Doppler Sonography in the ambulatory hemodynamics surgery of the venous insufficiency

Transcription

1 Doppler Sonography in the ambulatory hemodynamics surgery of the venous insufficiency Poster No.: C-0164 Congress: ECR 2013 Type: Educational Exhibit Authors: M. García Carriazo, C. Gómez de la Heras, A. Monteagudo Parreño, J. M. Sanchez Rodriguez; Sevilla/ES Keywords: Varices, Ultrasound-Spectral Doppler, Ultrasound-Colour Doppler, Ultrasound, Vascular, Extremities DOI: /ecr2013/C-0164 Any information contained in this pdf file is automatically generated from digital material submitted to EPOS by third parties in the form of scientific presentations. References to any names, marks, products, or services of third parties or hypertext links to thirdparty sites or information are provided solely as a convenience to you and do not in any way constitute or imply ECR's endorsement, sponsorship or recommendation of the third party, information, product or service. ECR is not responsible for the content of these pages and does not make any representations regarding the content or accuracy of material in this file. As per copyright regulations, any unauthorised use of the material or parts thereof as well as commercial reproduction or multiple distribution by any traditional or electronically based reproduction/publication method ist strictly prohibited. You agree to defend, indemnify, and hold ECR harmless from and against any and all claims, damages, costs, and expenses, including attorneys' fees, arising from or related to your use of these pages. Please note: Links to movies, ppt slideshows and any other multimedia files are not available in the pdf version of presentations. Page 1 of 41

2 Learning objectives 1. Exploration methodology of chronic venous insufficiency by Doppler ultrasound 2. Understandind of the concepts: - venous insufficiency - venous network - retrograde and anterograde flow - entry point and leak point veno-venous shunt - CHIVA strategy (Conservative Hemodynamic Cure of Incompetent and varicose veins in Ambulatory patients) 3. Cutaneus venous mapping and preoperative marking. Background Definition of venous insufficiency Difficulty of a vein to drive a proper display of blood flow in cardiopeto sense, regardless of its position and activity. Its visible sign is varicose veins, permanently dilated pathological veins ( Fig. 1 on page 3) Prevalence Ït s the most common vascular disease, with a prevalence of up to 50% in those over 50 years. Doppler Examination It s the only non-invasive procedure capable of providing a anatomical and hemodynamic topography of the lower limbs on real time. Page 2 of 41

3 It has laid the groundwork for conservative treatment of chronic venous insufficiency. Images for this section: Page 3 of 41

4 Fig. 1 Page 4 of 41

5 Imaging findings OR Procedure details Methodology - 7,5-10 Mhz transducer - Supine assements of permeability and / or insufficiency of the deep venous system - Standing exploration of superficiail venous system ( Fig. 2 on page 7 : Stage used for exploration in standing) - Maneuvers: Valsalva, Paraná, compression-relaxation ( Fig. 3 on page 9 a) Maneuver of Paraná b) distal compression) Morphological aspects: venous networks There are two venous fascias, both hyperechoic and esasily recognizable: - deep: plane overlayins muscle - superficial: delimits the subcutaneous tissue Venous networks ( Fig. 4 on page 9 : venous network) ( Fig. 5 on page 10 : scheme venous networks) R1: deep in relation to the deep fascia, deep venous system R2: between both fascia: internal and external saphenouds, anterior saphenous and Giacomini vein ( Fig. 6 on page 12 : "eye sign") ( Fig. 7 on page 12 : R2) ( Fig. 8 on page 12 : R2) ( Fig. 9 on page 13 : R1: common femoral vein - R2 anterior saphenous) R3: outside the superficial fascia. Originate or end in saphenous or perforators ( Fig. 10 on page 14 : R3) R4: R3 that connect two segments of R2 (longitudinal or transverse) Hemodynamic aspects Anterograde flow: physiologic flow from a vein Retrograde flow: flow in the opposite direction to the physiological Leakage point: blood flow from inner to outer compartment to another outside. usually ther will be a change in the R2 gauge "thick point" ( Fig. 11 on page 15 : leakage point R2-R3) Entry point: blood flow outside to inner compartment ( Fig. 12 on page 16 : entry point R2-R1) Page 5 of 41

