The hemodynamics and diagnosis of venous disease

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Presentation transcript:

The hemodynamics and diagnosis of venous disease Mark H. Meissner, MD, Gregory Moneta, MD, Kevin Burnand, MD, Peter Gloviczki, MD, Joann M. Lohr, MD, Fedor Lurie, MD, Mark A. Mattos, MD, Robert B. McLafferty, MD, Geza Mozes, MD, Robert B. Rutherford, MD, Frank Padberg, MD, David S. Sumner, MD Journal of Vascular Surgery Volume 46, Issue 6, Pages S4-S24 (December 2007) DOI: 10.1016/j.jvs.2007.09.043 Copyright © 2007 The Society for Vascular Surgery Terms and Conditions

Fig 1 Development of the inferior vena cava and iliac veins (adopted from Avery LB. Developmental Anatomy, revised 7th ed. Philadelphia: WB Saunders, 1974.) Journal of Vascular Surgery 2007 46, S4-S24DOI: (10.1016/j.jvs.2007.09.043) Copyright © 2007 The Society for Vascular Surgery Terms and Conditions

Fig 2 Relationship between the fascia and veins of the lower extremity. The fascia covers the muscle and separates the deep from the superficial compartment. Superficial veins (a) drain the subpapillary and reticular venous plexuses and they are connected to deep veins through perforating veins (b). The saphenous fascia invests the saphenous vein. The saphenous compartment is a subcompartment of the superficial compartment. From Mozes G, Gloviczki P. New discoveries in anatomy and new terminology of leg veins: clinical implications. Vasc Endovasc Surg 2004;38:367-374.121 Journal of Vascular Surgery 2007 46, S4-S24DOI: (10.1016/j.jvs.2007.09.043) Copyright © 2007 The Society for Vascular Surgery Terms and Conditions

Fig 3 Superficial and perforating veins of the leg. From Mozes G, Gloviczki P. New discoveries in anatomy and new terminology of leg veins: clinical implications. Vasc Endovasc Surg 2004;38:367-74.121 Journal of Vascular Surgery 2007 46, S4-S24DOI: (10.1016/j.jvs.2007.09.043) Copyright © 2007 The Society for Vascular Surgery Terms and Conditions

Fig 4 Deep veins of the leg. From Mozes G, Gloviczki P. New discoveries in anatomy and new terminology of leg veins: clinical implications. Vasc Endovasc Surg 2004;38:367-74.121 Journal of Vascular Surgery 2007 46, S4-S24DOI: (10.1016/j.jvs.2007.09.043) Copyright © 2007 The Society for Vascular Surgery Terms and Conditions

Fig 5 Relationship of the posterior tibial perforators to the deep and superficial posterior compartments (SPC) of the calf (PTVs, posterior tibial veins). From Mozes G, Gloviczki P. New discoveries in anatomy and new terminology of leg veins: clinical implications. Vasc and Endovasc Surg 2004;38:367-74.121 Journal of Vascular Surgery 2007 46, S4-S24DOI: (10.1016/j.jvs.2007.09.043) Copyright © 2007 The Society for Vascular Surgery Terms and Conditions

Fig 6 Pressure/volume relationships in the distensible venous lumen are reflected in this diagram. Considerable volume is introduced before pressure rises; pressures begin to rise as the vein becomes elliptical and increase further as a circular configuration is reached. Katz AI, Chen Y, Moreno AH. Flow through a collapsible tube; Experimental analysis and mathematical model. Biophysical J 1969;9:1261-79.14 Journal of Vascular Surgery 2007 46, S4-S24DOI: (10.1016/j.jvs.2007.09.043) Copyright © 2007 The Society for Vascular Surgery Terms and Conditions

Fig 7 Relative venous hydrostatic (HP) and dynamic (DP) pressures at various heights (Ht) and distances from the right atrium (RA) in the upright individual. Dynamic pressure derive from the activity of the cardiac pump while hydrostatic pressures are related to position and gravity. The figure has been standing motionless with the dependent veins filling by gravity. Upper extremity pressures vary with the position of the arm. Journal of Vascular Surgery 2007 46, S4-S24DOI: (10.1016/j.jvs.2007.09.043) Copyright © 2007 The Society for Vascular Surgery Terms and Conditions

Fig 8 The pressure and volume changes with activation of the calf muscle pump are demonstrated. Beginning in the standing posture, the hydrostatic pressure baseline is demonstrated in a dependent, but non-weight bearing limb. The subject then performs 10 tip-toe (heel-raising) maneuvers and resumes the non-weight bearing posture. A, This schematic compares the pressure and volume changes along a concomitant timeline. Note the efficiency of the calf pump in rapidly reducing either volume or pressure upon commencement of muscle activity. Although volume filling begins within 5 to 7 seconds, pressure does not rise substantially for 30 to 40 seconds. Alterations in these relationships can generate chronic, sustained venous pressure elevations, the end products of which are the symptoms and findings of chronic venous insufficiency. B, Pressure changes during these maneuvers are illustrated in this recording from cannulation of a dorsal foot vein reported in mm Hg. C, Volume changes during these maneuvers are illustrated in this air plethysmographic examination. The volume remaining in the limb after exercise divided by the venous volume standing still is reported as the residual volume fraction (RVF, %). Journal of Vascular Surgery 2007 46, S4-S24DOI: (10.1016/j.jvs.2007.09.043) Copyright © 2007 The Society for Vascular Surgery Terms and Conditions

Fig 9 A, Zones of reference for upper extremity venous scanning: midline = 1.0, acromion = 3.0, elbow = 5.0, wrist = 8.0, fingertips = 9.0. B, Zones of reference for lower extremity venous scanning: femoral vessels at the inguinal ligament = 1.0, midpatella to popliteal crease = 5.0, midmedial malleolus to midlateral malleolus = 8.0, tips of the toes = 9.0. Journal of Vascular Surgery 2007 46, S4-S24DOI: (10.1016/j.jvs.2007.09.043) Copyright © 2007 The Society for Vascular Surgery Terms and Conditions