Venous Valve Insufficiency 2025

Chapter Overview

• Chapter 20 discusses Venous Valvular Insufficiency Testing.

Objectives

• Define the conditions related to chronic venous valvular insufficiency, including:

  • Clinical

  • Etiologic

  • Anatomic

  • Pathophysiologic

• Describe noninvasive vascular testing:

  • Direct testing methods

  • Indirect testing methods

• Outline protocol differences based on testing objectives:

  • Screening

  • Definitive diagnosis

  • Pretreatment mapping

  • Peritreatment imaging

  • Procedure/patient follow-up

• Define ha duplex ultrasonography's role in evaluating lower extremity venous disorders.

Anatomy of Saphenous Veins

• Types of veins:

  • Great Saphenous Vein (GSV)

  • Small Saphenous Vein (SSV)

• Tributaries include:

  • Anterior Accessory Saphenous Vein (AASV)

  • Posterior Accessory Saphenous Vein (PASV)

  • Vein of Giacomini (VOG)

• Veins lie within saphenous fascia layers, giving an "eye" appearance.

Ultrasound Imaging of Veins

Transverse Ultrasound Description

• Normal positioning of the GSV within the saphenous compartment illustrated.

  • Arrows indicate fascia surrounding the vein.

Positioning of Veins

• GSV courses medially in the thigh and leg.

• AASV aligned with the femoral artery in a transverse plane.

• PASV may connect with the VOG.

Identification Signs

Angle Sign

• Identified in the GSV below the knee:

  • Triangle formed by:

    • Gastrocnemius muscle

    • Tibial bone

    • GSV

• Helps differentiate the saphenous vein from tributaries.

Duplications and Junctions

Duplications

• Mostly segmental; complete duplications are rare.

• Duplicated veins must follow the same path and remain parallel.

Saphenofemoral Junction (SFJ)

• Terminal valve present at SFJ; second preterminal valve distal to tributaries.

• Important landmarks include:

  • Superficial epigastric vein (SEV)

  • Superficial external pudendal vein

  • Superficial circumflex iliac vein

Venous Valves

• Bicuspid valves identified with B-mode imaging.

• Leaflets open with muscular contraction, close with relaxation.

• Regulate blood return efficiently; incompetence leads to retrograde flow.

Epidemiology of Venous Disorders

Chronic Venous Insufficiency (CVI)

• Common finding in the general population.

• Varicose veins prevalence rates:

  • 60% in women

  • 56% in men

• Associated conditions:

  • Telangiectasias

  • Edema

  • Skin changes

  • Ulcers

• Reflux prevalence in lower extremities is 35%; increases with age.

Symptoms of Venous Insufficiency

• Visual Signs:

  • Spider veins

  • Telangiectasias

  • Varicose veins

  • Edema

  • Skin changes

  • Ulceration

Edema

• Temporary swelling may occur after prolonged standing or specific activities.

• Sources to differentiate include lymphatic obstruction, cardiac disease, and arterial disease.

Skin Changes

• Manifestations include:

  • Localized redness

  • Atrophic blanche

  • Lipodermatosclerosis

  • Ulcerated wounds

CEAP Classification

Clinical Classification System

• C0: No signs/symptoms.

• C1: Telangiectasias/reticular veins.

• C2: Varicose veins.

• C3: Edema.

• C4: Skin changes.

• C5: Healed ulcers.

• C6: Open ulcers.

Etiological and Anatomical Classifications

• Different subclasses to explore potential causes of CVI.

Treatment Types for Venous Insufficiency

• Treatments include:

  • Stripping and ligation

  • Endovenous thermal ablation

  • Chemical ablation/sclerotherapy

  • Phlebectomy

  • Deep venous disease treatments like anticoagulation and thrombolysis.

Endovenous Thermal Ablation

• Performed with ultrasound guidance; vein is closed from within.

• Device used induces thermal injury, causing vein shrinkage.

Diagnostic Techniques

Duplex Ultrasound

• Standard technology for evaluating CVI includes:

  • Assessment of deep and superficial veins.

  • Flow characterization using Doppler assessment.

Other Techniques

• Photoplethysmography (PPG) for reflux detection.

• Air plethysmography (APG) for quantifying CVI.

• Near-infrared imaging for visualizing superficial veins.

Summary of Key Features

• B-mode Ultrasound Findings:

  • Normal veins: Thin-walled and compressible.

  • DVT: Enlarged and incompressible.

  • Chronic CVI: Enlarged diameter with anechoic lumen and visible valve leaflets.

Conclusion

• Emphasizes importance of understanding anatomy and appropriate testing for diagnosing and treating venous insufficiency.