Duplex ultrasound of Vericose vein

Doppler of varicose vein and treatment

1. Varicose veins DUPLEX US Dr. Ravi patel

2. DEFINI T ION Varicose veins are defined as dilated, elongated, tortuous and palpable superficial veins as a result of venous hypertension. The term commonly refers to the veins on the leg although varicose veins can occur elsewhere i.e. Abdominal Wall ,Anus , Vulva, Oesophagus. Varicose veins are bulging veins that are larger than spider veins i.e. typically 3 mm or more in diameter.

3. Venous System of lower limb Consists of: Deep system of veins which lies below the deep fascia. Superficial system of veins which lies outside the deep fascia (carry 10% blood) Perforating veins which pass through the deep fascia joining the superficial to the deep system of veins.

4. Long saphenous vein Originates at the medial border of the foot. It passes 1-1.5 inches anterior to the medial malleolus over the distal 1/3 rd of the tibia. It is accompanied by the saphenous nerve below the knee joint Travels close to the deep fascia except at the knee joint, where it may become subcuticular In the thigh it passes antero-superiorly to reach the saphenous opening which is 3.75 cm below and lateral to the pubic tubercle. The vein of Giacomini joins LSV to SSV in thigh , responsible for recurrences.

5. T he long saphenous vein (V) lies in The superficial compartment ,bounded by deep muscular fascia (upward arrow) and the saphenous fascia (downward arrow) long saphenous vein

6. Longitudinal scan of a sapheno-femoral junction. The superficial long saphenous vein (LSV) joins the deep superficial femoral vein (SFV) to form the deep common femoral vein (CFV)

7. Location of perforators Six Perforators joining the superficial to deep venous system are located at constant positions which are: 2, 4 and 6 inches above the medial malleolus (Cockett’s perforator) Just below the Tibial tubercle (Boyd’s) In the adductor canal of the thigh (Dodd’s perforator) Level of Mid-thigh (Hunter’s) Around 200 perforators are described most of them unnamed

8. Short Saphenous vein Arises on the lateral border of the foot by joining of lateral marginal vein and lateral deep venous arch. Passes behind the lateral malleolus Runs up in the midline posteriorly in the intra fascial compartment. Pierces the deep fascia in the upper part of the calf, and terminates in the popliteal vein in the midline 4cm below the popliteal skin crease. It is accompanied by the Sural nerve , lymphatics and popliteal nerve along its course.

9. T he short saphenous vein (V) is bounded by the deep fascia (upward arrow) and saphenous fascia (downward arrow). The medial gastrocenemius muscle (MG) and lateral gastrocenemius (LG) are shown on this image of the right leg

10. Location of short saphenous perforators Bassi’s perforator- 5 cm above calcaneous Soleus point perforator Gastroenemius point perforator

11. Valves in the veins Valves present in superficial veins. Prevent flow of blood from proximal to distal and from deep to superficial Absent from above groin level Valves can resist pressure up to 300 mm of Hg.

12. A normal valve in the superficial femoral vein.

13. Dr Ahmed SFJ Pre-terminal Valve / Terminal Valve Pre-Terminal Valve Saphenous Ligament

14. Interfascial Veins GSV Egyptian Eye Leaflets of the Valve

15. Varicose presentation More common in males in India Left lower limb more commonly involved Long saphenous system affected in 2/3 rd of cases

16. Negative pressure in thorax during inspiration to -6 mm. Calf muscle pump: Normal venous pressure in relaxed state 20mm of Hg.Rises to 80-100 mm of Hg during muscle contraction. Vis a tergo : arterial pressure transmitted to venous side through capillary bed Competent valves Venae commitants: lie by the side of artery, helped by arterial pulsation to propel blood. Factors Helping in Venous return

17. VARICOSE VEIN P rimary varicose (superficial s y stem a b n o rma l ly d i l a ted torto u s , no history of DVT) Intrinsic weakness of smooth muscle media layer of vein wall (hereditary, hormonal, endothelial damage) Intrinsic “leakiness” of valve S econdary varicose (deep system 2ry to obstruction or incompetence )with ankle oedema venous ulcer at ankle) Post–thrombotic damage to valve leaflets

