A is for ANATOMY. Veins of Lower Extremity

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1 DISCLOSURE St. Joseph Mercy Health System endorses the Essentials and Standards of the Accreditation Council for Continuing Medical Education: Faculty are expected to disclose to the audience all relationships with pharmaceutical companies, biomedical device manufacturers, and other healthcarerelated for-profit entities... Michalene McPharlin has nothing to disclose

2 A is for ANATOMY Veins of Lower Extremity

3 Veins of Lower Extremity

4 Superficial Veins Small saphenous Great saphenous

5 Superficial Veins of Lower Extremity Veins at Saphenous Opening (Fossa ovalis)

6 Superficial Veins of Upper Extremity

7 Venous Valves Superficial Veins of Upper Extremity Extension of intima Provide unidirectional flow

8 Venous Perforators & Sinuses A: Perforators between GSV and PTV B: Soleal sinuses

9 Main Groups of Perforators (Vein Book, John J. Bergan) (J. Vasc Surg, 2002; 36:416-22)

10 (Vein Book, John J. Bergan) Anatomic Variants

11 Anatomic Variants Anatomic Variants (Duplex scanning in Vascular Disorders, 4 th Ed.) A. Most common B. Dominant basilic w/small cephalic C. Dominant basilic w/2 small cephalics D. Median cubital vein coming a deep muscular branch

12 B means BY THE BOOK Society for Vascular Ultrasound 4601 Presidents Drive, Suite 260, Lanham, MD Toll-free: Telephone: Fax: svunet.org

13 Professional Performance Guidelines Upper Extremity Venous Duplex Evaluation (2/5/13) Upper Extremity Vein Mapping for Creation of a Dialysis Access or Peripheral Vascular Bypass Graft (8/10/12) Evaluation of Dialysis Access (04/11/12) Quality Assurance Guidelines for Accuracy of Examinations in the Vascular Laboratory (3/13/12) Lower Extremity Vein Mapping (revised 11/11) Lower Extremity Venous Duplex Evaluation (revised 06/11) Lower Extremity Venous Insufficiency Evaluation (revised 10/10/10) Scope of Practice: Diagnostic Ultrasound Clinical Practice Standards Standards are designed to reflect behavior and performance levels expected in clinical practice for the Diagnostic Ultrasound Professional. These Clinical Practice Standards set forth the standards (principles) that are common to all of the specialties within the larger category of the diagnostic ultrasound profession. Individual specialties or subspecialties may adopt standards that extend or refine these general Standards and that better reflect the day to day practice of these specialties. Certification is considered the standard of practice in ultrasound. Individuals not yet certified may reference these Clinical Practice Standards to optimize patient care.

14 Intersocietal Commission on the Accreditation of Vascular Laboratories (ICAVL) 6021 University Blvd, Suite 500, Ellicott, MD Toll-free: Fax: Intersocietal.org/vascular 4.4.3B Duplex ultrasonography for the venous examination must include: 4.4.3B Duplex ultrasonography for the venous examination must include: B transverse grayscale imaging without and with transducer compressions; B long axis spectral Doppler evaluation with or without color imaging; B the entire length of the veins must be evaluated for assessing venous patency;

15 4.6.3B Lower Extremity Venous Duplex for Thrombosis and Patency B Transverse grayscale images without and with transducer compressions (when anatomically possible or not contraindicated) for assessing venous patency of the lower extremity must be documented as required by the protocol and must include at a minimum: 4.6.3B Lower Extremity Venous Duplex for Thrombosis and Patency i. common femoral vein; ii. saphenofemoral junction; iii. proximal femoral vein; iv. mid femoral vein; v. distal femoral vein; vi. popliteal vein; vii. posterior tibial veins; viii. peroneal veins; ix. additional images to document areas of suspected thrombus; and x. additional images (if required by the facility protocol).

16 Remember to Think Outside the Box Protocols are guidelines that represent best practice in the majority of patient situations. Thinking Outside the Box Atypical signs/symptoms or unusual findings compel you to obtain additional information, e.g., more anatomic images and/or flow patterns than stated in protocol. Innovative surgical procedures may require additional documentation in post-op or surveillance studies. Our goal should be to help answer the clinical question whether it follows a protocol or not.

17 C COMPLETES THE PROCESS The Most Important Question Did you help answer the clinical question/s?

18 Critical Components of Any Noninvasive Evaluation Requires thinking outside the box: truly listening to the patient, being willing to do more than what is stated in the protocol Requires knowledge of: Limitations of the study Normal anatomy & anatomic variants Normal & abnormal findings Differential diagnoses Limitations of the Study Body habitus Patient position and/or cooperation Access may be limited, e.g., staples, lines, tubes, drains, dressings Visualization may be difficult, e.g., edema, hematoma, scar tissue

19 Limitations (cont) Bones alter ability to thoroughly assess some veins of the upper extremity Collaterals often seen Presence of dialysis graft or fistula greatly alters flow characteristics Helpful Hints for Venous Studies To maximize color fill: Steer color box Decrease color scale (PRF) Decrease wall filters Increase color gain Increase Persistance Heel-toe transducer so vessel not parallel to skin line

20 Helpful Hints: DVT Study Reverse Trendelenburg position to evaluate the lower extremities helps to dilate veins Slight side lying to lateral decubitus position to decrease extrinsic compression Helpful Hints: Reflux Study Have patient stand Provide safety for patient such as having something they can hold on to, e.g., bed, hand rail, walker, etc Provide safety for technologist/sonographer, e.g., team concept, raised platform for patient to stand on, etc

21 Methodical Process Lower extremity: CFV, DFV, FV, PV, Tibials, GSV, SSV, Muscular Veins Perforators (when evaluating for reflux) Upper Extremity: IJ, Subc, Ax, Brach, Rad, Ulnar Cephalic & basilic (for vein mapping) Abdomen: Vessel/s of interest, e.g., IVC, Portal, Hepatic (Techniques in Venous Imaging, Steve Talbot, RVT and Mark Oliver, MD, RVT)

22 Completing the process includes providing a preliminary report

23 Lt Trans FV w/o comp Lt Trans w/o comp Does vein compress? Normal Flow Patterns? Spontaneous* Phasic* Augments with distal compression Augments with proximal release * Not normally evident in the tibial veins

24 Venous Reflux? GSV: At Rest GSV: With Valsalva

25 Completing the Process also includes Identifying Some Miscellaneous Findings... Bakers Cyst Hematoma Lymph node Sarcoma

26 In conclusion... Know the A, B, Cs of venous testing It will help you to provide important diagnostic information critical to the medical and/or surgical management of your patient. However, the value of that information is directly related to your knowledge, skill, and willingness to sometimes think outside the box in order to answer the clinical question. YOU make the Difference... Between an adequate study and an exceptional one Whether the patient needs to have additional images obtained Determining which treatment would be most beneficial Evaluating the success of a nontraditional treatment

27 YOU make the Difference... Did you help the patient? After all, that s why we re here!