Anatomy. Patterns of reflux. Technique. Testing Reflux time Patient position. Difficult! Learning. NOT system optimisation. Clinical Assesment

Transcription

1 Anatomy Patterns of reflux Awareness Technique Testing Reflux time Patient position Difficult! Learning NOT system optimisation Enlarged Clinical Assesment Twisted Where are the symptoms? Why they are there? Female 25-33% Male 10-20% Plan appropriate intervention What are the options? The best test Ulcers 0.3% Colour Duplex Imaging $$ Health budget Superficial venous reflux Is there reflux? Origin Distribution Severity R ship to clinical presentation... Common Femoral JVS 2005 Paired Systems Proximal/ Distal Gastroc/ Soleal Deep venous reflux Patency (?old/recent DVT) Foot Venous Drainage Deep Femoral Vein Femoral Vein

2 Sup. Epigastric V. Sup. Epigastric V. Superficial circumflex iliac vein Superficial circumflex iliac vein Anterior Acc Great Saph V Ext Pudendal V. SPJ Ext Pudendal V. Anterior thigh circumflex vein Anterior Accessory GSV Anterior Accessory GSV Posterior thigh circumflex vein Posterior thigh circumflex vein Multiple Accessory V Anterior Thigh Circumflex Anterior Thigh Circumflex Great saphenous vein Ascending Small Saphanous V Ascending Small Saphanous V WHY VV s Valve failure Complex aetiology (VV s form up or down) Endothelial change Genetics Trigger mechanisms Increased venous pressure Incompetency Flow Deep- Superficial Insufficient venous return Valve failure Great saphenous vein Incompetency Pressure Major junctions SFJ SPJ Incompetent perforators

3 Major junctions SFJ SPJ Incompetent perforators Importance Documenting Size/ Variations Biggest change (covered) EVLT Pelvic contribution 8% (Jung 2009) Can be higher Patient demographics Sometimes Pelvic congestion syndrome Not always ovarian V Source Ovarian Veins Anterior abdominal wall Lumbar Other (not well understood) Communicate via Tiny- small varices Sup. Epigastric V. Superficial circumflex iliac vein Ext Pudendal V. Perineal/ Medial Postero- Lateral Free use available Insert:Between terminal/ preterminal : Segmental GSV reflux Ext Pudendal V. Communication with Posterior accessory GSV Vein of Giacomini Ascending SS Any veins! Present as Small varices Sup. Epigastric V. Careful mapping/ The questions Where do they come from Size/ Reflux Distribute to

4 Junctional SFJ, SPJ Incompetent Perforator Pelvic Numerous sources Now less common Anatomical Sup-Inf Clinical assessment Erect High Frequency transducer Approach Awareness : Clinical setting Transducer technique Varied pressure, Anatomy- Trans. Scan superiorly Sup Epigastric Ext pudendal V Superficial circumflex iliac V Size- (? dilated) Is there SFJ reflux SFJ Sagittal Valsalva Augment 1 SFJ cross section Evaluate the GSV Main GSV Posterior Thigh Circumflex V Document size Intrafascial Extrafascial

5 Saphenous eye Rare External pudendal reflux Segmental competence Thigh incompetent perforator Saphenous ligament Hunter s Canal Segmental competence CFV - Inferior to SFJ Thigh Perforators Is there calf extension Seat patient : re test Deep Femoral V Superior Reflect atypical anatomy Femoral V - Mid Predictor of SSV Above inf thigh perforator Add Canal CFV - Inferior to SFJ Scan for post. VV s Deep Femoral V Superior Reflect atypical anatomy Femoral V - Mid Predictor of SSV Above inf thigh perforator Vein of Giacomini Deep post varices - Gluteal /Sciatic Check all thigh VV s assessed NB Multiple sources

6 Have I resolved the upper leg? 9 V of Giac. Detailed review : Posterior thigh Anatomical variants Insertion Anatomical variants Insertion Size -? Dilated Size -? Dilated Insertion Meas. from knee crease Insertion Meas. from knee crease Reflux Reflux Intersaphenous connection Intersaphenous connection LSV reflux SSV syphon LSV reflux SSV syphon Add canal V of Giac. Segmental Superior reflux Not Clinically significant SSV -» GSV SPJ SSV- Pop fossa GSV SSV - Mid calf SSV

7 Gastrocnemius Vein Incompetent perforator Perforator Popliteal Gastrocnemius V Posterior Tibial, Peroneal Only if inf. popliteal reflux Baker s cyst GV Tibio-per. trunk PT Peroneal Strobe fascia/ sub fascial V s Size Location - (fascia) Dist. from Med. Malleolus Strobe fascia/ sub fascial V s Size Location - (fascia) Dist. from Med. Malleolus MARKING -No Black/Blue texta ALL OF LEG MUST BE EXAMINED MARKING -No Black/Blue texta ALL OF LEG MUST BE EXAMINED cm. Strobe fascia/ sub fascial V s Size Location - (fascia) Dist. from Med. Malleolus MARKING -No Black/Blue texta ALL OF LEG MUST BE EXAMINED

8 Inferior calf augment Valsalva Time based Negle n JVS sec (3 consecutive augments) Delis JVS 2004, Delis Radiology 2004 Size Negle n JVS 2004 > 4.0 mm Describe Location Presence of reflux Relationship to VV s The toe wiggle Tourniquet: Upper calf Limited Full study Hx of DVT Leg swelling Significant deep venous reflux Nomenclature of the veins of the lower limbs: An international interdisciplinary consensus statement Alberto Caggiati, et al 2002 JVS 64yo recent CVA Lt leg swollen - Peroneal V DVT Rt leg Multiple Sources Abdomen Ovarian Haemorrhoidal Abdominal Wall Long Saphenous V Short Saphanous Deep system Is there reflux? Origin? Distribution? Severity? R ship to clinical presentation...? Significant variations in: Design Few prospective studies Technique Expertise Results Criteria Insufficient attention: Normal population Anatomical difference Atypical reflux patterns Description of technique Incompetent Perforators

9 Creating physiological reflux Manual squeeze Create significant void Time based > 0.5 sec > 0.7 sec > 1.0 sec > 2.0 sec Reflux > 0.5 secs Nicholaidis Circulation 2000 Consensus Statement Thigh Velocity criteria Neglen 2004 Reproducible technique Calf Foot How do we test it? Is there reflux? Severity? Efficiency/ Reflux Index Beckwith TAV* Time = Area Clinical reflux < 70 % Calf Augment Qualitative- Subjective (experience) 1. SIGNIFICANT - (Moderate -> Gross) 2. MILD 3. V. mild/trickle flow? Clinical Significance Infinite Congenital Time > 0.5 sec. Efficiency Index (Qualitative) Clinical Presentation Tool for communication Pelvic Incompetence Internal Iliac V. Ovarian V s Imaging CO eg. Knee perforators Ovarian V Quality worksheet SSV GSV Structured reporting AAGSV Liaise Vascular consultant Feedback Detail Vein Sizes

10 Anatomy Now where is that freeze button? Practical approach No strict guideline Testing Complexity of the pathology Multiple positions/ Multiple testing methods Time based > 0.5 sec > 0.7 sec > 1.0 sec > 2.0 sec Velocity criteria Neglen 2004 AA = augment area AR= reflux area Efficiency/ Reflux Index Beckwith TAV* Time = Area Clinical reflux < 70 %