18. Calf muscle pump dysfunction muscle wasting neuromuscular disease deep fasciotomies local vein valve failure within the muscle fascia sheath Venous obstruction DVT / Post-thrombotic syndrome Mass Congenital abnormalities ( Klippel - Trenaunay - Weber Syndrome) A rtery - Venous valvular in copetence Primary Secondary Impaired venous drainage Varicose veins etiology Reflux (most common)

19. Klippel Trenaunay syndrome Varicose veins Limb hypertrophy Port wine Stains

20. Complications due to vericosity Bleeding Thrombophlebitis Venous Hypertension leading to venous ulcer Calcification Talipes Equinovarus deformity of foot Eczematoid dermatitis and pigmentation Periostitis of subcutaneous surface of tibia Carcinoma in long standing v enous ulce r - Mar j olin s ulcer

21. Varicosities color duplex examination objectives 1-ascertian whether the deep or superficial system is patent 2-identify,localize,grade reflux in deep and superficial system 3-to determine the source of blood flow to varicose segment , evaluation of cause of varicosities 4-to evaluate the potential benefits for occluding the source of inflow to varicose segment 5- extent of post-thrombotic abnormalities

22. Telangectasia Dermis Reticular vein Varicose vein Perforators Sup. fascia Deep fascia Deep vein Superficial & Deep connections

23. Dr Ahmed Esawy Type Class Size Color I Telangectasia /spiders 0.1-1 mm Red II Venul-ectasia 1-2 mm Violet III Reticular veins 2-4 mm Blue IV No n - saphenous varicose 3-8 mm Blue V Sap h e n o u s varicose 7-8 mm Blue varicose veins Classification

24. D eep venous system incompetence A n enlargement of the deep venous system, which increases in standing position, consequently slow venous flow. Typical symptoms are restless legs, calf pain during the night, and severe muscle cramps. The degree of dilatation can be measured easily with M-mode during Valsalva maneuve r.

25. Evaluation of valvular competence in the deep venous system E valuated in thrombosis with a swollen lower extremity. With valvular competence , no significant retrograde is observed (a brief and low amplitude physiologic flow reversal may occur prior to valve closure). With valvular incompetence , high amplitude flow reversal will be observed during the entire period of abdominal compression. A long waveform corresponding to venous emptying will follow.

26. Evaluation of valvular competence in the deep venous system At the level of the thigh With the patient in decubitus, the Doppler sampling volume is placed within the femoral vein and pressure is applied on the abdomen or the patient is asked to do a Valsalva At the level of the calf With the patient erect , muscular compression should only result in minimal flow reversal, again related to normal valve closure. Prolonged and large flow reversal is suggestive of valvular incompetence .

27. Evaluation of valvular competence in the deep venous system Q ualitative assessment On color Doppler observing reversal of color- saturation, corresponding to forward and reversed flow directions, especially during functional maneuvers Quantitative assessment R elative to the duration of flow reversal can be obtained with spectru m.

28. Evaluation of valvular competence in the superficial venous system

29. Veins have leaflet valves to prevent blood from flowing backwards (retrograde flow). T he leaflets of the valves no longer meet properly allows blood to flow backwards and they enlarge even more this backflow will dilate the supple superficial veins making them tortuous and dilated (varicose veins). Valve damage Incompetence with reversal of flow due to pooling and venous hypertension. Familial factors with 'lax' veins. These distend slightly allowing the valve leaflets to no longer oppose each other. Injury or thrombosis. Both of these can lead to adherence of valve leaflets to the vein wall, rendering the valve useless. Varicose veins (valvular)

30. Dr Ahmed B shows a varicose vein with a deformed valve, abnormal blood flow, and thin, stretched walls. The middle image shows where varicose vein might appear in a leg. The illustration shows how a varicose vein forms in a leg. Figure A shows a normal vein with a working valve and normal blood flow.

