Venous procedures and treatment

Treatment for superficial venous thrombosis

Conservative treatment methods usually suffice

Apply a warm compress to the vein

Elevate legs when seated

Ambulation

Ibuprofen or other non-steroidal anti-inflammatory drug

If the thrombus extends into the deep system, more aggressive treatment is required

Acute DVT treatment

Subcutaneous shot of Lovenox immediately

Heparin administered for 5-10 days to stop the progression of the clot, but does not have clot lysing properties to decrease the clot that has already formed

After heparin dosage completed and recanalization has occurred, warfarin is administered to prevent future clot formation

First DVT occurrence - Coumadin or Warfarin prescribed for 3 months

Xarelto and Eliquis are two newer medications that may be used to treat DVT instead of Coumadin or Warfarin

Calf vein DVT was formerly treated conservatively with leg elevation and warm compresses; new recommendations call for 4 weeks of low dose heparin treatment

Systemic thrombolysis

Significant DVT ,ay be treated with a lytic agent such as streptokinase

The clot-busting benefits of the medication must outweigh the risk for other bleeding complications caused by lytic agents

Catheter directed thrombolysis

Refers to the delivery of the lytic agent directly to the site of thrombus using an intravenous catheter

This method offers improved clot resolution and decreased risk of hemorrhage compared to standard systemic therapy

Percutaneous mechanical thrombectomy

Catheter used to deliver thrombolytic drugs directly to the area of thrombus

The “jets” of flow of the lytic drug help to break up the thrombus as the catheter is advanced within the vein

The catheter also has a suction function that retrieves the particles of thrombis

Some physicians may place a Greenfield filter in the IVC before the procedure

This method offers immediate improvement of symptoms, decreased treatment times, and reduced incidence of post-thrombotic syndrome when compared to standard systemic thrombolysis

Venous thrombectomy

Open surgical procedure where thrombus is manually extracted

Used in pts with phlegmasia alba folens and phlegmasia cerulean dolens

Also used for pts that cannot undergo lytic therapy

Performed to correct ilio-femoral vein stenosis

Persistent chronic thrombosis treatment

Warfarin or Coumadin administered as oral medication for up to 6 months post diagnosis; both interfere with clot formation, DO NOT lyse current clot just prevent more from forming

Greenfield filter

Most commonly inserted through the femoral vein or IJV, but subclavian vein may also be used

Usually made of stainless steel, titanium or nitinol

Umbrella-like device that is anchored into the IVC below the level of the renal veins

Designed to prevent embolism from the legs from reaching the lungs

Used in pts that have Hx of multiple DVT formation or PE and those cannot maintain the necessary coagulation therapy

Venous stent

Most commonly used to treat chronic iliocaval venous obstruction and May-Thurners

IV catheter used to evaluate the pressure in the IVC and in the iliac vein

>2mmHg difference indicates significant venous stenosis is present

IV balloon catheter used to deploy the stent and the balloon is inflated to open the vessel and expand the stent into place

Can also be placed during a percutaneous mechanical thrombectomy

Intravenous ultrasound can be used to assess the stenosis in the vein prior to the procedure

2D and Doppler evaluation should be performed to assess patency of the graft
Much lower incidence of thrombosis and stenosis of the graft than arterial BPG

Venous BPG

used to treat ilio-femoral venous obstruction

Performed on pts that cannot be stented, have a Hx of stent failure or lengthy areas of occlusion

Femoral-Femoral graft

Ilio-caval graft

Saphenous vein can be used as an autogenous graft but it must be unaffected by disease and of adequate size

Best results are seen with PTFE graft

2D and Doppler eval should be performed to assess patency of the graft

Much lower incidence of thrombosis and stenosis of the graft than arterial BPG

Insufficiency treatment

Conservation therapy - compression stockings, avoid high heel shoes, elevate the legs and exercise in mild cases

Eval the venous outflow system of a pt prior to removal or closure of saphenous vein

Sclerotherapy

Injection of saline or other sclerosing agent that damages the vein and causes fibrosis to occur to occlude vein

Does not require use of sterile technique

Contraindications include allergy to the injectate, pregnancy, lactation, hypercoagulability

Cardiovascular activities are encouraged after the procedure, but activities that involve the Valsalva maneuver are discouraged

Endovenous radiofrequency ablation

Can be used to avoid surgical intervention in some cases

Catheter based radiofrequency application can cause fibrosis and occlude the vessels leading to overall atrophy of the vessels

