1. Page Title Here US Evaluation of Truncal Veins
What to Look For, Measure and Report
Linda Antonucci, RPhS, RVT, RDCS

2. I have no financial relationships to disclose relevant to this talk.

3. Environment and Equipment
Hydraulic table - Trendelenburg/Reverse Trendelenburg
Comfortable chair that adjust up and down
Adjustable equipment or if portable equipment stand
Step stool
Auto inflate unit
Room - comfortably warm to enhance venous dilatation
Superficial venous exams need to be performed in a comfortable environment. These patients can be with you for over an hour making this is a challenging test for both the patient and the sonographer. A hydraulic table that can be positioned in Trendelenburg and reverse Trendelenburg is a must. Along with a comfortable, adjustable chair. The equipment should also be adjustable or if you are using a small portable ultrasound machine it should be set on an adjustable stand. A step stool to elevate the patient limb for evaluation may be helpful. And an auto inflate unit can really save your back.
Lastly, the room should be comfortably warm to enhance venous dilatation.
The lighting should be even and consistent. The temperature in the room should be warm to enhance venous dilatation.

4. Basic Questions specific for SVI exam
Do you have pain in your legs?
Does one leg bother you more than the other?
Do your legs bother you at the beginning or at the end of the day?
Before you begin mapping, it’s important to ask a few basic questions. I usually ask the patient if they have pain in their legs. If yes, both legs or one. Does one leg bother them more than the other? Do their legs bother them at the beginning or at the end of the day?
Photo of Daniella DePeri, PA

5. DETAILED Physical Examination
Patient Position
Supine
Standing
Visual Inspection
Skin changes
Varicose veins
Scars from previous surgeries or procedures
Palpation
Sub dermal varicosities
It is also very helpful to perform a visual inspection of the limbs. I usually ask the patient to change and remain standing until I return. By the time I enter the room the veins are completely engorged. I perform a visual and palpable inspection in the standing position and then I ask them to lie down and reassess the limb for surgical scars. Inspecting the limbs and getting answers to a few simple questions will help you perform a more targeted exam.

6. Patient Position SVI Evaluation
4 Choices
Standing
4 Choices when performing a superficial venous exam Standing, Standing, Standing, Standing. And if none of these positions suit you………

7. S T A N D I G
You can try standing the patient. Standing is the preferred method used for assessing superficial venous insufficiency. It is well documented in the literature. Most experts agree that the supine position is unacceptable for evaluating reflux because it does not generate enough pressure to physiologically stress the valves.

8. Before You Begin Complete bilateral evaluation of the deep system
Supine
Reverse Trendelenburg >20 degrees
Complete a bilateral evaluation of the deep system unless a unilateral exam is specifically requested. The patient should be in the supine position in reverse Trendelenburg of >20 degrees. Proceed with the previously mentioned DVT/DVI protocol.

9. Patient Position for SVI of GSV
Standing on floor, stool or platform
Facing the examiner
Open stance
External rotation of the hip
Knee slightly bent with heel flat
Weight on the contralateral limb
Hold on to the table or a stool
The great saphenous vein examination requires the patient to stand on the floor, stool, or platform while facing the examiner. He or she should maintain an open stance by externally rotating the hip with the knee slightly flexed and the heel flat on the floor. Weight should be shifted to the contralateral limb. It’s a good idea to have the patient hold the stool or table for stability/safety and to prevent muscle contractions, which can produce waveform artifacts.

10. GSV WithPeripheralCalf Augmentation
Augment by hand or place a pneumatic cuff below the level of interrogation (preferably the calf so you force an adequate volume of blood upward). Peripheral compression followed by rapid release is performed. Reflux is measured after rapid release.

11. SVI evaluation for GSV LAX at the SFJ
PW Doppler (Color Doppler can be used
but it may not pick up subtle reflux)
Use the Valsalva maneuver or manual
peripheral compression to assess for reflux
Examine the entire length of the vein and
appropriately label each segment
Start at the SFJ, using the transverse view to identify the vein; then turn to the LAX view, and with the PW Doppler perform peripheral compression or the Valsalva maneuver to assess for reflux. One of the advantages of valsalva is that it is more comfortable for the examiner, but not every patient can perform this maneuver. Examine the entire length of the vein and appropriately label each segment. Color Doppler can be used but it may not pick up subtle reflux.

12. Patient Position for SVI of SSV
Standing on floor, stool or platform
Patient turned around so they are facing
away from the examiner
Open stance
Step forward with knee slightly bent and heel flat
Weight on the contralateral limb
Hold on to the table or a stool
LVS face appropriate side
Perforators depends on topography
The small saphenous vein examination requires the patient to stand on the floor, stool, or platform facing away from the examiner. He or she should maintain an open stance and take a step forward with the knee slightly flexed and the heel flat on the floor. Weight should be shifted to the contralateral limb. Have the patient hold the stool or table for stability and safety. For the LVS the side being evaluated should face the examiner; for perforators it will depend on their location.

13. SSV WithPeripheralCalf Augmentation
Augment below the level of interrogation, which will initially be the calf, but as you move peripherally, you will have to use the ankle or the foot.

14. SVI Evaluation for SSV LAX at the SPJ for SSV PW Doppler
Using the Valsalva maneuver or peripheral compression
to assess for reflux
Examine the entire length of the vein and appropriately
label each segment
Start at the SPJ, using the transverse view to identify the vein; then turn to the LAX view, and with the PW Doppler use peripheral compression to assess for reflux. Examine the entire length of the vein and appropriately label each segment.

15. If Positive for SVI Supine – true diameter Standing – largest diameter
Measure diameter and depth of vein in SAX
from junction to proposed access point
Evaluate access site in LAX and SAX
If the vein is incompetent, have the patient get back on to the exam and measure the true diameter and depth of the vein in SAX from the junction to the access point. If the vein is a candidate for ablation, evaluate the access site in LAX and SAX.

16. Normal GSV & SSV GSV 3-4 mm SSV 3 mm
The normal GSV is between 3-4 mm, and the SSV is around 3 mm.

17. Detailed Mapping Create a detailed map
Close attention to detail is necessary for an accurate mapping. You must identify the highest source of reflux to insure successful treatment.
Reflux
Be persistent
Peripheral augmentation
Valsalva maneuver
Provocative maneuvers
Attention to detail is essential for accurate mapping. You must identify the highest source of reflux to insure successful treatment. Regarding reflux; be persistent, use not only peripheral augmentation, but Valsalva maneuver and any other available provocative maneuvers. However, keep in mind the Valsalva maneuver will not detect reflux peripheral to an ablated vein segment unless there is a connection with a centrally refluxing segment from a pelvic source.
* Valsalva will not detect reflux peripheral to an ablated vein segment unless there
is a connection with a centrally refluxing segment from a pelvic source.

18. LE VENOUS US WORKSHEET WITH MAPPING
This is an example of what a completed worksheet looks like.

19. BUILD KNOWLEDGE BASE Societies – ACP, AVF, SIR, SVS, UIP
Non societal – IVC, NY Venous Symposium, VEITH
ACP Preceptorship Program, AVF Attendings Course, AVF Fellows Course
Venous Ultrasound A Comprehensive Approach - Dr. Miguel LoVuolo
Handbook of Venous Disease – ed. Gloviczki
The Fundamentals of Phlebology
The Vein Book – ed. Bergan
Phlebology, JVS, JVIR

20. Thank You
Linda Antonucci, RPhS, RVT, RDCS -