31. In the normal cicumstance , the superficial system drains the subcutaneous tissues and periodically empties into the deep system via perforating veins. Flow direction should always be: Cephalad Superficial to deep.

32. INCOMPETENT FLOW With distal augmentation, flow initially goes cephalad. It then refluxes back down the leg through the malfunctioning valve . An incompetent perforating vein also allows blood to flow from the deep veins to the surface veins. This combination of back pressure causes dilation and tortuosity of the veins varicosites).

33. Diagram of the pathways of reflux Reflux begins at the saphenofemoral junction (SFJ) and extends down the great saphenous vein (GSV) to the thigh.At this point the reflux spills into a varicose tributary (point A) The incompetent tributary then refills the GSV at a lower level (point B) and leads to an additional segmental incompetence of the GSV. The GSV between the takeoff and reentry of the tributary is not incompetent. If this segment of GSV is visible to Doppler ultrasonography , it is probably traversable and a single access (near point C) may be all that is required for treatment of both the higher and lower segments If this segment is not visible, two punctures are needed (near points A and C) to treat both incompetent segments of the GSV.

34. B-mode appearance of varicose veins and perforators Varicose veins are relatively easy to identify on the B- mode image. They appear as single or multiple dilated tortuous vessels that vary randomly in diameter . They are superficial and may be located in the thigh as well as the calf. The main trunk supplying varicose areas, such as the LSV in the thigh, may be dilated but often has a reasonably even caliber and is frequently not visible on the skin surface.

35. Occasionally a large localized dilation can be seen in the main trunk, called a varix. Sometimes the supplying vein may appear reasonably small, but reflux is demonstrated with color and spectral Doppler. The easiest way of locating perforators is to run the transducer steadily along the trunk of the superficial vein in transverse section.A break in the fascia will be seen on the B-mode image as the perforator runs between the subcutaneous and subfascial areas .

36. Normally, the vein is 4 mm in diameter. Veins > 7 mm have a high incidence of reflux. Reflux can occur in smaller veins but is usually clinically unimportant. Peripheral to the takeoff of incompetent tributary veins, the caliber of the vein often decreases. Conversely, the caliber of the GSV generally increases at the level of a significant incompetent perforator vein careful search should be made at points of GSV dilatation for this important source of reflux

37. Inc o mp e te n t GSV n o rmal GSV

38. GSV standing GSV supine

39. The blue in the long saphenous vein shows flow towards the heart. The blood velocity waveform shows flow towards the heart as the thigh is sq u e e zed an d th e flow co n tin u e s in t he sam e d i recti o n a s th e sq u e e z e i s rel e as ed . A normal sapheno-femoral junction on squeeze/ release.

40. Anterior accessory GSV

41. c C ompensatory Anterior accessory GSV Hypo plastic GSV

42. Duplicated GSV

43. Echogenic lining Sclerosed vein

44. Thrombosed GSV

45. Transverse image of tortuous dilated varicose veins

46. Refl u x Retrograde Reversed flow due to Delayed closure of the valve 1ry or 2ry CUT off Values of NORMAL LIMIT 0.5 seconds

47. Reflux Velocity Volume ( Venous Filling index > 2ml/sec ) Duration T he duration and volume of reflux can be evaluated with spectrum analysis or with color duplex .

48. Superficial Venous reflux types Isolated ostial reflux SFJ SPJ combined ostial , p e r f o r a ti n g reflux. p e rf o ra t i n g reflux GSV / SSV reflux

49. E xamined Reflux sites d e ep thi g h V e i ns CFV Deep Femoral Vein Pro x im a l & Distal SFV p e rf o r a ti n g vein deep Veins Proximal & Distal Popliteal Vein Gastrocnemius Veins Posterior Tibial Veins Anterior Tibial Veins S u p e rfici a l V e i ns Sapheno-femoral Junction Great Saphenous Vein *GSV (Thigh /upper & lower leg) Sapheno-popliteal junction (SPJ) Small Saphenous Vein *SSV (mid leg)

