1. Vascular Technology Venous Vascular Lecture 29: Alternative Diagnostic Test and Treatments HHHoldorf

2. Miscellaneous Diagnostic Tests and Treatments
Contrast venography (Phlebography)
Capabilities:
Although contrast venography is still considered the GOLD STANDARD, the numbers of venograms has markedly decreased due to the accuracy of duplex scanning.

3. Ascending Venography: Utilized for evaluation of acute DVT, congenital venous disease and or anomalies, evaluation of chronic venous thrombosis
Descending venography used primarily to detect and quantify reversed flow from incompetent venous valves.

4. Limitations: Highly technical in technique and interpretation
Relatively expensive
Uncomfortable
Adverse effects: allergic reactions or extravasation of contrast media
May be contraindicated in patients with severe Peripheral Arterial Disease (PAD) secondary to risk of extravasation and patients with allergies to iodine.

5. Technique: Ascending Venography
Radio-opaque contrast media injected into vein on dorsum of the foot to visualize anatomy
Serial x-rays taken as media passes through veins identifying filling defects, anatomic variations, development of collateral channels.

6. Ascending venography

7. Descending venography
Radio-opaque contrast media injected into common femoral vein
Serial x-rays taken as material passes through veins to detect and quantify reversed flow and location of incompetent valves

8. Descending venography

9. Treatment – Medical Lifestyle modifications
Control risk factors (related to Virchow’s Triad)
Decrease venous stasis
Limit long periods of inactivity or bed rest
Promote venous drainage
Wear support hose or elastic stockings
Elevate legs
Intermittent pneumatic calf compressions during and after surgery
Prevent injury of infection
Aware of hypercoagulability states/factors

10. Treatment - Pharmacologic
Anticoagulant therapy
Prophylaxis
Low-Dose Heparin
Interferes with formation of blood clots
Does not lyse an existing thrombus
Acute DVT and or PE
Heparin: Loading does followed by continuous intravenous infusion for 5 – 10 days
Coumadin
Nearing end of heparinization: anticoagulation started
Prescribed for three to six months

11. Treatment - Pharmacologic
Lytic therapy
Breakdown of thrombus, i. e., hemolysis
Urokinase or streptokinase may be recommended in acute iliofemoral DVT
Treat venous ulcers with medicated compressing dressing, e. g., unna boot, Profore (4 layer) dressing

13. Treatment – Surgical and Endovascular
Acute DVT or PE
Vena Caval interruption devices: AKA IVC filter
Performed to prevent PE in patients who cannot be anticoagulated
Using Fluoroscopy, a filter placed in IVC (below the renal veins) Via jugular or femoral vein.
An external caval clip may be placed around IVC during abdominal surgery to decrease risk of PE

14. IVC Filter

16. Iliofemoral venous thrombectomy
Performed for impending limb loss, i. e., phlegmasia cerulean dolens, if thrombolytic therapy, e. g., streptokinase or Urokinase, does not dissolve clot.
Phlegmasia Cerulean Dolens: (literally: painful blue edema) is an uncommon severe form of deep venous thrombosis which results from extensive thrombotic occlusion (blockage by a thrombus) of the major and the collateral veins of an extremity.

17. Phlegmasia cerulea dolens

18. Chronic Venous Insufficiency
Vein ligation of incompetent perforators performed
Valvular reconstruction or valve transplantation procedures: infrequent

19. Varicose Veins
Surgical procedure includes: saphenous vein removal or local excision (phlebectomy) of varicosities
Endovenous procedures treat the veins from the inside. Using heat energy that causes the vein to shrink, then slowly disappear
Major ablation types are radio frequency ablation and laser ablation
Duplex scanning utilized to confirm patency of veins and depth of vein to be treated.

20. Varicose veins continued…
During procedure, Duplex scanning is used to access the vein, confirm placement of wire, guide injection of tumescent anesthesia, verify laser is firing correctly, and assists with accurate pullback.
Post procedure, Duplex scanning is used to confirm vein ablation and absence of thrombosis.

21. 3. Sclerotherapy used to treat varicosities by sealing them off: Sclerosing agent, e. g., sodium sulfate, injected into varix and compression dressing applied.

22. Portal Hypertension
Transjugular Intrahepatic portosystemic Shunt (TIPSS): Percutaneously created shunt between portal and hepatic veins:
Usual approach : Right IJV to IVC into Right hepatic vein
BRIDGE created to portal vein
Tract stented with metallic endoprostheis

23. TIPSS Shunt

24. Homework Textbook: Chapter 31: Alternative Diagnostic Tests
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