Palermo 2009Palermo 2009

P.L. Antignani

Dept. of Angiology, (Director: C. Allegra)s.Giovanni Hospital, Rome, Italy

Non invasive diagnostic methods: how have they modified the therapeutical indications?

The non invasive diagnostic methods have modified our therapeutical decision in several vascular diseases.

Particularly, many forms of surgical treatment, both endovascular and open, are performed based exclusively on evaluation with duplex scanning.

We discuss the main conditions in which this change is more evident:

Carotid stenosis Abdominal aortic aneurysmDeep venous thrombosisSuperficial venous thrombosisChronic venous insufficiency

Definition of carotid lesion

Investigation techniquesHigh-resolution B-mode imagingColor Doppler flow imagingPower Doppler imagingCompounded imagingFour-Dimensional ColorDoppler flow imagingContrast ultrasonic agentsTranscranial DopplerIVUSSpiral CT scanContrast-enhanced MR angiographyDiffusion weighted MR imaging (DWI)

A carotid color flow duplex scanning allows:

to quantify the stenosis to assess its morphological characteristics

Evaluation of stenosisEvaluation of stenosis

Degree of stenosis inDegree of stenosis in diameterdiameter

Degree of stenosis in Degree of stenosis in cross-sectionalcross-sectional areaarea

Evaluation ofEvaluation of velocityvelocity

Degree of stenosisDegree of stenosis

Color Flow Duplex imagingCAROTID PLAQUE

THICKNESSTHICKNESS

ECHOGENICITYECHOGENICITY

STRUCTURESTRUCTURE

SURFACESURFACE

mmmm

REGULAR REGULAR IRREGULARIRREGULAR

HOMOGENEOUS HOMOGENEOUS HETEROGENEOUSHETEROGENEOUS

HYPOECHOIC HYPOECHOIC HYPERECHOICHYPERECHOIC

Plaque ClassificationPlaque Classification

• Type I (uniformly echolucent)• Type II (predominately echolucent)• Type III (predominately echogenic)• Type IV (uniformly echogenic)• Type V (heavy calcification)

Color flow duplex imaging

Carotid plaque and Risk of Carotid plaque and Risk of strokestrokeOther criterion:Other criterion: PLAQUE MORPHOLOGYPLAQUE MORPHOLOGY

StructureStructure

Fibrous capFibrous cap

Intraplaque hemorrhage, surface Intraplaque hemorrhage, surface ulceration, ruptureulceration, rupture

Morphology of plaqueMorphology of plaque

“The higher the degree of stenosis, the more likely it is associated with ultrasonic heterogeneous and hypoechoic plaque”

( MM Sabetai, J Vasc Surg 2000)( MM Sabetai, J Vasc Surg 2000)

Diagnosis of presence and grading of carotid stenosis

Colour-flow duplex scanning is the Colour-flow duplex scanning is the investigation of choice for the diagnosis investigation of choice for the diagnosis and measurement of carotid stenosis, and measurement of carotid stenosis, provided that objective criteria are used, provided that objective criteria are used, by experienced operators.by experienced operators.

The velocities detected should be mentioned in the report as well as whether the percent stenosis reported refers to the angiographic ECST or NASCET method.

Guidelines of ISVI Guidelines of ISVI and ACC- AHA-EVESand ACC- AHA-EVES

Plaque characteristics

Surface ulceration, low GSM (<25), heterogeneous appearance Surface ulceration, low GSM (<25), heterogeneous appearance of the plaque and the juxta-luminal location of the echolucent of the plaque and the juxta-luminal location of the echolucent area after image normalisation are area after image normalisation are ultrasonographic indicators of ultrasonographic indicators of plaque vulnerabilityplaque vulnerability and should be considered in the selection of and should be considered in the selection of appropriate therapy and the frequency of follow upappropriate therapy and the frequency of follow up.