50. venous reflux grading grade I reflux defined as retrograde venous flow that lasts only for 0.5-2 seconds grade I V reflux reversed flow persist as long as valsalva effort is maintained grade II reflux lasts slightly longer for 2- 3 seconds grade III reflux produces prominent reversed flow phase that persists 4-6 seconds < 0.5 sec NO reflux

51. Augmentation of flow toward the heart is seen in both instances (velocities mapped below the x-axis). However,upon release of external compression, flow directed toward the feet is seen in incompetent segments (velocities above the x - axis).

52. Relationship Between Reflux and diameter of the vein. The normal limit of the calibre of GSV 5 mm and SSV 3 mm in upright Sudden caliber change of the vessels is an important marker of regurgitant flow within that segment Perforating veins with diameters greater than 3.5 mm can also be taken as a sign of significant reflux

53. Spectral Doppler evaluation shows persistent retrograde flow beyond 0.5 second in the great saphenous vein suggestive of venous reflux. Retrograde flow can be seen up-to 3 seconds in (A) and 4 seconds in (B).

54. Normal flow pattern of the saphenous vein during Valsalva: flow stops during the maneuver; there is a very short, physiological reflux peak caused by the closing of the valve

55. Dr Ahmed Esawy

56. Reflux tips &tricks Distal compression is standard for forward flow But proximal compression or valsalva can be used but will demonstrate reverse flow as far as the first comptent valve so underlying incomptent valve is missed . Reflux seen by color and spectrum Reflux make turbulance as result of forward and reverse flow appear together

57. Dr Ahmed Esawy Prblem in quantifying reflux as in this example . T he LSV was very large (8) mm in diameter but the duration of reflux (0.9) blood flow during reflux is probably very significant due to the size of the vein it should be noted that volume flow calculation are not routinely used in venous examination

58. B: venous reflux (R) of 2 s duration is seen across SFJ A. venous reflux of 0.55 s duration is recorded across the SFJ following distal augmentation

59. P artial incompetence of a venous valve is demonstrated by an area of retrograde flow (arrow) between the two valve cusps

60. NO reflux with Valsalva

61. Reflux of 0.5 sec duration

62. Prolonged duration with Valsalva

63. Dr Ahmed Esawy SPJ incompetence Distal augmentation flow toward heart Following squeeze release retrograde flow in SSV

64. Incompetent SFJ Mickey Mouse view LSV is very large ,small branches are Dividing from junction LSV (L) ,anterolateral branch (arrow) C FV=V C FA=A

65. Transverse image of the left popliteal fossa showing an abnormally large sapheno-popliteal junction (arrow) ,proximal SSV (S) ,popliteal vein (V) and popliteal artery (A) . popliteal vein in this example but its position can vary

66. A large incompetent upper thigh perforator. The large perforator joins the deep superficial femoral vein (SFV) to the superficial long saphenous vein (LSV). On release of a thigh or calf squeeze, blood would flow from the deep vein through the incompetent perforator into the superficial system.

67. D iameter of the common femoral vein in the groin of > 14 mm at rest (patient lying down) and of > 20 mm after Valsalva is to be considered as an significant. D egree of deep venous insufficiency, and seems to correlate well with the typical clinical symptoms.

68. Chronic reflux gives dilatation and tortuous deformity of the superficial veins, with typical "cork screw" appearance; infra-valvular aneurysms are also common.

69. Enlargement of the vein is not always present, especially in the early stages of disease. Saphenous vein: diameter of only 3 mm (patient standing, Valsalva), with clear demonstration of reflux.

70. The popliteal fossa should also be evaluated in case of varices. Short saphenous vein (VSP) and gastrocnemius veins (GCNM) are frequently incompetent. They should be studied with the patient standing.

