Clinical/Duplex Evaluation of Varicose Veins: Who to Treat?
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1 Clinical/Duplex Evaluation of Varicose Veins: Who to Treat? Sanjoy Kundu MD, FASA, FCIRSE, FSIR The Vein Institute of Toronto Scarborough Vascular Group Scarborough Vascular Ultrasound Scarborough Vascular Institute Toronto Endovascular Centre Scarborough Hospital
2 Disclosure Consultant: Bard Canada Boston Scientific Canada Edwards Life Sciences Baylis Canada Sigmacon Diomed Dornier
3 Outline Clinic Setting Pathophysiology Anatomy History Physical Exam Duplex Ultrasound Treatment Algorithm
4 Background 1 in 5 Europeans Approximately 25% of women have some type of lower extremity venous insufficiency 72% of European women over 60 Approximately 15% of men have some type of lower extremity venous insufficiency 40% of European men over 60
5
6 CLINIC SETTING
7 Clinic Setting Not a regular Diagnostic Imaging Clinic A Cosmetic Medicine Environment Attractive, welcoming environment Bright Brass & Glass Setting Visit your nearest cosmetic medical clinic!
8 Clinic Setting Wrong Clinic Setting!
9 Clinic Setting
10 Clinic Setting
11 Pathophysiology
12 Vein Valves One-way valves allow blood to flow against the force of gravity flaps or cusps act as gates: Open to allow flow toward the heart Close to prevent backflow of blood
13 Backflow causes pileup of blood and increased pressure Vein becomes engorged: High pressure Thin walls Little muscle support Diseased GSV can enlarge to diameters above 10mm Venous Reflux
14 Failure of valves reflux Blood falls down by gravity causing increased pressure Varicosities are formed
15
16 Venous Anatomy
17 Venous System
18 Compartments of the Thigh SC, Superficial compartment; DC, deep compartment.
19 Circumflex Iliac Vein Saphenofemoral Junction Common Femoral Vein Anterior Circumflex Vein of Thigh Posterior Accessory Saphenous Vein of Thigh Anterior Accessory Saphenous Vein of Thigh Superficial Femoral Vein Posterior Circumflex Vein of Thigh Great Saphenous Vein Popliteal Vein Posterior Accessory Saphenous Vein of Calf Intersaphenous Vein Great Saphenous Vein Small Saphenous Vein Dorsal Venous Arch of Foot
20 Great Saphenous Vein Anatomy
21 Small SV Anatomy
22 Perforating Veins
23
24 Venous History
25 Patient History What are symptoms Swelling Heaviness (wooden legs) Pain Ulceration Itching Night cramps Location of varices Vulvar/vaginal Symptoms of pelvic congestion?
26
27 Relevant History Prior vein treatment(s) Prior history of DVT History of multiple spontaneous abortions can indicate hypercoaguable state Family history of DVT Personal or family history of PVD or CAD Patients do need to be counseled that the saphenous vein is potential bypass
28 Patient Expectations What are patient s expectations Symptom relief Cosmetic Both
29
30 Venous Physical Exam
31 Physical Exam Swelling Skin changes Corona phlebectasia Clusters of spiderveins Hemosiderin deposition Healed or open ulcers Location of varices 360 degree viewing Leads to detailed evaluation of highly suspect veins (e.g. ALT or SSV) Distal pulses
32 360 Degree View
33 External Rotation
34
35 The BIC Pen
36
37 CEAP Classification
38 CEAP Classification C: Clinical E: Etiology A: Anatomy P: Pathophysiology
39 CEAP Classification C-Clinical findings C0-no visible varicose veins C1-spider or reticular veins C2-varicose veins C3-edema C4-skin changes without ulceration C5-skin changes with healed ulceration C6-skin changes with active ulceration
40 CEAP Classification E-Etiology C-congenital P-primary disease Not due to other cause S-secondary Usually due to prior DVT A-Anatomy Which vein is involved Superficial Deep Perforating P-Pathophysiologic component Reflux Obstruction
41 What is the Physical Appearance of Venous Insufficiency?
42 C1 Telangiectasias & Reticular veins C2 Varicose Veins C3 Edema C4 Venostasis dermatitis C4 Hyperpigmentation C4 Atrophie Blanche C4 Lipodermatosclerosis C5 Healed Ulceration C6 Current Ulceration
43
44 Venous Ultrasound
45 Duplex Evaluation For those starting to treat these patients, participation in the duplex is essential Evaluate for deep venous pathology Current/prior DVT Deep venous reflux Evaluation of Superficial System Done with patient standing Examiner positioning/comfort is important
46 Goals of Ultrasound Exam Determine highest point of reflux Identify anomalies/unusual vessels Establish treatment plan Useful tool to show to patients so that they understand treatment plan
47 Superficial Venous US Evaluation Gray scale transverse covering entire length of vein Size of vein Caliber changes Location of tributaries Location of perforators Course of vein/anomalies Duplicated system Does it exit fascia
48 Great Saphenous Vein
49 Gray Scale Imaging Great Saphenous Vein
50 Small Saphenous Vein
51 Gray Scale Imaging Small Saphenous Vein
52 Superficial Venous US Evaluation Color flow and duplex Compression on varicosities to assess for reflux Reflux less than 0.5 sec is physiologic Greater than 0.5 sec is pathologic
53 Longitudinal Color Flow
54 Venous Duplex Assessment
55
56 Vulvar and Lower Extremity Varicosities
57 End of Exam Determine Patient Expectations Risk factor assessment What is etiology of varicose veins What is the highest point of reflux Treatment options Stripping Thermal ablation of incompetent vein Ambulatory phlebectomy or sclerotherapy
58 Treatment Algorithm GSV or SSV Insufficiency Endovenous Thermal Ablation Isolated Branch Vein Varicosity Foam Sclerotherapy Ambulatory Phlebectomy Incompetent Perforator Vein US guided foam sclerotherapy Endovenous Thermal Ablation
59
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