Carotid Stenosis 50% GSM 17

Guidelines of ISVI Guidelines of ISVI and ACC- AHA-EVESand ACC- AHA-EVES

A carotid color flow duplex scanning allows to evaluate in the follow up:

surgical results the restenosis the efficacy of medical treatment

Angio CT/MR allow to evaluate:

Cohexisting aortic arch lesions

Intracranial vessels anatomy

Avoiding angiography

before after

Diffusion-weighted magnetic resonance imaging (DWI) allows a fast evaluation ofISCHEMIC LESIONS

Transcranial color Doppler can be used before CE/CAS to evaluate:

Cohexisting lesions of intracranial vessels Circle of Willis efficiency Intracranial haemodynamic effects of extracranial carotid lesions Cerebrovascular reserve Microembolic events due to ulcerated plaques Crossclamping risk and indication for shunting

INDICATION FOR SURGERY IN ASYMPTOMATIC SUBJECTS OR IN PATIENTS WITH BILATERAL CAROTID LESIONS

Surgical indicationsCE could be better in patients with:

Long multifocal lesions Echolucent plaque Severe ulceration Heavy circumferential calcifications of carotid bifurcation Severe tortuosities Extensive aortic or brachiocephalic trunk lesions

If a clot is suspected

‘91-’93 ’94 ’95 ’96 ’97 ’98 ’99 ’00 -’04 ’05-’07 ys

Carotid surgery without angiography Experience of Dept. of Vascular Surgery – La Sapienza University

(prof. F. Benedetti Valentini – B. Gossetti) 1991-2007AngiographyWithout angiography

100

100

80

60

40

20

%94.5 5.5

79.1 20.964.1 35.9

36.4 63.6

19.1 80.915.0 85.0

10.3 89.78.3 91.7

Abdominal aortic aneurysm

Abdominal aortic aneurysm

Among asymptomatic patients, ultrasound detects the presence of an abdominal aortic aneurysm accurately, riproducibly an at low cost.

Sensitivity and specificity approach 100 %.

Ultrasound is ideal for screening and in determination of aneurysm growth rate.

A growth rate of > 0,7 cm per sex months or 1 cm per years has been suggested as a threshold for proceeding to surgery,

irrespective of size.

Chaikof EJ et al: The care of patients with abdominal aortic aneurysm: the Society for VascularSurgery practice guidelines. J. Vasc. Surg. 2009;50 suppl October: 8S

Morphology:

Endovascular wall thrombus

Ulceration and calcification

“true” vessel lumen

Size and longitudinal extension

Color flow duplex imaging

Color flow duplex imaging

Hemodynamics

Decrease of flow velocity

Color: “mosaic” immaging

Color flow duplex imaging

Acute conditions:

Wall dissection

Wall rupture

Rapid growth

Acute thrombosis

Follow up of endovascular treatment

Position and patency of endograft Diameters and pulsatility of aneurysm Endoleak (sensitivity 81-100 %, specificity

74-99 %) Patency of other vessels Infections Fistulas

Deep venous thrombosis

VTE and symptomsVTE and symptomsEach of these stages of Venous Thromboembolism Each of these stages of Venous Thromboembolism

(calf DVT, proximal(calf DVT, proximal DVT, PE) may or may not be DVT, PE) may or may not be associated withassociated with symptoms.symptoms.

The development of symptoms depends on theThe development of symptoms depends on the extent of thrombosis, the adequacy of collateral extent of thrombosis, the adequacy of collateral vessels, and the severity of associated vascular vessels, and the severity of associated vascular occlusion and inflammation.occlusion and inflammation.

For the diagnosis and monitoring of VTE theFor the diagnosis and monitoring of VTE the clinical findingsclinical findings areare useful but inadequate useful but inadequate (accuracy no more than 30 %).(accuracy no more than 30 %).

DEEP VENOUS THROMBOSIS DEEP VENOUS THROMBOSIS Diagnosis and monitoringDiagnosis and monitoring

CLINICAL DIAGNOSIS: inadequateCLINICAL DIAGNOSIS: inadequate

VENOGRAPHY: gold standard (?)VENOGRAPHY: gold standard (?)

DUPLEX SCANNING: high accuracyDUPLEX SCANNING: high accuracy

COLOR-FLOW IMAGING: NEW GOLD STANDARDCOLOR-FLOW IMAGING: NEW GOLD STANDARD

PLETHYSMOGRAPHY: complementaryPLETHYSMOGRAPHY: complementary (quantitative evaluation)(quantitative evaluation)

Colour Flow Duplex Scanning can Colour Flow Duplex Scanning can provide bothprovide both

morphologic and haemodynamicmorphologic and haemodynamic findings and findings and

represent now arepresent now a quick and non-invasivequick and non-invasive alternative method of diagnosing deep alternative method of diagnosing deep

veinveinthrombosis in the lower limbs.thrombosis in the lower limbs.

