Vein mapping/Venous Insufficiency
GSV mapping techniques
-Begin at SFJ -Follow GSV and see where it goes -Sagittal - keep perpendicular to vein, stretched out on screen -Transverse - keep veins circular and centered on screen, Watch pressure so you don't compress -Document diameter - prox mid dist in thigh and calf - don't include walls inner to inner -Mark every 2-3 cm -Document tributaries in trans - mark where they terminate -Connect dots
SSV mapping techniques
-Begin at SPJ -Mark every 2-3 cm to the ankle -Same process as GSV
Angle sign
-Below the knee; triangle is formed by tibia, GSV, gastrocnemius vein (helps to differentiate the saphenous veins from tributaries)
Ways to treat valvular insufficiency
-Chemical ablation: put chemical/foam in and scrape it/burn it inside to break down the -Thermal ablation: use a laser to clot off the effected valve -Stripping: taking out the faulty vein -Ligation: tying off the faulty vein above the faulty valve -Phlebectomy: remove small veins near the skin
A stenotic valve will display these US characteristics...
-Color aliasing -Bright protruding leaflet seen unmoving in the vessel lumen -Elevated velocities in the area of the valve
Perforating veins:
-Connects superficial veins to deep veins -Come up through the muscular fascia to join the great saphenous vein -Must be ligated and identified
Spectral waveform with normal veins during and after Valsalva
-During Valsalva the flow stops -After the flow will return to normal
Spectral waveform with CVVI during and after Valsalva
-During Valsalva the spectral waveform will be above the baseline -After Valsalva it will return to normal
Cephalic/Basilic Mapping techniques
-Follow basilic from axillary to wrist -Follow cephalic from upper arm to subclavian, then down to wrist -Make marks every 2 to 3 cm like with legs -Document connections with the medial cubital vein connect dots -Document size of both
Significant reflux (CVVI) findings
-Gray scale: vein diameter enlarged, valve sinus enlarged, toruosity, varicosities, venous aneurysms -Spectral Doppler: saphenous veins and tributaries = retrograde flow greater than 500ms; deep veins = retrograde flow greater than 1 sec; perforating veins = retrograde flow greater than .35sec (35ms) -Color Doppler: retrograde color flow, turbulent/multiple color patterns seen within valves sinuses
Technical settings for mapping
-High freq: 10-12MHz -Doppler not used - use if patency is in question (low PRF, high gain) -Watch pressure
3 things that the presence of small vessels with arterial, venous or fistula-like flow near an obstructed vein may represent...
-Inflammation -Neovascularization -Recanalization
What are the tributaries of the main trunk of the great saphenous vein in the thigh?
-Intersaphenous vein -Posterior accessory saphenous vein -Anterior accessory saphenous vein
General Venous mapping techiniques
-Markers - make dots/ marks -Straws - make indentions
Chronic venous valvular insufficiency causes
-Most don't have a venous obstruction -Associated reflux (due to valves not closing all the way) -Associated prolapse -Varicose veins
How to measure reflux
-Must show flow return to baseline - decrease sweep speed in order to see more of the reflux
Superficial external pudendal & superficial circumflex iliacs
-Other 2 tributaries in GSV between terminal and pre-terminal veins -May be other most prox source for GSV reflux
Preoperative US assessment tells what about the veins
-Patency -Position -Depth -Size
Purpose of valvular insufficiency exam
-Rule out obstruction in deep veins (acute thrombus) -Evaluate insufficiency or reflux
Saphenous vein is in the __________ compartment
-Saphenous compartment (superficial fascia and muscular fascia)
US follow-up post thermal ablation of the saphenous vein may show what 3 things...
-Segmental recanalization -Segmental thrombosis -Segmental fibrosis
Synchronization of venous return in the legs
-Skin to tributaries to saphenous veins (GSV/SSV) to perforating veins to deep veins to the heart
SEV
-Superficial epigastric vein: tributary that lies between the terminal and preterminal valve in GSV (landmark for thermal ablation treatment)
Basilic vein anatomy
-Superficial vein in the arm, begins at wrist along the medial forearm and arm, joins with brachial veins to form axillary -Used for dialysis fistulas
Proximal GSV valves
-Terminal: at the junction of SFV -Pretermial: distal to tributaries that join the GSV at that junction (lie in-between terminal and preterminal valves)
What are 3 things concerning the technique of vein mapping?
