Lower

Extremity
Venous
Insufficiency
Duplex
Objectives
• Define the clinical, etiologic, anatomic, and
pathophysiologic conditions of chronic venous valvular
insufficiency used as indicators for vascular laboratory
venous testing
• Describe both direct and indirect noninvasive vascular
testing performed by vascular laboratory personnel
• Define the role of duplex ultrasonography in the
evaluation of patients with lower extremity venous
valvular disorders
Anatomy

• Saphenous veins
• Great saphenous vein (GSV) and small saphenous vein (SSV)
• Tributaries include
• Anterior accessory saphenous vein (AASV)
• Posterior accessory saphenous vein (PASV)
• Vein of Giacomini (VOG)
• Lie within saphenous fascia layers (give “eye” appearance)
Anatomy—(cont.)

A transverse ultrasound image of the great saphenous vein illustrating the normal position of
the vein within the saphenous compartment. Arrows indicate fascia both superficial and deep to
the vein.
Anatomy—(cont.)

A transverse ultrasound image of the SSV within the saphenous compartment distally
within the leg. Arrows indicate fascia both superficial and deep to the vein.
Anatomy—(cont.)

• GSV
• Courses medially in the thigh and leg
• AASV is aligned with femoral artery and vein in a transverse plane; lies
within a saphenous compartment.
• AASV courses anteriorly through thigh; PASV courses posteriorly
through the thigh.
• PASV may connect with VOG.
Anatomy- SFJ Diagram
Anatomy—(cont.)

The “alignment sign” with the anterior accessory saphenous vein (AASV) aligned over the deep
system artery and vein, whereas the great saphenous vein (GSV) lies more medially.
Anatomy- SFJ with AAGSV
Anatomy—(cont.)
• Tributaries
• Vessels that drain into another major vein
• Pierce saphenous fascia, enter the saphenous compartment, and
drain into corresponding saphenous vein
• Often associated with bulging varicose veins
Anatomy—(cont.)

A tributary vein (T) positioned outside the saphenous compartment and superficial to the great
saphenous vein (GSV).
Anatomy—(cont.)

A tributary vein positioned superficially outside the saphenous compartment.

Anatomy—(cont.)

• GSV below the knee identified by “angle sign”

• Triangular form between the
• Gastrocnemius muscle
• Tibial bone
• GSV within fascia
• Helps differentiate saphenous vein from prominent tributaries
Anatomy—(cont.)

The “angle sign” of the great saphenous vein below the knee. A triangle is formed by the
gastrocnemius muscle (GM), the tibial bone (T), and the great saphenous vein (GSV).
Anatomy—(cont.)
• Duplications
• Most are segmental; complete duplications are rare.
• To be duplicated, both saphenous veins must follow the same
path and remain parallel within the fascia.
• Duplication demonstrates a beginning and end along the same
path.
Duplicated GSV
Anatomy—(cont.)
• Saphenofemoral junction (SFJ)
• Confluence of the GSV and common femoral vein
• Contains terminal valve of the GSV
• Second valve (preterminal) is distal to tributaries that join GSV
and the SFJ.
• Superficial epigastric vein (SEV) (tributary used as landmark for
treatment)
• Superficial external pudendal vein
• Superficial circumflex iliac vein
Terminal and preterminal valves
Terminal and preterminal valves cont.
SEV
SEV
Anatomy—(cont.)
• SSV confluence with deep system is variable.
• Popliteal vein at the saphenopopliteal junction
• Gastrocnemius vein
• Distal femoral vein of the thigh
• Small unnamed deep vein
• Perforating vein at the posterior thigh
• GSV via the VOG
SPJ with VOG
SPJ
Anatomy—(cont.)
• Venous valves
• Leaflets can be identified on B-mode imaging.
• Bicuspid valves with leaflets that point in the direction of normal
venous drainage
• Vary in number, increasing frequency with distance away from
the heart
• Open with muscular contraction and close with muscular
relaxation
• Series regulates blood return from skin to tributaries to
saphenous veins to perforators to deep veins to heart.
• Incompetent valves allow abnormal retrograde flow.
Anatomy—(cont.)

Bicuspid leaflets of a venous valve.

Anatomy—(cont.)