Colour Flow Duplex Colour Flow Duplex ScanningScanning

Colour Flow Duplex Colour Flow Duplex ScanningScanning

Colour Flow Duplex Scanning represents a valid Colour Flow Duplex Scanning represents a valid clinical tool, not only for theclinical tool, not only for the initial diagnosisinitial diagnosis of DVT of DVT but also to assessbut also to assess long-term outcomelong-term outcome of thrombus.of thrombus.

This test can guide initial patient management, This test can guide initial patient management, providing information aboutproviding information about clot attachmentclot attachment to the to the vein wall and resolution. vein wall and resolution.

In addition, it can identify those patients with a In addition, it can identify those patients with a potential high risk forpotential high risk for post-thrombotic syndromepost-thrombotic syndrome. .

Finally, CFDS may be used to compare and evaluate Finally, CFDS may be used to compare and evaluate thethe results of different regimensresults of different regimens of anticoagulant of anticoagulant and fibrinolytic drug therapy on theand fibrinolytic drug therapy on the long-term long-term outcomeoutcome of venous thrombi in the lower extremity. of venous thrombi in the lower extremity.

Compression manouvre

Accuracy 100 %

Thrombus “at risk”

CHARACTERISTICS OF THE THROMBI CHARACTERISTICS OF THE THROMBI AND INCIDENCE OF PULMONARY EMBOLISMAND INCIDENCE OF PULMONARY EMBOLISM

(354 patients with DVT -28.5%- out of 1238 cases with suspected (354 patients with DVT -28.5%- out of 1238 cases with suspected

DVT)DVT)

cases PE

- free-floating thrombi: 40 (11,2%) 25 (60.2%) (----> 2 cm)

- “cutted” thrombi: 81 (22.8%) 81 (100%) - “peduncle” thrombi: 5 ( 1,4%) 5 (100%) (free head in venous confluence) - “moving” thrombi: 2 ( 0.5%) 2 (100%) (only fixed base) - adhered thrombi: 226 (63.8%) 35 (15.4%)- adhered thrombi: 226 (63.8%) 35 (15.4%)

WFUMB WFUMB 20002000

LOCALIZATION OF THE THROMBI LOCALIZATION OF THE THROMBI AND INCIDENCE OF PULMONARY EMBOLISMAND INCIDENCE OF PULMONARY EMBOLISM ((354 patients354 patients with DVT -with DVT -28.5%-28.5%- out of 1238 cases with suspected DVT) out of 1238 cases with suspected DVT)

DVT EP % m EP fDVT EP % m EP f EPEP

-iliac+inferior cava v. 35 19 54.2% 24 14 11 5 -iliac+inferior cava v. 35 19 54.2% 24 14 11 5

-femoral+ex. iliac v. 144 52 36.1% 77 32 67 20-femoral+ex. iliac v. 144 52 36.1% 77 32 67 20

-popliteal+femoral v. 107 6-popliteal+femoral v. 107 666 6161..66% 65 40 42 26% 65 40 42 26

-popliteal v. 18 6 33.3% 9 5 9 1 -popliteal v. 18 6 33.3% 9 5 9 1

-gastrocnemious v. 34 4 -gastrocnemious v. 34 4 11.7%11.7% 7 - 32 4 7 - 32 4

-long saphenous v. 16 5 -long saphenous v. 16 5 31.2%31.2% - - 16 5 - - 16 5

Antignani PL, WFUMB, 2000

The presence of an antiphospholipid antibody (lupus anticoagulant or anticardiolipin antibody) is associated with a 2-fold increase in risk of recurrent VTE.

Deficiencies of antithrombin, protein C, and protein S, homozygous factor V Leiden and elevated levels of homocysteine and coagulation factor VIII (> 234 IU/L) have also been associated with higher recurrence rates.

Heterozygous forms of factor V Leiden and the G20210A prothrombin gene mutation confer relatively little increased risk of recurrent VTE.

