Venous Insufficiency (12)

anatomy

review

what is venous insufficiency?

refers to valvular incompetence in superficial, deep and/or perforating veins

• permits reversal of flow

• promotes venous hypertension

varicosities only occur in

superficial system

primary viscosities are caused by

weak vein walls and/or supericial venous valve failure

*occurs without any deep venous incompetence/disease

seconday viscosities are caused by

DVT/obstruction or deep valvular incompetence

what is the etiology of venous insufficiency?

genetic

history of venous thrombosis

venous hypertension (caused by valve damage or dysfunction)

what are the risk factors for venous insufficiency?

age

female

pregnancy

obesity

long perods of standing

family history

congenital abn

arteriovenous fistula

Qs what are the signs and symptoms of venous insufficiency?

leg pain

edema

skin changes in ankle region

spider veins

varicose veins

healed skil ulcers

open skin ulcers

how is the patient positioned when scanning for venous insufficiency?

patient examined while standing

Qs what are the three methods used to check for reflux?

distal compression/augmentation w/ release

prox compression

valsalva maneuver

Qs what is a competent valve?

valve that prevents blood from flowing backward

Qs what veins are examined for valvular insufficiency?

deep veins

• CFV → deep

• saphenofem junction (greater and lesser) → superficial

• FV → deep

• pop v → deep

• (sometimes profunda femoris and anterior tib)

what is the normal response to proximal compression?

no flow with proximal compression

flow appears with release of proximal compression

what is the normal response to distal compression?

augmentation with compression

no flow upon release of compression

what does this show

normal distal augment

normal

what does this show

abn distal augmentation due to reflux above baseline after augment

is this normal or abnormal

abnormal

• retrograde flow → reflux

what is the normal response to valsalva maneuver

no flow while bearing down

return of flow upon exhaling

normal or abn?

norm

normal or abn

abn

normal or abn

normal

what do these waveforms depict?

resp phasicity

valsalva

cardiac pulsatility

normal or abn

abn → incomp vein

review

what is normal reflux in deep, superficial and perforator veins?

deep : <1 sec

superficial : <.5

perforator : <.35

what is normal flow with deep, superficial and perforator veins?

superficial → perforator → deep

when using pressure cuffs to measure reflux, what is a normal response vs abn response?

reflux is tested prox to cuff → transducer placed prox to cuff

• normal

  • no flow detected during cuff inflation

• abn

  • retrograde flow during cuff deflation due to valvular incompetence

why is cuff based duplex the primary method to measure reflux?

because of it accuracy and ability to localize reflux

what is venous photoplethysmography?

PPG transducer emits infrared light and senses signal reflected back from blood

• baseline recorded while limb is relaxed

• next tracing recorded with flexion/relaxation of foot

  • tracing falls to bottom

• returns back to baseline during venous return time (VRT)

how does VRT indicate reflux?

the timing of blood return to the region indicates presence or absence of reflux

• venous reflux is VRT is less than 20 seconds

  • large slope (faster rise) = worse

norm or abn?

normal

• VRT of 25 seconds

norm or abn

abn

• shortened VRT of 5 seconds

what is injection sclerotherapy?

sclerosant directly injected into varicose or spider veins causign them to collpage, scar and eventually reabsorbed by the body

what are surgical treatments for venous insufficiency?

ligation (vein tied off)

venous ablation (thermal)

stab avulsion or ambulatory phlebectomy (extracts superficial varicose veins)

vein stripping removal of diseased veins

subfascial endoscopic perforator vein surgery (perforators clipped)

Qs what techniques are used to check for valvular competency?

prox/distal compression

valsalva manuever

Qs what should you see on spectral doppler during valsalva maneuver when valves are not competent?

reversal of flow

Qs what is the normal response for proximal compression?

no flow

Qs what is the abnormal response for distal compression?

flow reversal for greater than 1 sec

Qs what does PPG measure?

changes in blood volume through infrared light to look for venous refill time (VRT)

• <20 sec is abn

Qs what is the treatment for superficial and deep venous disease?

superficial

• compression therapy

• minimally invasive

deep

• valve repair

• venous stenting

• more aggressive w dvt

what is pelvic congestion syndrome?

occurs from varicose ovarian veins

• mostly from left ovary since left ovarian vein inserts into the left renal vein

pelvic pain with not discernable cause

you can see dilated tortuous veins more than 10mm in size

what are the nonvascular pathology findings during venous exams?

soft tissue edema - leg swelling

lymphedema

hematoma

lymph nodes (usually seen in groin, neck and axillary)

muscle injury

popliteal (baker’s cyst)

• result from fluid collections in knee joint

joint effusion

infection

cellulitis

• soft tissue inflammation from bacterial infection

soft tissue tumors

this shows

soft tissue edema

• leg swelling

• associated with CHF

what is this?

hematoma

• can be cystic, solid or complex

what is this?

enlarged groin lymph node

what is this?

muscle injury/bakers cyst

what is this?

soft tissue masses

• benign

  • lipoma (most common)

  • firboma

  • leiomyoma

pseudoaneurysm

what is contrast venography?

x-ray test that provides an image of veins after contrast dye injection in patient’s vessel

what is ascending vs descending venography?

ascending

• contrast is injected into foot

• evaluates acute DVT, congenital venous disease/anomalies

• chronic venous changes

descending

• contrast injected into CFV

• detects and quantifies reversed flow from incompetent valves

what is a lung perfusion scan (VQ)?

nuclear medicine screen testing for detection of perfusion defects of the lungs

• looks for pulmonary embolism

Qs what is the difference between true aneurysm and false aneursyms?

true : all three layers

false : one layer, neck

Qs what is a VQ scan

lung perfusion scan

used for pulmonary embolism detection

Qs what is the d-dimer test used for?

clot breakfown/ prior to dvt

• positive : breakdown of thrombus

• negative : absence of thrombotic process

Qs what is ascending venography?

used to check for DVT

Qs what is descending venography?

used to check for reflux