Figure 20-8. A Doppler spectrum demonstrating retrograde flow or reflux (displayed above the
baseline).
Risk Factors

• Age • Family history

• Previous DVT • Occupation requiring long
• Female periods of standing or sitting

• Pregnancy • Congenital abnormalities

• Obesity
Signs and Symptoms
• Visual signs include
• Spider veins
• Telangiectasias, reticular veins
• Varicose veins
• Edema (also a palpable sign)
• Skin changes
• Ulceration
Signs and Symptoms—(cont.)
• Edema
• May patients have temporary swelling at the end of a work day,
after prolonged standing, or as a consequence of certain
activities or leg positioning
• Edema source must be differentiated; sources include (besides
venous obstruction or insufficiency)
Lymphatic obstruction Sympathetic tone
Cardiac disease Lipid disorders
Arterial disease
Signs and Symptoms—(cont.)
• Skin changes
• Localized redness (with light or dark coloration)
• Atrophic blanche
• Corona phlebectatica (cluster of veins and skin changes)
• Lipodermatosclerosis (hardening of skin)
• Ulcerated wounds
Signs and Symptoms—(cont.)
• Other symptoms
Heaviness Pain
Tension Burning
Aching and fatigue Itching
Restless legs Skin irritation
Muscle cramps Tightness
Tingling discomfort
Sonographic Examination
Techniques
• Duplex ultrasound is standard technology to evaluate CVI.
• Uses include
• Screening
• Definitive diagnosis
• Pretreatment mapping
• Peritreatment mapping, guidance, and completion exam
• Posttreatment follow-up
• Longer term patient follow-up
Patient Preparation
• Symptoms should be assessed.
• Testing procedure should be explained to patient.
• Patient removes clothing from waist down (except
undergarments).
• While standing, patients may wear shoes or nonslip
booties.
• Sonographer should review Valsalva maneuver with
patient before beginning the exam.
Patient Positioning
• Deep veins are evaluated initially using reverse
Trendelenburg position.
• CVI evaluation should then be performed with the patient
standing.
• A platform can be used to allow for better ergonomic positioning.
• Standing allows for optimal dilatation and venous filling.
• Patient shifts the weight onto the leg not being examined.
Patient Positioning—(cont.)

A platform device used for evaluation of patients in the standing position.

Patient Positioning—(cont.)
• Contraindications to standing include
• Advanced CVI with obvious varicose veins and/or severe reflux
• Patients who are susceptible to
• Fainting
• Motion sickness
• Dizziness
• Nausea
• Patients who are handicapped or have extreme discomfort while
standing
Patient Positioning—(cont.)
• Reverse Trendelenburg should be used if standing is not
possible.
• In order to minimize patient discomfort, the following
exam order is recommended:
• Most symptomatic or affected thigh
• Least symptomatic or affected thigh
• Most symptomatic or affected calf or saphenous vein
• Least symptomatic or affected calf or saphenous vein
Patient Positioning—(cont.)
• This order reduces standing time as patient can sit with
leg dangling off side of bed for calf evaluation.
• GSV is examined with patient’s knee rotated outward.
• SSV is examined with the patient’s back facing the
sonographer.
• Sonographer position and ergonomics are very important.
• Height-adjustable stools
• Keep torso upright
• Keep arms as close to the body as possible
Patient Positioning—(cont.)

Proper patient and technologist position for a sitting CVI examination.

Patient Positioning—(cont.)

An adjustable examination stool used by technologists during venous evaluations.

Scanning Technique
• Essential protocol includes evaluation of patency and
reflux.
• Deep veins (femoropopliteal and calf veins)
• Perforating veins
• Veins in saphenous compartments
• Nonsaphenous superficial veins
• Tributaries
• Also include differential diagnosis of nonvenous
pathologies
Scanning Technique—(cont.)
• If acute deep vein thrombosis (DVT) is identified, CVI
exam is discontinued and patient is referred for
treatment.
• Chronic DVT is part of CVI examination.
• Suspected in patients with history of DVT

• Superficial thrombosis does not deter evaluation of CVI.