(Kryle P. et al. N Engl J Med 2000; Eichinger S et al. Thromb Haemost.1999; Miles JS et al. J Am Coll Cardiol. 2001; Simioni P et al. Blood 2000)

Monitoring of coagulative factors

Risk of Recurrent VTERisk of Recurrent VTE

Risk of recurrent VTERisk of recurrent VTE Although not predictive of the location of thrombosis, Although not predictive of the location of thrombosis,

the risk ofthe risk of recurrencerecurrence is greater when anticoagulants is greater when anticoagulants are stoppedare stopped while there is still evidence of residual while there is still evidence of residual DVT on ultrasound imagingDVT on ultrasound imaging..

Recurrent DVT may be caused by a disturbed balance Recurrent DVT may be caused by a disturbed balance between propagation and thrombus regression.between propagation and thrombus regression.

Recurrent DVT was reported inRecurrent DVT was reported in 17%17% of the patients of the patients after 2 years.after 2 years.

(Kearon C. (Kearon C. Clin Chest Med. Clin Chest Med. 2003; Heit JA et al. 2003; Heit JA et al. Arch Intern Med. Arch Intern Med. 2000)2000)

Monitoring with ultrasoundMonitoring with ultrasound

AboutAbout 60 %60 % of patients with the history at one of patients with the history at one episode of proximal deep vein thrombosis develop episode of proximal deep vein thrombosis develop post-thrombotic syndromepost-thrombotic syndrome within two yearswithin two years. .

Compression stockings have reduced this rate by Compression stockings have reduced this rate by aboutabout 50 %.50 %.

The post-thrombotic syndrome is strongly related The post-thrombotic syndrome is strongly related to recurrent ipsilateral deep vein thrombosis.to recurrent ipsilateral deep vein thrombosis.

monitoring of deep venous system with monitoring of deep venous system with ultrasound ultrasound

Post-thrombotic syndrome after Post-thrombotic syndrome after DVTDVT

Post thrombotic syndromePost thrombotic syndromeInstrumental evaluationInstrumental evaluation

The pathophysiology of PTS is not entirely The pathophysiology of PTS is not entirely understood. understood.

Factors that are probably important in the Factors that are probably important in the development of PTS are venous reflux, deep vein development of PTS are venous reflux, deep vein obstruction and calf muscle pump dysfunction. obstruction and calf muscle pump dysfunction.

The presence and location of The presence and location of venous reflux and obstruction venous reflux and obstruction can be measured withcan be measured with ultrasoundultrasound with high accuracywith high accuracy..

Differential diagnosis

Venous popliteal aneurysm

Neoplasia in inferior cava vein

Superficial venous thrombosis

Superficial venous thrombosisExtension and involvement

Clinical assessment underestimates the thrombus

Superficial venous thrombosis

…is estimated like a thrombus on risk if its distance from SF-J is 2 cm (guidelines by Italian Society for Vascular Investigation - 2007): Treatment of SVT as DVT.

Murgia AP et al: Int Angiol. 1999 Dec;18(4):343-7.

Surgical management of ascending saphenous thrombophlebitis.METHODS: We retrospectively reviewed 146 patients referred to our Vascular Laboratory for acute superficial thrombophlebitis from 1987 to 1997. Duplex scanning identified 85 cases of superficial thrombophlebitis involving at least a segment of the saphenous vein localized below the knee (58.2%); 37 of thrombophlebitis extending into both the superficial and deep venous systems (25.3%) and 24 of saphenous thrombosis extending to within 5 cm of the saphenofemoral junction (16.4%). The latter group underwent saphenofemoral disconnection.

CONCLUSIONS: Duplex scanning showed 100% accuracy both in determining the presence of thrombosis and its

extent. Saphenofemoral disconnection for thrombosis involving the

saphenofemoral junction is a safe procedure and can be performed on an outpatient

basis.

Deep venous thrombosis after radiofrequency ablation of greater saphenous vein: a word of caution.

Hingorani AP et al.

PURPOSE: Radiofrequency ablation (RFA) of the greater saphenous vein (GSV; "closure") ………potentially lethal complication, deep venous thrombosis (DVT).