-Transducer should be perpendicular to the skin -Light transducer pressure should be used -When in longitudinal view, vein should completely fill the screen from left to right
Air plethysmography
-Used to quantify the insufficiency -Measures venous volume and the amount of blood in the vein -If there's a greater volume in there then the blood has refluxed down into that segment
Venous disorders
-Varicosities: dilated, tortuous portions of the saphenous system -Thrombus: acute/chronic, occlusive/non-occlusive -Recanalization: previously thrombosed vein with irregular intimal surface or wall thickening -Calcification: diffuse/focal, diabetes
What happens after treatment for CVVI
-Vein closes off after treatment (this provides relief of symptoms and prevents pooling of blood) -Can have no flow right away or it will eventually stop -Follow up US done to check for recanalization
Venous air plethysmography measures what 5 things?
-Venous volume -Filling time -Filling rate -Residual volume -Ejection fraction
Suitability of veins include
-Wall status: smooth, thin, compressible, valves moving -Planar arrangements: how they are laid out (hard to find?) -Diameter: vessel size (less than 2mm is too small for surgery)
The small saphenous vein may terminate in what 6 places...
1. Popliteal vein at SPJ 2. Gastrocnemius vein 3. The great saphenous vein via the vein of Giacomini 4. The distal femoral vein 5. Perforating vein at posterior thigh 6. Small unnamed deep vein
In what percentage of patients does the small saphenous vein have a significant segment which continues above the popliteal fossa?
20%
How many configurations of the great saphenous vein have been categorized in the thigh?
5
In what percentage of patients is the calf portion of the great saphenous vein a single dominant system?
65%
The small saphenous vein may communicate with the gastrocnemius veins via...
A perforating vein
What is an alternative to the Valsalva maneuver?
An automatic cuff compression device
GSV is commonly used for:
Cabbage procedure
GSV variation:
Can have accessory - won't be in the fascia provide measurements of both to determine which is larger
SSV variant
Can terminate above the Pop V at the FV
Classification of CVVI
Clinical, Etiologic, Anatomical, Pathophysiological (CEAP)
Dialysis fistula:
Connects the artery and deep vein for dialysis
Reflux is more commonly found in the ______
GSV
Primarily used veins in the legs for bypass grafts
GSV SSV
Patient positioning for venous mapping
GSV - positioned like DVT study SSV - have the patient roll out on their side some to access the posterior calf the best Keep room warm and patient covered For the arm - keep arm below chest level
GSV is located where
In the saphenous compartment - fascia that appear echogenic around the GSV (superficial fascia and muscular fascia)
Valve number _______ the _________ away from the heart
Increases; farther
Indications for a vein mapping US
Info to surgeons for bypass grafts/ dialysis fistulas
A recanalized vein will have what appearance on US?
Irregular wall surface and wall thickening
Hardening of the skin is known as...
Lipodermatosclerosis
Differential diagnosis that could cause edema
Lymphatic obstruction, edema related to cardiac disease, arterial disease, sympathetic tone, lipid disorders (lipedema)
What vein communicates between the cephalic and basilic vein at antecubital fossa?
Median Cubital Vein
Valves _____ with contraction ________ with relaxation
Open; close
Why is tourniquet used and what is it used with
Photoplethysmography: tourniquet can be used to compress superficial veins (if reflux is still present then it indicates there is reflux in the deep veins. If no reflux is detected, then it indicates there is insufficiency in the superficial veins)
We can detect ________ information with color Doppler
Qualitative
A major advantage of the use of an automatic compression device is...
Reproducibility and standardization
Incompetent valves permit
Retrograde flow
Small saphenous normal anatomy
Single trunk, forms at achilles up the middle of the posterior calf to the pop vein
Anatomical configuration of GSV
Single trunk, originates near medial malleolous, anterior to tibia, medially along the thigh, dumps into CFV
Clinical symptoms/signs of valvular incompetance
Skin changes (localized redness atrophie blanche, corona phlebectatica, hardening of the skin), ulcers, edema, varicose veins, spider veins, telangiectasias (red webs of veins) reticular veins (blue/purple veins) phlebedema- type of edema-temporary edema aching, tension, restless leg, tingling, fatigue, muscle cramps, pain, burning, itching
Cephalic vein anatomy
Superficial vein in the arm, begins at wrist along the lateral forearm and arm, terminates into subclavian v used for dialysis fistulas
Cutaneous tributaries:
Superficial, smaller not as clinically significant either ligated or left to thrombose can be harvested for use of a patch
Describe the alignment sign...
The anterior accessory saphenous is aligned above the femoral artery and vein
Tributaries of the great saphenous vein are best identified in what scan plane?
Transverse
Photoplethysmography
Used to detect reflux- can't tell exactly where it is like US can
Valvular insufficiency aka.....
Valvular incompetence
Venous photoplethysmography is performed to measure...
Venous recovery time
Primary basis for the CEAP clinical classification
Visual signs
Valvular insufficiency and augmentation
Will go below the baseline and then above for a period of time and then return - the amount of time it is above is the amount of reflux, the longer it is the more severe the reflux
