Insufficiency venous evaluation

Venous insufficiency

Chronic swelling of the lower legs and ankles (NOT FEET), brawny discoloration of the gaiter zone, visible spider veins, palpable varicosities

Most common complication of DVT

Venous insufficiency

Most common venous disease of the extremities

Venous insufficiency

Most commonly occurs at the SFJ at the groin

Venous insufficiency

Varicosities are most commonly tributaries of …

GSV

Primary Venous insufficiency

Most common type

Incompetent valves in the superficial system

Intact deep venous system

Pregnancy and obesity will increase the risk of developing varicose veins

Oral contraceptives increase the risk of varicose vein formation

Can be hereditary

More common in females

Secondary Venous insufficiency

Incompetence of the superficial system caused by an obstructed or incompetent deep system

In a normal pt, muscle contraction causes the deep veins to empty as the flow moves ________ the heart and the pressure in the deep system DROPS

Towards

Pressure in the superficial system should _________ during muscle contraction as flow moves through the perforators and increase as the muscle relaxes and reduces outflow in the perforators

Decrease

The drop in pressure allows for normal flow from…

Superficial veins to deep veins

The smaller drop in pressure decreases….

The pressure gradient across the perforators and limits superficial system outflow

Incompetent perforators allow for ….

Flow from the deep system into the superficial system with muscle contraction

With a chronic increase in deep system pressure, the superficial system will also __________ and valves become for ineffective at managing proper flow direction

Dilate

Venous HTN

Venous pressure is significantly increased with standing

Calf muscle pumps blood in all directions and is ineffective for reducing venous pressure in the calf

Edema, hyperpigmentation and ulceration occur

Signs and symptoms of venous insufficiency

Edema, tightness of skin, skin irritation, eczema

Stasis dermatitis (common inflammatory skin disease, usually earliest cutaneous sequela of chronic venous insufficiency with venous HTN, causes discoloration of ankle and calf)

Hyperpigmentation (brawny discoloration of the distal 1/3rd of the calf → GAITER ZONE)

Heaviness in legs, muscle cramps, swelling of calf (not ankle), aching pain after standing/sitting with legs dependent, walking relieves symptoms

Varicosities (telangiectasia, spider veins, varicose veins)

Venous claudication results in

Severe cramping and burning feeling in the legs with exercise that is relieved by elevating the legs

Ulcer formation

Wet ulcers

• Medial ankle - GSV disease

• Lateral ankle - SSV disease

Risk factors of Venous insufficiency

Female, pregnancy, oral contraceptive use, age, obesity, family Hx, personal Hx of DVT, job that requires standing

If the valve immediately distal to the probe is incompetent…

Flow reversal will be noted with the compression during proximal augmentation

Perforator diameter >____ = incompetent

4mm

2D eval for Venous insufficiency

Eval the deep veins for thrombosis and reflux

Measure the inner to inner wall diameter of the vessels

The saphenous veins lie between the deep and superficial fascia of the leg

AASV and vein of Giacomini are usually easily identified and can be assessed for size and reflux

Color Doppler eval for Venous insufficiency

Helpful for evaluating multiple veins in the same view

Helps identify the presence and timing of the reflux to identify recirculating reflux

Minimum of 30 secs between each augment

Manual compression, valsalva or cuff inflator used

Rapid cuff inflator

Provides consistent augment for each vessel

Most reproducible and consistent results

Cuff placed distal to the area of interest

Cuff pressure varies with hydrostatic pressure and is applies quickly, held for a few seconds and released quickly

Reversal of flow is assessed after release of the augmentation compression

Normal vein response to distal augmentation

Increase in flow toward the heart with no retrograde flow before flow normalizes

Abnormal vein response from distal augmentation

Increase in flow towards the heart, then retrograde flow occurring towards the feet

Abnormal reflux times

Deep veins - >1.0 seconds

Superficial veins - >0.5s

Perf veins - >0.5s

Normal venous response from prox augmentation

Venous flow ceases at onset of the Valsalva/compression with NO flow reversal

Abnormal venous response to prox augmentation

Venous flow reversal occurs at the onset of Valsalva maneuver or compression

False negatives for Venous insufficiency exam

Pt evaluated in supine position

Partial obstruction

Collateralization

Paired veins

Duplicated venous system

Post-Ablation US

Venous occlusion with internal echogenicity and incompressibility should be seen within days of the procedure

Eval treated veins and deep veins with US immediately after treatment to confirm patency of deep system

Risk of DVT is very low → <1%

Assess the distance of the end of the treated segment from the SFJ or SPJ

GSV should be <2mm diameter and no DVT in deep vessels

Coagulation usually occurs within ___________ seconds after radiofrequency or laser applied

10-20

Aftercare for post ablation

Class 2 compression stockings 30-40mmHg with daily ambulation of at least 30 mins

F/u exam performed every 2 weeks after procedure to confirm contraction/occlusion of GSV

Lymphedema

Common differential diagnosis for lower extremity edema

Caused by abnormal lymphatic system

Causes extensive swelling that INCLUDES SWELLING OF THE FEET

Associated with radiation therapy of the affected extremity

Severe cases can develop into lymphangiosarcoma

Elephantiasis is a common complication

Lymphedema most commonly affects:

A unilateral extremity because the most common cause is surgical removal of lymph nodes as part of Ca treatment

Primary lymphedema

Caused by congenital malformation of system or impaired transport of the lymphatic fluid

Secondary lymphedema

Related to injury, obstruction or damage to the lymphatic system

Common causes include wounds, burns, cancer treatment (#1 in US), filariasis (#1 in world)

Stemmer sign

Significant edema of the lower extremity that causes a skin fold at the base of the second toe

Confirmed by trying to pinch the skin but the skin is too tight to allow pinching

Which of the following describes venous insufficiency?

Most common venous disease of the extremities

Most commonly occurs at the SFJ

Most common DVT complication

All of the above

All of the above

Chronic DVT leads to:

Secondary varicose veins

Increased pressure in the deep venous system due to obstruction will cause:

Dilated perforator veins with bidirectional flow

Which of the following is an early sign of chronic insufficiency

Stasis dermatitis

Significant venous claudication is caused by

Obstructed deep system and incompetent superficial system

Which of the following is a risk factor for venous insufficiency:

Working as a math teacher

Working as a gym teacher

Lower BMI

Being male

Working as a math teacher

First step in insufficiency exams:

Eval the deep system for DVT

When evaluating the pt for insufficiency and potential venous ablation, it is important to measure:

Inner to inner diameter of the GSV at multiple locations in the leg

The depth of the GSV

The depth of the tributaries

A rapid cuff inflator provides:

A consistent level of augmentation for all veins

What described as abnormal lower extremity venous flow response to distal augmentation in a superficial vein?

Augmentation causes increased flow toward the heart followed by flow reversal >5.0 secs towards the feet

What is a differential diagnosis for symptoms of venous insufficiency

Lymphedema