Seventy-three lower extremities were treated…. All patients underwent venous duplex ultrasound scanning 2 to 30 days (mean, 10 +/- 6 days) after the procedure

The duplex scanning documented occlusion of the GSV in 70 limbs (96%). In addition, DVT was found in 12 limbs (16%). None of these patients had pulmonary embolism.

Early postoperative duplex scanning are essential, and should be mandatory in all patients undergoing RFA of the GSV.

Endovenous laser therapy and radiofrequency ablation of the great saphenous vein: analysis of early efficacy and complications. Puggioni A et al. J Vasc Surg. 2005 Sep;42(3):488-93.

Between June 1, 2001, and June 25, 2004, endovenous GSV ablation was performed on 130 limbs in 92 patients. RFA was the procedure of choice in 53 limbs over the first 24-month period of the study Routine postoperative duplex scanning was initiated at our institution only after recent publications reported thrombotic complications following RFA Thrombus protruded into the lumen of the CFV in three limbs (2.3%) after EVLT. One received a temporary inferior vena cava filter because of a floating thrombus in the CFV. No cases of pulmonary embolism occurred.

…we recommend early duplex scanning in all patients after endovenous saphenous ablations.

Venous disorders: treatment with foam sclerotherapy.

Bergan J at al

DVT (1.8%) was limited to gastrocnemius veins (3 cases) and posterior tibial veins (3 veins).

No pulmonary emboli or lung complications occurred.

CONCLUSIONS: Treatment of a variety of venous disorders can be accomplished using foam sclerotherapy with results comparable to surgery and with an acceptably low rate of adverse events.

These results, however, must be confirmed by larger experience in other institutions.

This report describes initial experience in treating 332 patients

Chronic venous insufficiency

• Pre-operative evaluation is best performed by means of duplex scanning and physical examination.

• Duplex scanning for venous insufficiency is simple and cost-effective.

• Duplex mapping defines individual patient anatomy with considerable precision and provides valuable information that supplements the physician's clinical impression.

Introduction

Pre surgical Duplex mapping

The superiority of duplex ultrasound scanning over clinicalexamination for presurgical mapping has been well documented.

Although ultrasound determinations of reflux at the junctions and

at specific locations above and below the knee may be adequate for

diagnosis and epidemiologic studies, pre-operative mapping mustinclude the entire length of the saphenous veins.

Such mapping may lead to selective surgical treatment and avoidance of complications related to extensive surgery.

Ultrasound mapping provides an opportunity forconservative ligation and perhaps sclerotherapy oftributary and perforating veins acting as the mainsource of reflux.

Such procedures could be performed under ultrasound guidance in an outpatient setting.

Pre-surgical Duplex mapping

Examination The examination consists of

interrogating specific points of reflux with the patient standing.

Forward flow is produced with muscular compression, and reverse flow is then assessed in the crucial areas that are important to operative planning.

The patient is placed in an upright position so that the leg veins are maximally dilated.

Engelhorn CA; J Vasc Surg 2005

Pattern of great saphenous vein

Pattern of small saphenous vein

Engelhorn CA; J Vasc Surg 2005

Prevalence of patterns of saphenous vein reflux

Engelhorn CA; J Vasc Surg 2005

Goals of treatment

Three principal goals must be kept in mind in planning treatment of varicose veins:

The varicosities must be permanently removed and the underlying cause of venous hypertension treated.

The repair must be done in as cosmetic a fashion as possible.

Complications must be minimized.

Guidelines of Italian College of Phlebology

The aim of varicose vein surgery is to relieve the symptoms, and prevent or treat any complications while recognising that the varicose disorder is likely to be progressive.

“Inadequate” venous surgery is sometimes the main reason for post-surgical recurrences despite a good surgical technique.

There are valid medical alternatives and sclerotherapy, for collateral veins, which therefore do not necessarily call for a surgical approach.

Int Angiol 2003

Ablative surgery Complete and resolutive treatment

Stripping Crossectomy Phlebectomy

“Before any decision is taken on which technique is indicated, a detailed color flow duplex study should be done to avoid diagnostic errors”

Conservative surgery

Sapheno-femoral external valvuloplasty

CHIVA type 1 e 2 hemodynamic correction

Crossectomy Duplex mapping is mandatory

Conservative surgery External valvuloplasty of the terminal and/or

subterminal valve of the great saphenous vein, after thorough preoperative assessment, and with careful intraoperative checks, is a good way to treat saphenous reflux in 5-8% of patients.

