compression

Hholdorf.com October, 2015 Deep Veins – Iliac Veins

Hholdorf.com October, 2015 Inferior Vena Cava

Hholdorf.com October, 2015 Perforator Veins – Flow Direction

Hholdorf.com October, 2015 Perforator Veins – Types I and II

Hholdorf.com October, 2015 Perforator Veins – Types III and IV

Hholdorf.com October, 2015 Perforator Veins – Above Popliteal Space C ommunicating veins – Above the Popliteal Space Connects  External Landmarks NameSuperficialDeep Upper 1/3 third of thigh Proximal terminal Terminal portion of the long saphenous Femoral vein PerineumPerineal Long saphenous trunk and its posterior branches via a Giacomini vein Uterine and ovarian veins of the Hypogastric network Middle 1/3 of thighDistal terminalLong saphenous networkFemoral vein Lower 1/3 of thigh, adductor canal Dodd'sLong saphenous networkFemoral vein

Hholdorf.com October, 2015 Perforator Veins – Below Popliteal Space C ommunicating veins – Above the Popliteal Space Connects  External Landmarks NameSuperficialDeep Upper 1/3 third of thigh Proximal terminal Terminal portion of the long saphenous Femoral vein PerineumPerineal Long saphenous trunk and its posterior branches via a Giacomini vein Uterine and ovarian veins of the Hypogastric network Middle 1/3 of thighDistal terminalLong saphenous networkFemoral vein Lower 1/3 of thigh, adductor canal Dodd'sLong saphenous networkFemoral vein

Hholdorf.com October, 2015 Perforator Veins – Topographical Anatomy

Hholdorf.com October, 2015 Perforator Veins – Cockett’s Perforators

Duplex-Color Flow Imaging Identify venous thrombosis – help differentiate acute from chronic Evaluate non-occluding/partial thrombus Detect calf lesions Distinguish between extrinsic compression and intrinsic obstruction Evaluate soft tissue masses Detect venous incompetence Document re-canalized channels or collateralization Hholdorf.com October, 2015

Limitations of Duplex Imaging Sources of false-Positive studies include: –Extrinsic compression: e.g., tumors such as SVC syndrome, ascites, pregnancy –Peripheral arterial disease (PAD): decreased venous filling –Chronic obstructive pulmonary disease COPD: Elevated central venous Pressure –Improper Doppler angle or probe pressure Hholdorf.com October, 2015

Patient Positioning Peripheral veins: Lower Extremities –Facilitate venous filling: i.e., reverse Trendelenburg –Diminish extrinsic compression: e.g., extreme Left lateral decubitus position Hholdorf.com October 2015

Technique Coaptation: From the Latin word meaning “To fit together” is another word for compressibility Hholdorf.com October 2015

Venous Flow Patterns Evaluate venous Doppler signals in sagittal view: Spontaneous Phasic (with respiration) Augment with distal compression Augment with proximal release Hholdorf.com October 2015

Cross-Section of the Femoral vein High thigh: left leg Hholdorf.com October 2015

MICKEY MOUSE SIGN Common Femoral Artery, Common Femoral Vein, and Sapheno-Femoral Junction: Right Leg Hholdorf.com October 2015

Longt Normal Superficial Vein and Superficial Femoral Artery Hholdorf.com October 2015

Longt: Superficial Femoral Vein with clot Note: Femoral Artery anterior Hholdorf.com October 2015

Cross-Section Popliteal Vein Hholdorf.com October 2015

Popliteal vein and Artery: “Double scoop ice cream cone” sign Hholdorf.com October 2015

Distal Augmentation With distal augmentation of the calf area, flow in the femoral vein initially goes cephalad. With the release of the calf area, flow should not reflux back down the leg. This maneuver demonstrates competent venous valves. Hholdorf.com October 2015

Compression Technique Hholdorf.com October 2015

Deep Vein Thrombosis of the superficial femoral vein Hholdorf.com October 2015

Hholdorf.com October 2015

Hholdorf.com October 2015