71. Cross section of the popliteal fossa: dilatation of the short saphenous vein in case of i n c o mp e te n c e .

72. Reflux occurring at the sapheno-femoral junction on colour Doppler. (a) forward flow; (B) reverse flow

73. Perforating Veins

74. Method to scan transversly to calf or lower thigh and the see perforators Calf vein incompetence is difficult or impossible to assess so if dilated mean incomptence Judicious compression on varices will show course of vein and reflux

75. Perforating Veins between Post tibial V. and GSV > 3 mm thickness Retrograde flow Traverse fascial plane

76. Perforating veins evaluation: patient erect. With compression of the calf, forward flow (blue, away from the transducer) is detected in the greater saphenous vein (top), SFV (bottom), and one perforating vein between them .—Because of its spiral configuration, the entire length of the perforating vein cannot be visualized on a single 2D image.

77. P erforator incompetence isolated perforator incompetence at distal thigh but also occur in calf from branches of ant or post arch vein In those selected cases where hemodynamic correction of varicose veins(CHIVA) is considered, detection of incompetent perforating veins is essential

78. Perforating vein coming through the fascia.

79. Pulsed Doppler confirmation of bidirectional flow in the incompetent perforating vein.

80. Recurrence of varicosis after surgery occurs in most cases in the groin, or at the level of perforating veins, which become incompetent. This image shows recurrence at the level of the former sapheno- femoral junction ; reflux is demonstrated using Color Doppler

81. VARICOSITY DISTRIBUTIONS

82. Varicose patterns on the leg often indicate the source of the problem Determining the source of the varicosities is important for treatment

83. J unctional tributaries are often the site of varicosities Saphenous nerve close contact with the GSV below the knee

84. Zone of Influence of GSV Terminal and subterminal valves at the SFJ Leaks cause VV Often causes varicosities in the tributaries Zone of influence GSV medial aspect

85. Zone of Influence of SSV and VG The sapheno - politeal junction is often the origin of reflux in the SSV The excess blood volume entering the SSV from the deep system causes varicosities to form in tributary braches that course along the posterior Calf Reflux in the VG often leads into the GSV and varicosities often occur in the posterior thigh VG-vein of giacomini

86. Varicose Veins Small Saphenous Reflux varicosities to form in tributary braches that course along the posterior aspect.

87. Varicosities of the Vein of Giacomini

88. Zone of Influence of LSVS The network of abnormal reticular vein demonstrate reflux A focal source of reflux often can not be found with ultrasound Spider veins often occur along the lateral aspect of the thigh and calf Large varicosities can occur LSVS- Lateral Subdermic Venous System

89. Varicose Veins Lateral Subdermic Venous System

90. U nusual distributions Varicose at the anterior aspect of the calf or lateral aspect of the thigh . The supply is frequently from varicose branches of the LSV or SSV, depending on the location of the varicose areas. varicose veins running along the lateral aspect of the thigh and calf can be related to isolated perforators located on the lateral aspect of the upper thigh.

91. Varicose veins in the lower posterior and posteromedial thigh can be supplied by the Giacomini vein. In this unusual situation, blood flows in a loop, across an incompetent saphenopopliteal junction and up the Giacomini vein, U nusual distributions

92. I n some patients, it may be impossible to clearly define the source of the varicose veins E specially if they are very small, are diffusely distributed and generally run into very small superficial tributaries.

93. RECURRENT VARICOSE VEIN

94. Possible causes of G SV recurrences Incomplete Ligation SFJ Neo-vascularization (cavernoma) Incomplete stripping of the G SV trunk in the thigh (Remnants of GSV) Duplicated GSV incomplete removal of incompetent Thigh or calf perforators failure to differentiate lesser from greater saphenous vein incompetence (incompetence of the SSV) Incompetent tributaries Secondary varicose veins

95. Possible causes of SSV recurrences incomplete ligation of the saphenopopliteal junction lncompetent Giacomini vein Incompetent perforators G SV incompetence Diffuse varicosities in the popliteal fossa

96. Difficulty in competency assess the assessment of patients with venous ulcers. continuous high-volume flow (hyperemic flow) in the superficial and deep veins due to infection. The high-volume flow toward the heart can lead to a reduction in reflux duration The leg can be reassessed when the hyperemia subsides (by antiobiotic therapy).