• Superficial thrombosis should be noted and may be treated in
thrombus close to deep system junction.
Scanning Technique—(cont.)
• Examination begins at groin.
• Vein compression in a transverse orientation should be
completed.
• Deep veins are evaluated for absence of thrombus.
• Deep and superficial venous systems are evaluated with
Doppler for valvular insufficiency.
• Several diameter measurements of the GSV should be
documented
Determination of Venous Flow
Patterns
• Color flow is helpful but spectral Doppler should be used
to determine flow directions and reflux times.
• Compression maneuvers are used to elicit reflux.
• Recommended to use automatic cuff system to perform
compressions
• Cuff is placed around upper calf to test veins above the knee or
thigh for CFV
• Cuff can be placed around ankle for calf veins or left on upper
calf.
• Cuff should quickly inflate to approximately 70 to 80 mm Hg, hold
for a few seconds, then quickly deflate.
Determination of Venous Flow
Patterns—(cont.)
• Normal responses to compressions:
• Proximal compression
• Cuff or other technique (i.e., Valsalva maneuver) is used to compress
veins proximal to segment being evaluated.
• Flow should stop during compression and resume upon release of
compression.
• Distal compression
• Cuff or other technique is used to compress veins distal to segment
being evaluated.
• Flow should increase during compression (in an antegrade direction)
and stop upon release of compression.
Determination of Venous Flow
Patterns—(cont.)
• Abnormal responses:
• Proximal compression
• Retrograde flow occurs during compression.
• Antegrade flow resumes upon release of compression.
• Distal compression
• Increase in antegrade flow during compression
• Retrograde flow is noted upon release of compression.
Determination of Venous Flow
Patterns—(cont.)
• Reflux duration is dependent on
• Vein filling with blood and emptying with compression
• Duration of compression
• Interval between compressions
• Should wait at least 30 s between testing sites

• Reflux duration (time measurement) should be performed

with spectral Doppler with vein in longitudinal image.
Determination of Venous Flow
Patterns—(cont.)
• Other compression methods:
• “Parana maneuver”
• Force patient to shift weight slightly
• Hand compression
• Less reproducible but allows more testing variability
• Valsalva maneuver
• Laughing, coughing, or talking may be alternatives
Definitive Diagnosis for CVVI
• Complete evaluation of deep and superficial veins
• Include identification of any differential diagnoses (other types of
edema, arterial pathology, masses, etc.)

• Three common test objectives

• Selection of patients for thermal ablation
• Examination of patients of a phlebology clinic with perioperative
capabilities
• Examination of patients for limited or extensive
stripping/ligation/phlebectomy
Definitive Diagnosis for CVVI—(cont.)
• Each test objective may require slight modification to
protocol requirements.
• Patients requiring more extensive treatment may require more
extensive evaluation.
• Examinations may need to include extensive drawings of findings,
including sources of reflux, segments of nonrefluxing veins, and
drainage points.
• Vein diameters and distance from skin or other landmarks may be
needed.
Quantification of Reflux
• Measurement of reflux duration preferred over measurement
of peak reverse flow velocity or volume flow rate
• Normal valve closure times
• <0.5 seconds for saphenous veins and tibial veins
• <1 s for femoropopliteal veins
• <0.35 seconds for perforating veins

• Longer durations associated with abnormal reflux

• Duration of reflux depends on vein diameter, venous blood
volume distally, strength, and duration of distal compression
and characteristics of distal venous network.
Diagnosis—Spectral Doppler
Waveforms—(cont.)

A venous Doppler signal demonstrating reflux during a Valsalva maneuver.

Diagnosis—Spectral Doppler
Waveforms—(cont.)

A normal venous Doppler signal with no reflux present.

Treatment Types
• Treatment for superficial • Treatment for deep venous
venous disease disease
• Stripping and ligation • Anticoagulation
• Endovenous thermal • Valve replacement
ablation • Venoplasty/stenting
• Chemical • Thrombolysis
ablation/sclerotherapy • Chemical/physical
• Phlebectomy recanalization
(microincision)
Treatment Types—(cont.)
• Stripping and ligation have been traditional treatment.
• Associated with “neovascularization”; reappearance of varicose
veins

• Endovenous thermal ablation has become popular choice,

replacing stripping and ligation for most individuals.
• Performed with either radiofrequency or laser energy
• Vein is “closed” from within.
Treatment Types—(cont.)
• Endovenous thermal ablation
• Vein is accessed under ultrasound guidance.
• Guidewires and sheaths are placed.
• Thermal device tip is positioned in saphenous vein distal to
confluence with deep venous system.
• Anesthesia is placed in saphenous sheath.
• Heating of thermal device is activated.
• Device is pulled back through insertion site.
• Due to thermal injury inside vein, vein gradually shrinks.
• Treated vein will disappear after 6 to 9 months.
• Prior to disappearance, treated vein will appear “thrombosed.”
Treatment Types—(cont.)

An ultrasound image of the great saphenous vein with a thermal ablation device in place
just distal to the saphenofemoral junction (arrow).
Treatment Types—(cont.)

Tumescent anesthesia injected around the saphenous sheath and surrounding tissue.
Treatment Types—(cont.)

A postablation ultrasound of the great saphenous vein with no flow present.

Treatment Types—(cont.)
• Chemical ablation
• Foamed or liquid chemical (osmotic, detergent, or corrosive
agent) is injected directly into vein.
• Effective treatment for small or tortuous veins
• Often used as a complement of thermal ablation