Doppler ultrasound in the evaluation of chronic venous insufficiency: A step-by-step morphological and hemodynamic review Poster No.: C-3206 Congress: ECR 2010 Type: Educational Exhibit Topic: Vascular - US Authors: R. dos Santos, A. Cardoso, Â. Marques; Lisbon/PT Keywords: chronic venous disorders, varices, doppler ultrasound Keywords: Vascular, Ultrasound DOI: 10.1594/ecr2010/C-3206 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. www.myesr.org Page 1 of 47
Learning objectives To review the morphologic and hemodynamical changes in Chronic Venous Insufficiency in the lower limbs. To review the clinical manifestations and the most common patterns of Chronic Venous Insufficiency seen on Doppler Ultrasound and their therapeutic impact. To present a systematized Doppler Ultrasound protocol for thorough evaluation of the venous system in the lower limbs. Page 2 of 47
Background Chronic venous insufficiency is a major world-wide health problem. Doppler Ultrasound is an available, cheap, innocuous examination, which is nowadays widely implemented as the method of choice for assessment of the morphologic and hemodynamic changes of the venous system in the lower limbs. Page 3 of 47
Imaging findings OR Procedure details Chronic venous disorders depend on multifactorial risk factors and have a signifficant repercussion on the patient's lives and their families and represent ultimately a major economic impact in the community. Fig.: Epidemiology and risk factors for Chronic Venous Disorders. Page 4 of 47
Fig.: The objective examination Page 5 of 47
Fig.: Indications for Doppler-US in Chronic Venous disorders Page 6 of 47
Fig.: Objectives of the Doppler-US examination. Awareness of the therapeutical impact of different clinical pictures is fundamental for enhanced diagnostic performance and management of chronic venous disorders. In our Department we perform Doppler-US in a methodic way, always bearing in mind the objectives of the examination and the available therapeutic options. Page 7 of 47
Fig.: Doppler-US: equipment requirements. Page 8 of 47
Fig.: Doppler-US: equipment requirements. Familiarity with Doppler-US principles is crucial for optimal interpretation. Page 9 of 47
Fig.: Doppler-US: operator requirements. Page 10 of 47
Fig.: Doppler-US examination. Consensual nomenclature is fundamental for proper multidisciplinary communication. The radiologist and the surgeon must have a clear mutual understanding of the venous disorders lexicon. A consensus meeting has recently published the most important physiologic terms on chronic venous disorders, which are presented below (in Updated terminology of chronic venous disorders, Journal of vascular Surgery, 2009). Page 11 of 47
Fig.: Physiological Venous Terms Page 12 of 47
Fig.: Physiological Venous Terms Page 13 of 47
Fig.: Saphenofemoral reflux - B mode and color Doppler-US Page 14 of 47
Fig.: Physiological Venous Terms There are different methods for elliciting venous reflux; in our institution we use mostly distal manual compression and discompression. Page 15 of 47
Fig.: Assessment of venous reflux. One should be aware of the most common causes of false positives and false negatives, which preclude proper management of venous disease. Page 16 of 47
Fig.: Diagnostic Pitfalls The examination should be methodic and patient-tailored, always bearing in mind the specific information the surgeon needs in order to offer the patient the best therapeutics. ANATOMY AND HEMODYNAMICS # # # # # # # # # # # # # # # # # # # # # # # # - THE SUPERFICIAL VENOUS SYSTEM Page 17 of 47
Fig.: The saphenofemoral junction Page 18 of 47
Fig.: The saphenofemoral junction Page 19 of 47
Fig.: The saphenofemoral junction Page 20 of 47
Fig.: Pre-termina valve incompetence. Page 21 of 47
Fig.: The Great saphenous vein Page 22 of 47
Fig.: The Great saphenous vein tributaries Page 23 of 47
Fig.: The Great saphenous vein- anatomical variations (in Duplex Ultrasound Investigation of the Veins in Chronic venous Disease of the lower limbs - UIP consensus Document. PartII. Anatomy) Page 24 of 47
Fig.: The Great saphenous vein trunk Page 25 of 47
Fig.: The Anterior accessory saphenous vein Page 26 of 47
Fig.: Refluxive Anterior saphenous vein and competent Great saphenous vein Page 27 of 47
Fig.: Lymphoganglionar veins Page 28 of 47
Fig.: Lympho-ganglionar veins Page 29 of 47
Fig.: The Short saphenous vein Page 30 of 47
Fig.: The saphenopopliteal junction Page 31 of 47
Fig.: The saphenopopliteal junction In the presence of saphenous vein reflux, it is important to provide detailed anatomical information on the location of the SPJ, since it will only be accessible through a popliteal crease incision if it is in the range of 5 cm. Otherwise, an incision in a different topography will be required. Page 32 of 47
Fig.: Absence of the Saphenopopliteal junction Page 33 of 47
Fig.: The Giacomini vein Page 34 of 47
Fig.: Collaterals - THE PERFORATOR SYSTEM Page 35 of 47
Fig.: Perforators Page 36 of 47
Fig.: Perforators - THE DEEP VENOUS SYSTEM Deep venous system is sometimes the cause for varicose veins and it is mandatory to assess deep venous system patency and competence. Page 37 of 47
Fig.: The Deep venous system Page 38 of 47
Fig.: The Deep venous system- primary and secondary reflux Page 39 of 47
Fig.: Physiological Venous Terms TIPS AND TRICKS FOR A THOROUGH YET OBJECTIVE EXAMINATION (JUST LIKE WE DO IN OUR DEPARTMENT) # # # # # # # # # # # # # # # # # # Page 40 of 47
Fig.: Examination protocol Page 41 of 47
Fig.: Examination protocol Page 42 of 47
Fig.: Examination protocol CURRENT THERAPEUTICAL OPTIONS FOR CHRONIC VENOUS DISORDERS # # # ################################## KEY-POINTS ON REPORTING # # # # # # # # # # # # # # # # # # # # # # # # # # # Page 43 of 47
Fig.: Reporting Page 44 of 47
Conclusion In-depth knowledge of the major patterns of chronic venous insufficiency and familiarity with optimal parameters adjustments contributes to successful diagnosis and follow-up of patients with chronic venous insufficiency and is crucial for therapeutical planning. Page 45 of 47
Personal Information Rosana dos Santos; Radiology Resident rosanadossantos@hotmail.com Lisbon Portugal Page 46 of 47
References Eklof B, Perrin, M, Konstantinos TD et al. Updated terminology of chronic venous disorders: The VEIN-TERM transatlantic interdisciplinary consensus document. J Vasc Surg 2009;49:498-501. Coleridge-Smith P, Labropoulos N, Partsch H, Myers K, Nicolaides A, Cavezzi A. Duplex ultrasound investigation of the veins in chronic venous disease of the lower limbs-uip consensus document part I: basic principles]. Rev Port Cir Cardiotorac Vasc. 2007;14(1):53-60. Cavezzi A, Labropoulost N, Partscht H, Ricci S, Caggiati A, Myers K, Nicolaides A, Coleridge-Smith P. [Duplex ultrasound investigation of the veins in chronic venous disease of the lower limbs: UIP consensus document - Parte II: anatomy]. Rev Port Cir Cardiotorac Vasc. 2007;14(2):99-108. Page 47 of 47