41343122 doppler of varicose veins

7/30/2019 41343122 Doppler of Varicose Veins

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Doppler Of ChronicDoppler Of ChronicVenous InsuffeciencyVenous Insuffeciency


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Pathophysiology of chronic venousPathophysiology of chronic venous

insufficiencyinsufficiency Chronic venous insufficiency is an advanced

stage of venous disease caused either by

superficial or deep venous pathology, in whichvenous return is impaired, usually over a numberof years, by reflux, obstruction or calf muscle

pump failure.

This leads to sustained venous hypertension andultimately to clinical complications including

oedema, eczema, lipodermatosclerosis and

ulceration.


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CVI results from dysfunctional valves that

reduce venous return, which thus increasesvenous pressure.

Because existing valves are destroyed, venousblood flow is bi-directional, resulting in

inefficient venous outflow. So, the weight of the venous blood column

from the right atrium is transmitted along thefull length of the veins.

Very high venous pressure is exerted at the ankleand the venules become the final pathway forthe highest venous pressure.


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Aetiology

Chronic venous insufficiency can be divided

into primary and secondary varicose veins.

Both lead to venous hypertension Primary varicose veins are those which only

involve the superficial system.

Secondary varicose veins are caused by previousDVT, which have caused damage to the valvesof the deep veins and perforators.


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Primary varicose veins

Incompetent venous valves is an inherentstructural weakness of the veins

themselves. Positive family history usually obtained.

Other factors include heavy muscular work

such as lifting, repeated straining at stool,pregnancy, and pelvic tumours, all ofwhich increase intraabdominal tension.


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Secondary varicose veins

The most serious of all venous disorders

occur when the deep venous system is obstructed and thevalvular mechanisms are destroyed or rendered incompetent.

DVT leads to two problems obstruction of the deep veinsand subsequent destruction of the venous valves.

When venous obstruction occurs, the venous blood is forcedto follow alternate pathways to reach the heart.

One way is to force the opening of new pathways (collaterals),or to use the superficial system as the alternate pathway.

So, the flow in the communicating (perforating) veins is nowreversed, becoming deep to superficial.


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AnatomyAnatomy


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Important Lower Limb Perforators


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Indications of CD in CVIIndications of CD in CVI

a) Primary varicose veins

b) Recurrent varicose veins

c) Previous DVT

d) Pain and tenderness e) Leg swelling

f) Achingtired limbs

g) Chronic skin changes

h) Ulceration

i) Clinical venous statis

j) Pre-sclerotherapy assessment

k) Pr-operative leg markings


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Patient preparationPatient preparation The patient asked not to wear compression

stockings for at least 12 hours before.

The patient walk or stand to produce symptoms;about 30 minutes prior to the examination,

The patient should be rested to prevent exercise-induced hyperaemic venous flow (ie. Continuous

venous flow).

A short history is taken to document symptoms. Assess the leg in good light before the scan is

commenced, to visualize the distribution of anyvaricose veins and to document problem areassuch as signs of venous stasis,


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The examination will start with the patient in theupright position.

This can be done either with the patientstanding on a stool with side supports, or on astandard footstool, resting his/her buttocks

against the examination couch. The leg to be examined should be non-weight

bearing.

The leg being examined should be slightly flexedat the knee and the hip externally rotated.

Starting with B-Mode examine the CFV, SFVand popliteal veins. (transverse scan best).


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ProcedureProcedure

A) General considerations Assess with B-Mode, colour and spectral

duplex.

B-Mode Exclude any acute or chronic thrombus. Examine the vessel wall to look for signs of residual

thrombus such as thickening, recanalisation etc.

Look for anatomical anomalies such as duplication,or single calf vessel.

Be aware of chronic conditions such as cellulitis,lymphoedema, oedema, large popliteal (Bakers) cystor large muscle tears, haematoma etc.