6 Definig reflux: return flow in the opposite direction to the physiological, presupposes a prior flow in normal direction, bidirectional ( Fig. 13 on page 17 : reflux) ( Fig. 14 on page 18 : color Doppler reflux with Valsalva maneuver) The concept of competence or incompetencerefers to valvular function, no necessarily assuming the flow direction Concep of veno-venous shunt in chronic venous insufficiency: short circuit conditioned bay a leak point, a path usually retrograde (varicous veins) and a re-entry point to the deep venous system ( perforator). May be open o closed. It allows vicious recirculation of a certain volume of blood within the lower extremity Shunts types - Shunt type 1: R1 - R2- R1 ( Fig. 15 on page 19 :) - Shunt type 3: R1- R2- R3- R1. It s de most common ( Fig. 16 on page 21 ) - Shunt type 2: R2 - R4 - R2 (closed) R2 - R3 - R1 (open) ( Fig. 17 on page 23 ) - Shunt type 4: any type of shunt other than those described above, such as those originating in the pelvic vein ( Fig. 18 on page 25 ) Doppler ultrasound allows very reliably assesing of veno-venous shunts existing, characterization and labeling them as well as the elections of the most appropiate surgical technique. Venous mapping ( Fig. 19 on page 27 )( Fig. 20 on page 27 example shunt type 3) It should include: - saphenous caliper - leak point - type of shunt - flow direction CHIVA Strategy Page 6 of 41

7 It s based on: - fragmentation pressure blood column - preserving the saphenous vein - interruption of veno-venous shunt - preservation of communicating/perforator reentry veins - supression incompetent R3-R4 undrained CHIVA 1: in one procedure without creating hemodynamic compromise. Shunts type 1, 2 and 4 ( Fig. 21 on page 28 y Fig. 22 on page 30 : CHIVA 1 strategy) CHIVA 2: two separate procedure, shunt type 3: - at first it acts on the leak point R2-R3 (saphenous develops a new reentry perforating on R2 = shunt type 1) - in a second time closure the leak point R1-R2 - control periodic Doppler is required CHIVA 1+2 ( Fig. 23 on page 32 : strategy CHIVA 1+2) - shunt type 3 - in a single surgical procedure, generates hemodynamic conflic, supresses leak point unorganized drainage - neor3 sometimes develops Preoperative marking of the limb ( Fig. 24 on page 34, Fig. 25 on page 36 Fig. 26 on page 38 preoperative marking) - inmediately before surgery - standing (except the external saphenous arch) - leak point, entry point and segments R3 for phlebectomy are marked Images for this section: Page 7 of 41

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41 Conclusion Haemodynamic surgery or varicose veins is a valid option for the treatment of varicose syndrome with low morbidity and permits a rapid return to full activity Doppler ultrasound is the only noninvasive procedure that can provide a anatomic and hemodynamic topography of the venous circulation of the lower limbs in real time required for surgical planning. References J Juán Samso, J. M. Escribano Ferrer, A. Rodriguez Mori, R. Bofill Brossa, M. Matas Docampo. Cirugía hemodinámica venosa en el tratamiento del síndrome varicoso. Angiología 2003; 55(5) J. Fontcuberta García, J. Juán Samsó, M.E.Senin Fernández, R. Vila Coll. Guía básica para el diagnóstico no invasivo de la insuficiencia venosa. Capítulo de Diagnóstico Vascular no Invasivo de la Sociedad Española de Angiología y Cirugía Vascular E. Criado, S.Luján, L. Izquierdo, E. Puras, M. Gutierrez, J. Fontcuberta. Conservative Hemodynamic Surgery for Varicose veins. Seminars in Vascular Surgery 2002; 15 (1) J. Juán Samsó, J.M. Escribano, E. Criado, J. Fontcuberta. Hemodynamic surgery for varicose veins: surgical strategy. Phlebology 2005; 20 (1) 1-12 M.A. Menéndez herrero, J.A. Carreño Morrondo, A.I. Menéndez Perez, J.M- Llaneza Coto, L.A.Camblor Santervas, J. Rodriguez Olay. Cirugía hemodinámica de la insuficiencia venosa ambulatoria. Angiología 2006; 58 (suplem 2): P.Paolonelli. Ultrasonido Doppler de extremidades inferiors para el estudio de la insuficiencia venosa. Rev. Chil. Radiol. 2009: 15 (4) Personal Information Page 41 of 41