LOWER EXTREMITY VENOUS DUPLEX ULTRASOUND: Chronic Venous Insufficiency Phillip J Bendick, PhD William Beaumont Hospital Royal Oak, Michigan Prevalence: Carotid ASO ~ 3M Peripheral Arterial Dz ~ 5M + CAD Venous Insufficiency ~ 12M ~ 25M Prevalence: Varicose veins ~ 25M Significant edema ~ 6M Skin changes ~ 2M Active ulceration ~ 0.5M Chronic venous changes are a direct result of chronic ambulatory venous hypertension Venous Collapse Venous Dilation
Normal Venous Hemodynamics Normal Venous Hemodynamics Inspiration Expiration Augmented flow The CEAP Classification: C Clinical signs E Etiologic classification A Anatomic distribution P Pathophysiologic dysfunction The CEAP Classification: C Clinical signs... 4 = Skin changes 5 = Skin changes with healed ulceration 6 = Skin changes with active ulceration The CEAP Classification: E Etiologic classification Congenital Primary Secondary The CEAP Classification: A Anatomic distribution Deep Superficial Perforator - alone or in combination
The CEAP Classification: P Pathophysiologic dysfunction Obstruction Reflux - alone or in combination Venous Clinical Severity Score (VCSS): Pain Edema Varicose veins Pigmentation Induration Venous Clinical Severity Score (VCSS): Active ulceration Number Duration Size Use of compression therapy Abnormal Hemodynamics Valvular Incompetence Abnormal Hemodynamics Normal valve closure time: Textbook CFV, FV, Pop V Prof FV, Calf V, Saph V Perforating V < 1.0 sec < 0.5 sec < 0.35 sec Abnormal Hemodynamics Valve closure time: Clinically significant valvular incompetence Valvular incompetence for the duration of the maneuver
Evaluation The deep venous system The deep venous system Obstruction Valvular competence The deep venous system Superficial veins The superficial venous system Great saphenous vein (GSV) Small saphenous vein (SSV) Superficial veins Small Saphenous Vein Great Saphenous Vein
SSV Function The Calf Muscle Pump The superficial venous system Obstruction Valvular competence Varicosities / Branches Function The Calf Muscle Pump Normal: 80% decrease in AVP Chronic Venous Disease
The Calf Muscle Pump Normal: 80% decrease in AVP Primary VV: ~50% decrease in AVP Varicosities (from the Latin for twisted and swollen vein) Hippocrates 500BC Varicosities (from the Latin for twisted and swollen vein) Hippocrates Galen 500 BC ~ 190 AD Recommended they be torn out by a hook Varicosities (from the Latin for twisted and swollen vein) Hippocrates Galen Aegenita 500 BC ~ 190 AD ~ 670 AD Described ligation/excision
Varicosities (from the Latin for twisted and swollen vein) Ambroise Pare Noted association of leg ulcers with varicose veins ~ 1570 AD Treatment Options Compression Ligation of the SFJ Ligation and Stripping Radiofrequency Ablation Laser Ablation US-Guided Sclerotherapy (foam) Radiofrequency and Laser Ablation Secondary varicose veins Post-thrombotic thrombotic syndrome Stasis changes Ulceration The Calf Muscle Pump Normal: 80% decrease in AVP Primary VV: ~50% decrease in AVP Post-thrombotic: thrombotic: +/- 10% change in AVP Anatomy Deep veins Superficial veins Perforating veins
Perforating veins Hemodynamic Forces in CVI Gravitational reflux (GSV) Failed perforator valves Cockett FB. The ankle blow- out syndrome. Lancet 1953 Hemodynamic Forces in CVI Failed perforator valves: Clinical importance (+)( Negus (1985) Ann Roy Coll Surg Eng Clinical importance (-)( Burnard (1988) The debate is still ongoing Br J Surg Evaluation The perforating veins Location / Caliber Valvular competence Primary varicose veins: ~ 20% of limbs in patients with Chronic Venous Insufficiency have incompetent perforating veins Perforating vein diameter: Competent 2.2 +/- 0.8mm Incompetent 3.7 +/- 1.0mm < 2.2mm 92% competent > 3.5mm 90% incompetent Sandri J Vasc Surg 1999
Valvular competence of perforating veins can best be determined using color Doppler imaging with flow augmentation Color Doppler imaging and spectral Doppler with flow augmentation may also be used Etiology of perforating vein incompetence? Theory 1: Increased deep venous pressure during calf muscle contraction Etiology of perforating vein incompetence? Theory 2: Volume / pressure overload at entry point of incompetent saphenous vein Primary varicose veins: Perforating vein incompetence is always associated with superficial venous insufficiency Labropoulos J Vasc Surg 2006 Primary varicose veins: Perforating vein incompetence develops at sites - in a descending manner at a re-entry entry point - in an ascending manner at an extension of superficial venous insufficiency Labropoulos J Vasc Surg 2006
Treatment of saphenous vein insufficiency decreases number of limbs with incompetent perforating veins: Stuart JVascSurg 1998 65% 37% Mendes JVascSurg 2003 ~90% ~30% Blomgren JVascSurg 2005 ~90% ~40% ESCHAR BrJSurg 2005 51% 42% Role of perforating veins in primary venous insufficiency: Incompetent perforating veins appear to be secondary to saphenous vein incompetence Role of perforating veins in venous ulceration? Primary varicose veins: ~ 50% of venous ulceration primarily related to varicose veins Valvular incompetence, CEAP 4-6: 4 SVI only ~ 50% Perforator only < 5% Saphenous vein surgery improves chronic venous ulcer healing: ESCHAR 12mo Sx Cx 36mo Sx Cx Ulcer healed 82 76 93 89 Recurrent ulcer 15 34 31 56
Role of perforating veins in primary venous insufficiency: Incompetent perforating veins appear to be secondary to saphenous vein incompetence Incompetent perforating veins may have a minimal role in venous ulceration in these patients Post-thrombotic thrombotic syndrome The calf muscle pump Post-thrombotic thrombotic syndrome: ~ 70% prevalence Recurrence of venous ulceration after surgery for superficial insufficiency Normal deep veins 1/17 6% Post-thrombotic thrombotic 23/23 100% O Donnell J Vasc Surg 2008 Post-thrombotic thrombotic syndrome: Recurrence of venous ulceration after surgery for superficial / perforator insufficiency Primary incompetence 20% Post-thrombotic thrombotic 46% Conclusions: Duplex ultrasound provides good documentation of patterns of venous insufficiency Deep Superficial Perforators North American SEPS Registry Gloviczki J Vasc Surg 1999
Conclusions: Saphenous vein surgery is associated with prevention of venous ulcer recurrence, particularly in patients with primary varicose veins Conclusions: Treatment of incompetent perforating veins alone has little effect on healing or recurrence of venous ulceration Conclusions: Treatment of directly associated incompetent perforating vein(s) may be important to decrease recurrence of venous ulceration in patients with Post Thrombotic Syndrome