CHIVA 2 should not be used for saphenous veins with a caliber of more than 10 mm at the thigh, especially if the segment below the origin of the collaterals shows aplasia or hypoplasia, so as to limit the risk of saphenous thrombosis at the open cross.

ICP Guidelines. Int Angiol 2003

Mini invasive treatment

An increasingly popular alternative to traditional surgical stripping of the GSV for management of saphenous vein reflux is endovenous ablation (EVA) of that vein using laser energy, radiofrequency generated thermal energy or a chemical sclerosant.

In all of these treatment the color flow duplex examination represents the basis and it is a “part” of method.

Endovascular obliteration

Endovenous Laser - ELVT Radio frequency - VNUS Closure Foam ultrasound-guided sclerotherapy

Before Laser After 1 week After 6 months

Endovenous Laser treatmentPre-operative, a Duplex scanning is performed in theupright standing position to map incompetent

sourcesOf venous reflux and then to mark the skin overlying The incompetent portion of the GSV starting at the SFJ.

After venous duplex mapping a percutaneous entrypoint is chosen.

This point may be where reflux is no longer seen or where the GSV becomes too small to access (usuallyjust above or below knee level).

Endovenous treatment

Potential candidates for EVA include patients with reflux in an incompetent GSV or SSV or in a major tributary branch of the GSV or SSV such as the anterior thigh circumflex vein, posterior thigh circumflex vein, or anterior accessory GSV.

Therefore, the presence of reflux in these veins is important to document using duplex ultrasound imaging, as pertaining to the CEAP A5 nonsaphenous category.

Endovenous treatment

Variations to standard venous anatomy, when observedon the ultrasound examination, should be reported.

These include tortuosity of the target vein, duplications, atresia, the presence of anatomic venous variants, or variable termination of the SSV.

The diameter of the GSV and SSV, <= 2 cm of the junction with the deep vein (common femoral or popliteal) and target vein (if not the GSV or SSV) should be measured.

Endovascular methods

Neither of endovascular obliterative procedures is validated as yet for long follow-up in the literature but these methods were proven to be less aggressive and effective at mid-term.

They must therefore be considered as still in the clinical validation stage, and as such only used in accredited, qualified phlebology centers, after the necessary learning period.

ICP Guidelines. Int Angiol 2003

What surgery ?

Actually, there are not defined the hemodynamic specific patterns for each conservative surgical treatment.

End point: Mini-invasivity Optimal long-term results

Evolution of technique and methods

Recurrent varicose veins

“These are varicose veins that appear after surgical treatment, not the remains of the treated veins”.

The most frequent causes of recurrences are:

Errors of diagnostic strategy and treatment

Technical errors

Recurrent varicose veins “Radical surgery", defined as physical

extraction of the saphenous vein with all its collaterals and all the enlarged varices, which has been the surgical procedure of choice for varicose veins for almost a century, has been replaced by a "radical hemodynamic approach", meaning elimination of the hemodynamic defects at the root of the formation of the varices (the reflux).

Among the reasons leading to errors during surgery for varices in the legs, certainly the most important is the wide anatomical variety of the sapheno-femoral junction, and, moreover, of the sapheno-popliteal juncgtion, which can lead to the surgeon sometimes inadvertently leaving collaterals in place.

Recurrent varicose veins

A "map" of the varicose veins and circulation defects of the lower limbs is used in CHIVA interventions and "traditional" surgical procedures.

Incorrect application of these concepts, especially on an anatomical basis, can leave the way open to recurrences.

Conclusion After treatment, we have to control the patient by

means of duplex ultrasound at 1st week, at 1st month and every sex months for 1 year.

We have to know well the type of treatment for evaluating the results.

ConclusionThe most important factor in determining a

good treatment outcome is making an accurate diagnosis.

Recognizing common clinical patterns of venous insufficiency is important, but with duplex US now readily available to many providers, direct visualization and mapping of venous pathways is possible.

This will ensure not only complete treatment of all of the abnormal venous segments but preservation of normal veins.

Thank you for your attention !!

In the evaluation of chronic venous insufficiency such as in the other reported conditions, the duplex examination have modified the therapeutical approach.