97. Saphenous pulsation on duplex may be a marker of severe chronic superficial venous insufficiency Duplex tracing of a typical saphenous pulse (SP) waveform Etiology may be AV connections (arterial varices)

98. SUPERFICIAL PHLEBITIS

99. Color Doppler examination is frequently carried out to see if there is thrombus , or to evaluate the extension of the thrombus in the deep system. Example: thrombosis of the greater saphenous vein with extension of the thrombus (arrows) in the femoral vein.

100. Due to inflammatory infiltration of the surrounding subcutaneous fat, a hyperechoic halo is visible around the inflamed vein in case of phlebitis

101. A marked inflammatory hyper-vascularization is always visible around the inflamed part of the vein, with hypertrophic arterioles which are not visible in normal conditions.

102. A typical low-resistance inflammatory flow is seen in these tiny arterioles. .

103. Sonographic triad of superficial phlebitis 1)H yperechoic halo 2) small arterioles around th e vein 3) low-resistance flow

104. Conservative management  Elastic crepe bandage – stockings  30-40mm Hg  Elevation of limbs  Above the level of heart  Graded compression stockings

105. Co ntd..  Unna boot  Nonelastic compression  Zinc oxide, calamine, and glycerine  Dressing changed once in a week  Infection should not be there  Compression methods  Reduce ambulatory venous pressure  Trans capillary leakage  Improve cutaneous micro circulation

106. Me d icati o ns  Calcium dobesilate  Improves lymph flow, reduce edema  Diosmin  Protects venous valves / anti inflammatory  Not proven much beneficial

107. USG guided Sclerotherapy

108. Scler o ther a py  Complete sclerosis of the venous wall  Indications  Uncomplicated perforator incompetence  Smaller varices  Recurrent varices  Isolated varices  Aged/unfit patients

109. Co nt d …  Sclerosants used are  Sodium tetradecyl sulphate  Sodium morrhuate  Ethanolamine oleate  Polidocanol  Mechanism of action  Aseptic inflammation  Perivenous fibrosis  Endothelial damage  Obliteration by intimal approximation

110. Ultrasound guided foam sclerotherapy Under Ultrasound guidance. Polidocanol is used Polidocanol converted in foam by mixing air using three way tap. Spread of foam monitored under USG guidance as it spreads. Apex of saphenous opening compressed by probe to prevent foam entering deep veins. Leg also elevated

111. Co nt d … Saphenofemoral incompetence DVT Peripheral arterial disease Hypersensitivity Co n t r aindi c a tion OPD procedure No anesthesia Advantages Anaphylaxis/shock Abscess Thrombophlebitis Intravenous hematoma Temporary ocular disturbances Disadvantages

112. Radiofrequency Ablation The intima of smaller veins can be destroyed by heat generation and denaturation of collagen using a probe consisting of a bipolar heat generator. Performed under ultrasound guidance and position of the probe is confirmed near the Saphenofemoral junction. Probe is heated to 85 degrees and gradually retracted down at a constant rate of 2-3cm/minute. must be avoided in presence of dilated veins, veins with aneurysms and thrombosed veins.

113. Endovenous Laser Ablation - EVLA  US guidance LSV canulated above knee jt  Guide wire passed beyond SFJ  Tip is placed 1cm distal to SF junction  Laser fibre inserted upto the catheter  Diode laser used for firing Veins of all sizes can be treated with this procedure

114. RFA and Endovenous Laser

115. Co nt d …  Thermal damage of endothelium – occlusion of vein  Laser energy acts on blood – in turn heats the vein wall.  Complications  Pain / ecchymosis  Hematoma  Skin burns  DVT

116. Interventional Procedures  Relieve complaints  Pain / discomfort  Reverse complication  Cosmesis

117. THANK YOU