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Venous Insufficiency (Reflux)

SUBJECT: Venous Insufficiency (Reflux) Ultrasound
SECTION: Vascular Ultrasound
ORIGINATOR: Kraig Schuster
REVISED DATE: September 8, 2014

Scheduling: One-hour time slot.

Prep: None.

Patient Position: Reverse Trendelenburg position with head elevated about 10-20 degrees. Patient may be requested to sit or stand in order to reproduce symptoms.

Equipment: Color flow duplex ultrasound unit with 5.0 MHz and 7 MHz linear array transducers.
***Procedure should be performed at the lowest possible power settings.

Objective:

  1. Assessment of lower extremity valvular competency.
  2. Detection of incompetent perforator veins.

Exam Protocol: The venous insufficiency ultrasound exam has three major components:

  1. Patency: A complete exam of the deep and superficial veins of the lower extremity for evidence of acute or chronic DVT.
  2. Venous Insufficiency Exam (reflux): Assessment and grading of any retrograde flow in the deep and superficial veins of the lower extremity.
  3. Localization of perforating veins may be requested.

Patency Exam: The patency exam will consist of a transverse compression exam of the lower extremity veins for DVT. The Common Femoral vein through the Popliteal, Posterior Tibial, Peroneal, and Greater Saphenous Veins should be evaluated in this fashion. The vein will be compressed sequentially every one to two centimeters with moderate probe pressure. The vein should be observed to completely coapt and then reopen as pressure is released.

Venous Insufficiency Exam:

  1. Place the transducer on the mid FV and have the patient Valsalva while recording the spectral Doppler tracing. If the Valsalva maneuver does not cause retrograde flow, then squeeze the thigh distal to the transducer to cause augmentation while recording the spectral tracing. Using the time scale on the display, note the duration of any retrograde flow.
  2. A spectral tracing is taken at the popliteal vein with Valsalva. If the Valsalva maneuver doesn’t cause retrograde flow then distal augmentation is performed to demonstrate reflux.
  3. The transducer is then placed on the Greater Saphenous vein near the origin and just inferior to the epigastric vein branch and a spectral Doppler tracing is taken with Valsalva. Distal augmentation is also performed if the Valsalva maneuver doesn’t cause retrograde flow.
  4. The Greater Saphenous vein will have a spectral tracing taken at the mid and distal thigh with Valsalva, and distal augmentation if the Valsalva maneuver doesn’t cause reflux.
  5. If a duplicated GSV is seen it should also be evaluated for venous reflux.
  6. If requested, the Posterior Tibial, Peroneal, Anterior Tibial, and Lesser Saphenous veins may be evaluated using distal augmentation, and/or the Valsalva maneuver to assess valve competency.
  7. Because the surgeon has been starting most laser ablations of the GSV slightly below the knee, a transverse measurement of the GSV diameter will be obtained at 5 cm. BK.

Perforator Exam: This portion is performed as an adjunct to the venous insufficiency ultrasound exam. It is used for the evaluation perforator vein incompetence. Ulcers are frequently a local process due to perforator valve incompetence. The area adjacent to the ulcer is interrogated for perforating veins. Competent perforators have valves that only allow flow towards the deep system. An incompetent valve will allow retrograde flow. A spectral tracing of the perforator vein with distal compression or foot dorsi flexion should be taken.

Imaging Protocol

Patency exam

  • Transverse noncompressed/compressed CFV
  • Transverse noncompressed/compressed mid FV
  • Transverse noncompressed/compressed popliteal vein
  • Longitudinal color flow mid Posterior Tibial / Peroneal veins

Venous Insufficiency
***The time of any demonstrated reflux will be measured on the image (Augmentation images are only needed if Valsalva doesn’t produce reflux).

  • Longitudinal mid FV duplex with angle-corrected spectral Doppler with valsalva
  • Longitudinal mid FV duplex with angle-corrected spectral Doppler with distal augmentation
  • Longitudinal Popliteal vein duplex with angle-corrected spectral Doppler with valsalva
  • Longitudinal Popliteal vein duplex with angle-corrected spectral Doppler with distal augmentation
  • Longitudinal GSV, near saphenofemoral junction, duplex with angle-corrected spectral Doppler with valsalva
  • Longitudinal GSV, near saphenofemoral junction, duplex with angle-corrected spectral Doppler with distal augmentation
  • Longitudinal GSV upper thigh with angle-corrected spectral Doppler with Valsalva
  • Longitudinal GSV upper thigh with angle-corrected spectral Doppler with distal augmentation
  • Longitudinal GSV mid-thigh with angle-corrected spectral Doppler with Valsalva
  • Longitudinal GSV mid-thigh with angle-corrected spectral Doppler with distal augmentation
  • Longitudinal GSV distal thigh with angle-corrected spectral Doppler with Valsalva
  • Longitudinal GSV distal thigh with angle-corrected spectral Doppler with distal augmentation
  • Transverse diameter GSV at upper, mid, and distal thigh.
  • Transverse diameter GSV at 5 cm. BK
  • Longitudinal Lesser Saphenous duplex with angle-corrected spectral Doppler with distal augmentation and/or valsalva (upper calf if LSV is not specifically requested).

If specifically requested:

  • Longitudinal PT, Per V., and ATV’s duplex with angle-corrected spectral
  • Doppler with distal augmentation and/or valsalva.
  • Longitudinal Lesser Saphenous duplex with distal augmentation and/or valsalva (upper and mid-calf).

Perforator: Longitudinal Perforator vein duplex with angle-corrected spectral Doppler with distal compression or dorsi flexion of foot.

Diagnostic Criteria
Venous Insufficiency Ultrasound

Compression Criteria for Venous Thrombosis:

  • Lack of Venous compressibility.
  • Visualization of intraluminal thrombus with complete or partial obstruction of the vein lumen.

Criteria for Venous insufficiency:

  • Competent valves: "0"(0 to < 0.5 sec.)
  • Incompetent valves:
    • "1" Mild (0.5 to < 1 sec.)
    • "2" Moderate (1 to < 2 sec.)
    • "3" Severe (> 2 sec.)

Criteria for Incompetent Perforator Veins: Reverse flow, or flow from deep to superficial is abnormal.

References:

  1. Daigle R: Venous Colorflow Duplex Imaging of the Lower Extremities. In Program Supplement US: the Basics in Vascular Ultrasound July 31 and August 19, 1997 pp 10-23. TIP-TV 1997, General Electric Company.
  2. Priest DL, Zwiebel WJ: Chronic Venous Insufficiency, Varicose Veins, and Saphenous Vein Mapping. In Zwiebel WJ (ed): Introduction to Vascular Ultrasonography, 3rd ed. 1992, pp 323-331.

View the Venous Insufficiency US worksheet

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