1. Ultrasound Diagnosis of Lower Extremity Venous Insufficiency S. Lakhanpal MD President & CEO Center for Vein Restoration

2. Diagnostic Evaluation for Venous Disease: Assumes that a good clinical evaluation gas been completed. Suspected Chronic Ambulatory Venous Hypertension –lower extremity AVH (can be documented by But usually not needed) US examination. Reflux Disease Infra inguinal Deep venous reflux US Superficial Venous Reflux U.S Obstructive disease Supra inguinal Surface US Venogram/ IVUS CTV/MRV Infra inguinal US Phlebography

3. Essential Components of Duplex Scanning Visualization Compressibility Venous flow Augmentation

4. US Equipment & Basic Settings Examination room conditions: Warm and comfortable, prevents spasm Higher frequency probes(6-7MHz) are used for superficial structures and lower frequency probes(3MHz) for deeper structures. All veins can be interrogated by probes between 3-7 MHz. Curvilinear probes provide better depth. Other basic settings – – Pulse repetition frequency (PRF): 1500Hz(Low flow frequency). – – Focus: Posterior wall(allows better lateral resolution in the field of imaging). – – Time gain compensation(TGC): Set to perfect the imaging of the target vessel – – Gain: Dark background to avoid overestimation of velocities – – Angle of insonation: Set at 0 degrees, angle may have to be corrected to be parallel to the flow channel.

5. What to look for? Venous reflux: reversal of flow in the veins Physiologic(the time it takes for the valve leaflets to appose) CFV, FV, PV: <1sec Superficial Veins: <0.5sec. Pathological Congenital 1-2% Primary -24% Secondary(post thrombotic) – 75%

6. Technique Augmentation: – – Valsalva; evaluation of the valves in the groin – – Compression and release; distal to the point of evaluation » » Automated an standardized(size, duration & inflation) pneumatic cuffs used 5 cm below the probe site. – – Additional dorsi/plantar flexion in patients with significant edema Patient position: – – Starts with patient standing, with weight on the contralateral limb. Limb being evaluated flexed and externally rotated. Tilt table with a back rest. Sequence: – – Starts at the CFV, above the junction of the FV and the Deep FV – – SFJ with the terminal and pre terminal valves – – Pop.V, and the deep calf veins – – The GSV(surrounded by two layers of fascia – saphenous eye), SSV (triangular fascia), their tributaries, non saphenous veins are examined next. – – Perforating veins: Course perpendicular to the deep veins and pierce the fascia. Normal flow is superficial to deep.

7. Recurrent Varices after Surgery (REVAS) Incidence – – 20-80% Causes: – – True recurrence Technical failure to ligate SFJ (19%) Neovascularization in cases of SFJ disease(20%) – – Residual disease Failure to recognize perforator disease – – Progression of original disease Most common in patients with strong family histories

8. Theories of Reflux – Origination and Extension In cases of primary(non thrombotic) reflux of the superficial and deep system: – – The reflux circuit theory; The reflux in the superficial system and consequently the perforators will overload the deep system and lead to dilatation and reflux of the deep system. This kind of reflux involved the proximal vessels and valves(SFJ, SPJ, Gastro popliteal jn.) – – Walsh SH and Sales CM in two independent studies have suggested that treating the superficial system here will fix the deep reflux. In Primary CVD reflux in PV’s develops – – In an ascending manner through the adjoining incompetent superficial vein, – – In a descending manner from the reentry flow of refluxing superficial veins. In such cases treating the superficial veins treats the refluxing perforators.

9. Other Pathologies Other Pathologies Identified by US AneurysmsTumorsPhlebosclerosis

10. Further Evaluation of the pelvic & abdominal veins Indications: – – Symptomatic non saphenous varicosities – – Recurrent Varicose veins of the legs – – Leg Disease out of proportion for documented venous insufficiency in the legs – – Symptoms suggestive of pelvic venous congestion Evaluations: – – US – – Inferior veno cavography – – US guided B/L Femoral venous access 6fr sheath on the Rt side with a 4F sheath on the left. – – B/L injections – – LIMA catheter with a glide through the right to gain access to the renal vein – – IVUS – – Change sheath to 11 Fr. – – Criterion – – CTV; May Thurner syndrome ( normal size of the CIV 10-12 mm) – – MRV

11. Ultrasound Diagnosis of Venous Disease

12. Normal GSV Within the Fascial Plane

13. Competent Superficial Doppler

14. Valvular Competence

15. Evaluation of Deep Vein Reflux

16. Sapheno-femoral Junction

17. Dilated - GSV Within the Fascial Plane

18. Vessel Diameter

19. VI in Superficial Vessel

20. Documented Venous Insufficiency in SSV

21. Catheter to Deep Junction Measurement

22. Perforator with Measurement

23. Chronic, Non-Occlusive Deep Vein Thrombosis

24. Deep Vein Thrombosis

25. Superficial Venous Thrombosis

26. Baker ’ s Cyst in the Popliteal Fossa

27. US Findings and Their Clinical Correlation Duplex US and its correlation with symptoms: – – Up to 4/5th of the patients presenting with CVD are symptomatic with achiness heaviness, tiredness, restless limb, burning and ulceration. Duplex US and its correlation with signs: – – Varicose veins and telengectasias are present in 4/5 th. – – Skin changes of some sort are present in up to 1/4 th – – Active or healed ulcerations in up to 1/9 th.

28. US Findings and Their Clinical Correlation Duplex US and severity of disease: – – C1-2: Reflux limited to the superficial system – – C3-6: Prevalence of deep vein reflux and perforator reflux increases. – – C4-6: Higher incidence of combined obstruction and reflux.

29. US Findings and Their Clinical Correlation Presence of Reflux by Location: – – Superficial Veins in 90% of the Patients GSV 70-80% SSV 15-25% Non Saphenous Veins -10% – – Deep System in 30% Perforator Veins 20%

30. US Findings and Their Clinical Correlation Ulcers and reflux: – – Superficial system alone: up to 50% but Superficial reflux is present in up to 95% – – Isolated deep vein reflux<10%. Popliteal vein has strongest correlation. – – Veins in the ulcer bed and 2 cms around it, reflux in upto 90%

31. It is essential that all patients who complain of pelvic symptoms or associated non saphenous varicosities have their pelvic veins evaluated; Sonographic Evidence of Pelvic Venous Congestion – – The visualization of dilated ovarian veins greater than 4 mm in diameter. – – Dilated tortuous arcuate veins in the myometrium that communicate with bilateral pelvic varicose veins. – – Slow blood flow (less than 3 cm/s), and reversed caudal or retrograde venous blood flow particularly in the left ovarian vein. – – Interestingly, more than 50% of women with PCS have associated cystic ovaries as well. The US appearance may range from classic polycystic ovarian syndrome to clusters of cysts in bilaterally enlarged ovaries (4 to 6 cysts of 5 to 15 mm in diameter).

32. Thank You