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1 Diana L. Neuhardt, RVT RPhS CompuDiagnostics, Inc. Clinical Ultrasound Specialists Phoenix, Arizona Financial Disclosure: none Before Know what you should be looking for Diagnostic parameters Know what you should be listening for Historical timeline Symptoms Know what you are describing In all cases the ultrasound is patient specific 1

2 Surrogate outcomes assess specific technical questions about a particular therapy. Surrogate outcomes may include patency of the ablated saphenous or perforating vein, patency of a venous stent, or hemodynamic results after interventions. Anatomic success Patency of an ablated vein and the length of the patent or obstructed segment of the vein, as confirmed with duplex scanning, should be reported when assessing anatomic success. Post-procedural duplex scanning 1 month, at 1 year, at 1-3 years, and 3 years is important to define periprocedural, early, midterm, and late failures. Anatomic success Timing of the study is important because saphenous patency after ablation on a peri-procedural duplex image (3 days) indicates technical failure, whereas late patency after early occlusion suggests recanalization. Neovascularization The type of recurrence on late duplex scanning should also be documented, because recanalization of a previously occluded axial vein should be distinguished from neovascularization, which implies the presence of multiple small tortuous connections between the saphenous stump or the femoral vein and a residual saphenous vein or its tributaries. 2

3 Hemodynamic Success Post treatment follow up ultrasound studies include presence or absence of recurrent reflux within the treated segments. This determines the technical failure or success of the procedure. Duplex Ultrasound Investigation of the Veins of the Lower Limbs after Treatment for Varicose Veins UIP Consensus Currently there is no systematic agreement from phlebology or vascular societies on how duplex imaging is best performed, or interpreted for follow-up. Standardisation of follow-up imaging and reporting would reduce the confusion and give better clarity to the end points of treatment. Duplex Ultrasound Investigation of the Veins of the Lower Limbs after Treatment for Varicose Veins UIP Consensus Duplex imaging will describe the morphological and haemodynamic situation at the same follow-up intervals as those for evaluation of clinical outcome. Therefore, clear recording of pre-treatment clinical features and duplex findings is essential, since they may influence the interpretation of post treatment results and expectations. Morphology: obliteration or patency? The presence of a patent terminal portion of the GSV is considered to be a normal finding after endovenous treatment, if it is less than 3cm in length. When only the distal incompetent part of the GSV has been treated, the competent proximal section will exceed 3cm in length. The proximal section of the GSV may receive inflow from a Giacomini vein, pudendal veins and other tributaries. After EVA, duplex usually shows a patent SFJ or SPJ with obliteration of the upper GSV/AASV or SSV. This obliteration dramatically reduces the compliance of the remaining few centimetres of patent vein. The long term haemodynamic fate of the residual saphenous stump is debated and its course should be monitored during duplex follow-up. 3

4 Persistence of reflux at the SFJ and/or at the level of the saphenous stump is always considered pathological. Any varicose veins in connection with this vessel should be imaged; infrequently this consists of an incompetent non-obliterated saphenous trunk, but more often recurrent thigh varicosities connect with the incompetent part of the GSV in the groin, either through an incompetent AASV or PASV, or directly. Obliteration of the trunk can usually be observed on completion of the procedure, but it usually takes 6 to 12 months before complete ultrasonographic disappearance is achieved. Morphology: obliteration or patency? Treated veins (GSV and/or AASV) should be assessed by their compressibility, as well as using colour flow. It is standard practice to treat the whole above knee GSV with EVLA and RFA and this vein should be obliterated in its entire course. Morphology: obliteration or patency? Foam sclerotherapy may be less targeted, but in most cases a similar procedure and outcome is expected. However, the sonographic appearance of the obliterated vein will depend on the stage of post-treatment evolution. In the initial stages the vein behaves differently depending on whether it has been treated with EVLA, RFA or foam Haemodynamics: presence or absence of reflux The presence of reflux following a Valsalva or compression-release manoeuvre is a pathological finding. This reflux may be present over the whole length of the treated vein or may be segmental and the possible escape points should be described (SFJ, perforating vein.) 4

5 Recommended Reporting Standards for Endovenous Ablation for the Treatment of Venous Insufficiency: Joint Statement of the American Venous Forum and the Society of Interventional Radiology Recommended Reporting Standards for DESCRIBING Ablation of Venous Segments Reports of long-term results should use uniform terminology: a. Recanalization (with or without reflux): documentation of flow in a previously occluded vein. b. Neovascularization: presence of multiple small tortuous connections between the saphenous stump or the femoral vein and the residual saphenous vein or its tributaries (new, or pre-existing dilated vessels outside the venous wall). c. Primary ablation: ablation after initial treatment. Reports of long-term results should use uniform terminology Describe the finding with specifics of treatment goals, i.e. Sonographic absence Sonographic present Fibrosis Sclerosis NOT thrombosis unless this is specific to description of pathology J Vasc Interv Radiol 2009; 20:S417 S424 Patterns of Recurrence: Non-Surgical Duplex Basis Critical analysis of findings/outcomes Pitfalls: Operator based Focused based ultrasound Standardization is lacking How about SOURCE of reflux? Sonographic Absence Sonographic Presence 5

6 Anatomic & Hemodynamic Success These measures are critical for the future as we assess our patient population of venous therapies Most critical: is this NEW or RECURRENT? of Recurrence? Reality of Recurrence Not failure Before Know what you should be looking for Diagnostic parameters Know what you should be listening for Historical timeline Symptoms Know what you are describing Summary In all cases the ultrasound is patient specific 6