Sterile technique required

GSV MOST COMMONLY TREATED VEIN

SSV, anterior and posterior saphenous veins can also be treated with this method

Room should be kept warm

Pt will be in trendelenburg position

1cm ring of anesthetic medicine should surround the vein

Endovenous laser ablation

Catheter based application that uses laser or high frequency light to close varicosities

Sterile technique required

Causes endoluminal fibrosis and constriction of the vein

Occludes venous flow in the vessel and is intended to occlude tributaries and perforators attached to treated vessels

Procedure and complications are the same as an RF ablation

Post-ablation complications

Mispositioning of the thermal device into the deep system

Acquired AVF caused by puncture of groin

Endovenous heat-induced thrombosis

DVT

PE

Nerve injury

Cutaneous burn

External laser ablation

Laser to reduce the appearance of telangiectasia

Closes small dilated blood vessels near the surface of the skin or mucous membranes (spider veins)

Microphlebectomy

AKA stab phlebectomy

Performed for varicosities that are too large for sclerotherapy and too small for RF ablation

Before the procedure, the pt should remain standing for a minimum of 5-10 mins to ensure maximum distension of any superficial veins

Small incision is made in the leg to remove the vein; requires sterile technique

Complications include localized nerve damage in the skin, bruising and pain

Differs from vein stripping because the sutures are small and do not require stitches

Vein ligation

Remove affected portion and all superficial varicosities to prevent reoccurrence

GSV MOST COMMON SITE OF LIGATION

High ligation - removal of proximal GSV at saphenofemoral junction or SSV at the saphenopopliteal junction performed to correct gravitational reflux while preserving remaining vein for potential arterial bypass graft

Has greatest risk of varicosity recurrence and neovascularization of all treatment types

Not commonly performed today

Pre-procedure vein mapping

Confirms presence, location and adequacy of a vessel for coronary artery BPG or extremity arterial bypass

>3mm diameter preferred

Confirm thin walls and flexibility

Place extremity in dependent position

Central venous catheter placement

Often used when peripheral IV access is not an option, or when large volumes of fluid or medications are required

Used in the care of critically ill patients, patients requiring intravenous antibiotic therapy, central venous pressure monitoring and sampling, hemodialysis, chemotherapy and total parenteral nutrition

Peripherally inserted central catheters of PICC lines are usually inserted into the basilic, brachial or cephalic vein and advanced to the SVC

Central venous catheters are generally inserted through the IJ or subclavian veins

A complete and detailed assessment prior to device placement is ciritcal for the physician to select the right device and place it in the right location for the right therapy

USA PICC line

The normal catheter will be demonstrated by two parallel echogenic lines

If there are multiple lumens, there will be multiple pairs of echogenic lines

Thrombus formation appears appears as echogenic material on surface of the catheter

Thrombus may progress and fill the lumen of the vein

Which of the following is used as immediate treatment for an acute DVT

Compression stockings

Lovenox shots

Coumadin administration

Warfarin administration

Lovenox shots

What can be treated with streptokinase?

Phlegmasia cerulea dolens

Invasive procedures used to remove thrombus are typically reserved for pts with:

Phlegmasia cerulea dolens

Most common indication for a venous stent is:

May Thurner syndrome

What is part of the sonographer’s responsibilities when assisting with an endovenous ablation?

Review pt records an US images to confirm the diagnosis and the leg that will be treated

What is a contraindication for an endovenous ablation

Uncooperative pt

Which of the following is a contraindication for endovenous laser ablation of the GSV

Chronic obstruction of the femoral vein

At the start of an endovenous ablation procedure for the GSV, the catheter is inserted _____________ and advanced to a position ____________ before activating the device

Into the distal GSV; 2cm distal to the saphenofemoral junction

What is a difference between endovenous ablation of the GSV and of the SSV

At the start of the procedure, the pt is placed in supine position for the GSV treatment and in the prone position for the SSV treatment

What is the preferred pt position during retraction in an endovenous laser ablation treatment?

Trendelenburg

What is the preferred pt position during catheter retraction in an endovenous laser ablation treatment?

Trendelenburg

A pt presents for a follow up exam after radiofrequency ablation of the GSV. What is the purpose of the exam?

To confirm the contraction of the GSV and absence of thrombus in the deep system

Endovenous heat-induced thrombosis is a complication of:

Radiofrequency ablation

Which of the following correctly describes a pre-procedure vein mapping?

The diameter of the vein is usually written on the arm/leg at the location it was taken

In most pts with a central venous catheter the tip of the catheter is positioned in the:

Distal 1/3 of the SVC

A normal sonographic appearance of a longitudinal view of an intravenous catheter is:

Parallel linear echogenicitys