venous investigations - vaivenous.in/presentationtalk/dr ravul jindal.pdf · venous investigations...
TRANSCRIPT
Venous investigations
Dr Ravul jindal MS FRCS DNB FVSI
Director vascular surgery
Vice President Venous Association of India
Fortis Hospital
Mohali
www.indianvascularsurgery.com
Is pre-op duplex
assessment
important for
varicose vein
surgery?
Ultrasonic assessment
Explanation
Information provided by DS will have significant
impact on the selection of appropriate treatment
Failure to identify all sources of venous filling is
likely to result in early recurrence
Indications for Duplex Scan
Recommendation: both limbs should be studied
Primary uncomplicated GSV VVs
Debated whether all pts – if not 30% of important connections between deep
and superficial veins will be missed
Primary uncomplicated LSV VVs Essential
Non-saphenous & Recurrent VVs Essential
CVD with complications Essential
Surveillance after treatment the only way to obtain level I
evidence as to outcome in the future
Venous malformations
anatomical information about the extent of the malformation and its
relationship to other vessels
may be used to guide treatment by sclerotherapy
Position of the patient
Greater saphenous
Position of the patient Lesser saphenous
Anatomy of superficial veins of the
lower limb
Anatomical structures on B-mode
Images courtesy of Olivier Pichot, MD
Fascial layers creating “saphenous eye”
GSV
Bound anteriorly by superficial fascia &
posteriorly by deep fascia
Often called “saphenous eye”
Tortuosity Side branches
GSV Variables
Images courtesy of Olivier Pichot, MD
SFJ Tributary Veins
SCI: Superficial Circumflex Iliac
SE: Superficial Epigastric
SEP: Superficial External Pudendal
AASV: Anterior Accessory
Saphenous
PASV: Posterior Accessory
Saphenous
Image adapted from: Chandler JG et al. Defining the role of extended saphenofemoral junction ligation: A
prospective comparative study. JVS 2000;32:941-53
Final Tip Position Verification
◦ In both transverse and
longitudinal imaging planes
◦ Use measurement calipers to
confirm distance to SFJ
Important step to avoid
misaligning catheter
relative to deep venous
system
Recommendation is 2.0 cm distal to SFJ
Confirm tip position with ultrasound:
Image courtesy of Pranay Ramdev, MD
GSV Before Treatment
Image courtesy of Olivier Pichot, MD, CHU de Grenoble, France.
Image courtesy of Olivier Pichot, MD, CHU de Grenoble, France.
GSV After Treatment
Small Saphenous Vein (SSV)
Courses from lateral ankle up
posterior calf
Terminates in popliteal fossa at
Saphenopopliteal Junction (SPJ)
◦ Variable confluence with Popliteal Vein
(PV)
◦ Proximal portion lies between superficial
& deep fascial layers
SSV
SPJ
Pop V
Figure adapted from: Weiss RA, et al eds. Vein diagnosis and treatment: A comprehensive approach. McGraw-Hill Companies, Inc.; 2001.
Detection of reflux on colour facility
The aim of ablation procedures is to damage the inner
vein wall without causing a full-thickness burn, which
could lead to perforation of the vein resulting in bruising
or haematoma formation
If vein lies superficially, close to skin the ablation
may cause burn
Vein depth from the skin: Why is so
important?
Vein Mapping Make indentions in skin using a straw
Remove US gel from leg
Connect marks on leg with marker to identify
pathway of vein and important anatomy
Image courtesy of Nick Morrison, MD
Selective descending ovarian and hypogastric venogram
Significant ovarian vein reflux but
No hypogastric vein reflux was detected
Hypogastric vein reflux Ovarian vein reflux
Descending Ovarian Venogram 4 weeks after
embolisation
CT venography
Chronic Venous Obstruction
DP=22 mmHg DP=8 mmHg
DP=2 mmHg
Thank you for your attention