Venous Physiologic

Anterior Accessory Vein

Runs parallel and anterior to femoral vein

GSV

Saphenous Eye

Between facial layers

GSV in Calf

Angle Sign

Triangular form between gastrocnemius muscle and tibial bone

Tributary

Outside fascial plane

Perforator

Pass through muscular fascia layers - connect deep system to superficial system

Venous Valves in Lower Extremity

Femoral 1-6 valves

Pop 0-4 valves

GSV 10-12 valves

SSV 7-9 valves

Calf veins 8-19 (every 2 cm)

Perforations 1 each

Veins with No Valves

Soleal

Internal iliac

Common iliac

IVC

Subclavian VV

Innominate

SVC

Distribution of Venous Valves in Deep System

2.1 %

Distribution of Venous Valves in Superficial System

16.8 %

Distribution of Venous Valves in Perforator System

8.4 %

Risk Factors for Leg Swelling

Heart dysfunction (CHF)

Kidney disease

Liver disease

Lymphatic system/Lymphedema

Pulmonary HTN

High BMI

Medications (calcium channel blockers)

Multifactorial

Age

Family History

Obesity

Oral Contraceptive use

Smoking/Tobacco

Pregnancy

History of DVT

Prolonged standing or sitting

Sedentary lifestyle

Gender (women)

Primary Valvular Insufficiency

Congenital absence of veins

Secondary Valvular Insufficiency

Damaged valves caused by thrombotic events

Chronic Venous Insufficiency

Obstruction & valve insufficiency

Chronic Venous Valvular Insufficiency

Impaired superficial or deep flow

Causes venous hypertension

Duplex is primary modality for diagnosing

Symptoms of DVT

Swelling

Shortness of breath - emboli

Redness

Warmth

Painful

Throbbing

Phlebitis/Thrombophlebitis

Symptoms of CCVI

Swelling

Dull ache/heaviness or painful

Skin changes

Phlebitis/Thrombophlebitis

Ulcers

Varicose veins

Post-Thrombotic Syndrome

Venous stress disorder

Chronic pain and swelling at the site of a previous DVT

Symptoms of Post-Thrombotic Syndrome

Edema

Chronic pain

Skin changes

Heaviness of affected limb

Swelling

Venous Ulcers

Arterial Ulcers

Found in tibial area/bony areas

Severe pain

Deep, regular shape

Little bleeding

Shiny skin, hair loss, thickened toe nails

Venous Ulcers

Found near medial malleolus

Minimal pain

Shallow, irregular shape

Oozing/Odor

Stasis dermatitis/brown discoloration/varicosities

Venous Hypertension

Due to damaged valves, muscle atrophy, or poor ankle flexion

Increased venous pressure compromises capillary exchange

Low flow within capillaries leads to leukocyte trapping = damaged capillary membranes

Ambulatory Venous Hypertension

Pressure doesn't drop when walking

Intravenous pressure increases during exercise

Seen more in superficial and distal veins

Primary Varicose Veins

Tortuous superficial veins

Hereditary/congenital absence of valves

Secondary Varicose Veins

Obstruction of deep system - pregnancy, DVT, obesity

Reticular Veins

Smaller than varicose veins, larger than spider veins

Spider veins/Telangiectasia

Atrophie Blanche

Corona Phlebetcatica

Discoloration from grouping of spider veins

Phlebitis

Inflammation of a vein

Thrombophlebitis

Inflammation of a vein with clot formation

Lipedema

Accumulation of fat and fluid in the tissues just under the skin

Lymphedema

Swelling due to an accumulation of lymph fluid around tissues

CEAP Classification System

C = Clinical Classification

C0: no venous insufficiency signs or symptoms

C1: telangiectasias and/or reticular veins (<3 mm in diameter)

C2: varicose veins (≥3 mm in diameter)

C3: edema

C4A: minor skin changes

C4B: major skin changes - lipodermatosclerosis or atrophie blanche

C4c: major skin changes - corona phlebetcatica

C5: healed skin ulcers

C6: open skin ulcers

E = Etiological Classification

Ep: CVVI is the major cause

Es: CVI or CVVI is secondary to deep venous thrombosis or other pathology

Ec: CVI or CVVI has a congenital origin

En: unknown etiology

A = Anatomic Classification

Ad: affects deep veins

As: affects superficial veins

Ap: affects perforating veins

An: no venous anatomy identified

P = Pathophysiologic Classification

Pr: reflux or reverse venous flow

Po: chronic venous obstruction

Pro: a pathologic combination

Pn: no venous pathophysiology identified

Clinical Severity Score

Attempts to determine a numerical, quantifiable index for research comparisons

Each attribute is given a score from 0-3

Pain

Varicose veins

Edema

Skin pigmentation

Inflammation

Induration

Number of active ulcers

Duration of active ulcers

Size of active ulcers

Compressive therapy

Disability Score

0: asymptomatic

1: able to carry out usual activities without compressive therapy

2: able to carry out usual activities only with compressive therapy and/or leg elevation

