Ultrasongraphy: State of the Art 2015 NCVH New Cardiovascular Horizons Vein Forum 2015 A Multidisciplinary Approach to Otptimizing Venous Circulation From Wounds to WOW Anil K. Chagarlamudi, M.D. Cardiovascular Institute of the South Houma, LA
Disclosures None
US - Introduction Duplex US has become the test of choice for evaluation of venous insufficiency US is : Safe Non-invasive Cost-effective Reliable
US Probe Selection 4-7 MHz transducer is ideal for most veins Superficial veins Higher frequency probe (7.5 10 MHx) -provide better resolution Deep veins Curvilinear probe (3MHz) better depth of penetration Variable frequency probes Change frequency up or down
US - Settings During imaging low flow settings are used Pulse repetition frequency (PRF) set at 1500 Hz or lower Focus is set with the posterior wall to allow better resolution in the field of imaging Time Gain Compensation (TGC) set according to the echogenicity and depth of the relevant tissues Gain set to have a dark background when obtaining velocity waveforms to avoid overestimation Angle of insonation often set at 0 degrees
US - Maneuvers Distal augmentation Valsalva Active dorsiflexion and plantar flexion Parana maneuver Automatic cuffs Proximal augmentation REFLUX IS NOT STATIC
Distal Augmentation Manual compressions over calf or the varicose capacitance bed Squeeze and hold for 0.25 secs and release This allows interpretation of both phases systole and diastole Allows the spectral curve to display change in direction of flow
Valsalva Produces higher intra-abdominal pressure Done with forceful contraction of the abdomen Excellent for evaluation of reflux of the terminal and subterminal valves at the SFJ
Active dorsiflexion & plantar flexion Technically difficult for the examiner due to patient movement and pulsed doppler aiming Very effective in eliminating false negatives Helpful in patients with severe leg edema or lymphatically compromised lower extremities due to the extrinsic pressure on the vein from the edema
Parana maneuver Variation to the active muscular contraction Patient standing Rock forwards or backwards Causes isometric contraction of the calf muscles Also done by shifting weight from one leg to other Mimics muscular changes similar to walking
Automatic cuff devices Easy to use Facilitate compression augmentation Pressure from 80 120 mmhg Rapid, large caliber deflation port mimicks diastole
Proximal augmentation Similar to valsalva Apply proximal pressure to force blood down the vein Reverse velocities > 30 cm/sec can result in valve closure Cannot lead to reliable results Generally avoided as a testing method for reflux
Spontaneous flow Present in all normal veins Absence of spontaneous flow means obstruction central or peripheral to the point of augmentation
Phasic flow Phasicity flow in response to respiration Normal venous flow is phasic Changes in response to quiet respiration Non-phasic flow = Continuous flow
Continuous flow Usually low Usually due to obstruction central or peripheral to the site of interrogation
Pulsatile flow A-V malformations
Competent valve - PW
Incompetent valve - PW
Incompetent valve - PW
Competent valve - CDI
Incompetent valve - CDI
Ultrasound 3 Stages Diagnostic US Procedural US Follow-up US
DIAGNOSTIC ULTRASOUND
Diagnostic US
US Patient position 1. Standing 2. Standing 3. Standing
Patient position for scanning GSV STANDING on floor or platform Facing the examiner Open stance External rotation of the hip Knee slightly bent with heel flat Weight on the contralateral limb
Patient position for scanning - SSV STANDING on floor or platform Turned around facing away from examiner Open stance Step forward, knee slightly bent and heel flat Weight on contralateral limb
Imaging - Tip Observe in SAX and doppler in LAX
IF THERE IS REFLUX Measure true diameter Supine Measure largest diameter Standing Measure the diameter and depth of vein in SAX from SFJ / SPJ to the intended access point Evaluate access site in SAX and LAX
US - Report
US - Report
PROCEDURAL ULTRASOUND
Mapping From SFJ / SPJ to access point or vice versa Mark every 1 2 inches Identify and mark any aneurysms, tortuosities, large tributaries, access point, size, depth
Mapping Why? To determine size To determine depth Course of the vessel Location of large tributaries or perforators
Patient position for procedure GSV Supine Rev. Trendelenberg Leg slightly abducted and externally rotated SSV Prone Rev. Trendelenberg Pillow under foot to flex knee
Procedure - Access
Procedure - Access SAX short axis or transverse view Divides the vessel in cross section LAX long axis Divides the vessel longitudinally LAX long axis or longitudinal view Divides the vessel lengthwise
Procedure - Access
POST-PROCEDURE ULTRASOUND
Post-ablation scans - Why To confirm occlusion of the treated vein Insure patency of the deep system CFV, PV Insure patency of the epigastric vein
Immediate post-ablation scan Modified rule-out DVT protocol involving the ablated vein and the associated deep veins SAX - B-mode with and without compression SAX - Confirm the lumen is echo-free and demonstrate full coaptation of walls of deep vein LAX - with and without color demonstrating a patent SFJ, SPJ or other deep vein if perforators involved LAX with color to demonstrate patency of EV
Post-ablation scan
Post-ablation scans - Frequency Immediate post-ablation 3-7 days 6 weeks 3 months 6 months 1 year Yearly there after up to 5 years
Surveillance US Done to minimize the chance of recurrence Observe progressive nature of disease Arrest recruitment of new vessels
US Tips and Tricks GSV start at mid-thigh and then move to groin SSV start at mid-calf and move to popliteal fossa Do not concern yourself with every tributary; concentrate on tributaries that are same size or larger than the truncal vein it is connecting with If a vein is < 2mm no need for spectral doppler Do not waste time on perforators < 3mm Document normal and abnormal findings in main truncal veins Diameter measured in SAX ( ant. to post. walls) Spectral doppler waveforms done in LAX
US - Conclusions Reflux is not STATIC Look for the source does it match the clinical picture? Exam is very operator dependent Failure to identify and treat all sources may lead to early recurrence
Legs are staple articles and will never go out of fashion while the world lasts. - Jarrett and Palmer
Thank You