1

- Deep veins oft

he lower limb


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Colour and duplex Inspect the entire length not just junctions.

This can be done with colour flow, however, duplexwill need to be performed in order to measure the timeof the reversed flow.

Competent valves: Usually hear a thump as the valve closes. Normal physiological reflux/retro grade flow can occur,

however, this is usually less than 1 second.

Incompetent valves: Reflux is usually continuous, but must be >1 second and

>10cm/sec. leaking valves. The valves appear to close, however, some

leaking occurs when the tips of the cusps dont meet. Refluxwill often be >1 second, however


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Return to the CFV and examinelongitudinally using colour andduplex.

To assess competency, eithervalsalva or calf augmentation areused.

Valsalva the patient should

valsalva for at least 2 secs. Calf augmentation this may be

done by squeezing the calfpump then radpidly release.

Good distal augmentation isachieved by placing the footover the edge of the stool andthe patient then flexes the toescephalically.


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If the SFJ is grossly incompetent,then reflux will occur in the CFV

Examine the SFV using the sametechnique described above. (Dontforget if vessel is duplicated,examine both vessels).

Examine the popliteal vein

proximal and distal and at thetibio-peroneal level.

To assess the calf vessels, thepatient may sit down on the bed

Assess colour flow to determinepatency and/or any evidence ofreflux, a single Doppler recording

will be sufficient, in the PTV, andperoneal veins.


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2- Superficial and perforating

veins ofthe lower limb

A) General considerations

Look and document areas of acute or chronic

thrombophlebitis. For reflux in the superficial system use the

same criteria as the deep

Perforator flow goes from superficial to deep. Incompetence flow will travel from deep to

superficial. Bi-directional flow is considered

incompetent.


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Perforators > 4 mm are documented even ifcompetent.

Incompetent perforators may causeincompetence of the associated deep veinbetween valve segments.

All perforators and large tributaries aremeasured in the thigh from the groin downor knee crease up.

In the calf measure from the knee creasedown or sole of foot up. (some measure fromthe medial malleolus, however this can bedifficult with ankle swelling).


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B) Test procedure

At the groin examine the SFJ in transverseand B-mode measuring the SFJ at the origin

Assess SFJ with colour and spectral duplextesting for reflux.

Tributaries may course from the pelvis viathe SEPVand render the SFJ incompetent.

Valves vary in this area and may be at the

junction or distal to this. Follow the LSV the whole length of the

thigh.


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Look for perforators coursing from the LSVortributaries to the deep system and measure these

at the subcutaneous facia. At this point check for competency. You may

have to augment both proximal and distal to theperforator.

Sit the patient on the bed and examine the calfas you did with the deep system.

As with the thigh superficial veins, check for all

tributaries and perforators. Perforators in the calf are more numerous than

the thigh and more likely to be incompetent.


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Take special note of the tributaries around theclinical areas.

The SPJ is varied and may continue into thethigh.

The SSV is examined in a similar fashion to theLSV, taking note of varicose tributaries andperforating veins.

Recurrent veins carefully assess the groinregion for neovascularisation joining with a

stump of the LSV. The popliteal fossa is carefully assessed as it may

develop a recurrent SPJ.


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The main trunks of the superficial veins are shown in cross section.A: The long saphenous vein (V) lies in the superficial compartment,bounded by the deep muscular fascia (upward arrows) and the

saphenous fascia (downward arrows). B: The short saphenous vein (V) is also bounded by the deep fascia

(upward arrows) and saphenous fascia (downward arrows). Themedial gastrocnemius muscle (MG) and lateral gastrocnemius muscle(LG) are shown on this image of the right leg.


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A: Partial incompetence of a venous valve is demonstrated by an areaof retrograde flow (arrow) between the two valve cusps.

B: Spectral Doppler demonstrates trickle or low-velocity reflux (R) in

the popliteal vein following distal augmentation (S).


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41343122 doppler of varicose veins

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