3: unable to carry out usual activities even with compressive therapy and/or leg elevation

Contraindications to CCVI Exam

Advanced CVI with obvious varicose veins and/or severe reflux

Patients who are susceptible to fainting, motion sickness, dizziness, nausea

Patients who are handicapped or have extreme discomfort while standing

Patient Positioning for CCVI Exam

Standing/gravity dependent but NOT weight bearing

Reverse Trendelenburg if cannot stand

Complete symptomatic thigh or calf first

GSV - knee rotated outward

SSV - back facing sonographer

CCVI Techniques

Color, PW, CW each segment

Use auto cuff inflator for augmentation if available

Valsalva

Note any flow reversal & length of time

Augmentation

Promotes forward flow by squeezing calf

Valsalva

Increases abdominal pressure

Not useful in calf

Do not use in patients with arrhythmias

Proximal Compression

At groin

Mimics valsalva

Digital Release

Creates negative pressure distally

Normal Physiologic Reflux

Small amount of flow in the opposite channel is normal

Deep System Reflux

≥ 1 sec

Superficial System Reflux

≥ 0.5 sec

GSV Reflux

If terminal valve is incompetent, usually all of it is

Reflux Photoplethysmography (PPG)

Evaluates venous valve competency

Easy & reliable results

Positive findings must be confirmed with other studies

PPG Testing Protocol

Relaxed limb - normal baseline

Dorsiflex foot 5-6x - to empty calf veins

Venous refilling time - time from when exercise stops to stabilization period of ≥ 5 seconds

Normal PPG

Refill time/time to baseline > 20 seconds

Abnormal PPG

Does not return to baseline

PPG - Tourniquet Test

Differentiates superficial from deep system

GSV Reflux PPG

Refill time < 20 sec

Normalizes with tourniquet above knee

SSV Reflux PPG

Refill time < 20 sec

Normalizes with tourniquet below knee

Incompetent Deep Valves PPG

Consistent reflux < 20 sec

CW CCVI Testing

Evaluates for obstruction & incompetence

Cannot use with extrinsic or intrinsic obstructions, bifid systems, or collateral flow

Air Plethysmography (APG)

Recommended for chronic venous insufficiency

Cuff inflated to 10 mmHg

Leg is elevated

Patient quickly stands - bearing weight on non-tested leg

Distribute weight evenly

1 toe raise

10 toe raises

Return to supine and elevate tested leg

Venous Volume

Accumulated when patient moves from supine to standing

Filling Time

How long to accumulate blood in calf to 90% venous volume

NL = > 25 seconds

Ejection Fraction

After one toe

> 60% = normal

Volume Filling Rate

Blood accumulated per unit time

NL = < 2 mL/s

Residual Volume

Percentage of venous volume

How much volume is pumped from calf after 10 toe raises

NL = < 20 - 35%

Volumetric Emptying Rate

After thigh cuff deflation

Purpose of Vein Mapping

Bypass procedures use superficial veins

Ablation procedures

Dialysis fistulas/grafts

Reduces need for surgical exploration

Identify suitability for use as a graft

Vessel Mapping Techniques

Mark leg if surgery is planned

Place transducer over vein and center in view

Mark the skin directly over the vein

Move 1.5-2 inches and repeat down leg

Connect markings with a marking pen

Mark accessory (smaller) veins with dotted line

Use light pressure

High frequency transducer

Vein Diameter for Graft

≥ 2.5 mm

2.0 mm = smallest possible usable diameter

*Expand 2x when arterialized

Patient Prep & Positioning for Venous Mapping

No lotion/powers - interferes with skin marking

Keep patient warm

Thrombus

May be remnants of previous clot

Varicosities

Dilated tortuous veins

Impact ability to use vessel as bypass

Recanalization

Irregular intimal surface

Cannot be used for arterial bypass

Vein Wall Calcifications

Less common than arterial

Vein could still be usable

Valve Abnormalities

Frozen leaflets

Vein could still be usable

Vein Stripping

Surgical removal of varicose veins

Chemical Ablation

Chemical injected directly into vein = obliteration

Thermal Ablation

Vein closed from within itself via laser/catheter

Tumescent Anesthesia

Anesthetizes tissues

Prevents tissue/heat damage

Compresses vein - empties

Injected via ultrasound guidance