Chapter 20: Venous valvular insufficiency testing Flashcards
Superficial vein at the anterior thigh within a saphenous fascia
Anterior accessory great saphenous vein
Clinical etiologic anatomic pathophysiologic classification of venous disease
CEAP
Chronic venous insufficiency involving venous valvular malfunction; no obstructions
Chronic venous valvular insufficiency
Term describing the effects of increased pressure stockings that compresses the leg and its veins
Elastic compression
superficial vein in the medial calf, knee, and thigh within a saphenous fascia with variations in anatomy among patients
great saphenous vein (GSV)
leg swelling
leg edema
swelling attributed to fat tissue, most commonly painful
lipedema
swelling attributed to lymph channels or lymph node disorders
lymphedema
superficial veins exclusive of the saphenous systems. May originate from a gluteal, vulvular, posterolateral thigh-knee perforators, lower posterior thigh, popliteal fossa tributaries, and sciatic nerve vein source; also includes neovascularization
nonsaphenous veins
graphic presentation of waveforms that reflect temporary changes of regional venous volume
plethysmography
superior vein, posterior medial thigh within a saphenous fascia
posterior accessory great saphenous vein
abnormal reverse flow in veins with incompetent or absent valves
reflux
superficial dermal vein with diameter measuring less than 3 mm
reticular vein
term for telangiectasias, a small cluster of vessels at the skin surface that may be red, blue, or purple with diameters between 0.5 mm and 1 mm
spider vein
superficial vein in the posterior aspect of the calf within a saphenous fascia
small saphenous vein
a vein that terminates or empties into another; often truncal vein
tributary vein
superficial vein with diameter measuring 3 mm or greater
varicose vein
extension of SSV to GSV within a saphenous fascia
vein of Giacomini
vein diameter enlarged
valve sinuses enlarged
tortuosity, varicosities or venous aneursyms
B-mode ultrasound findings of CVVI
saphenous veins and tributaries retrograde flow >500 ms
deep veins retrograde flow > 1.0 s
perforating veins retrograde flow > 350 ms
Spectral Doppler ultrasound findings of CVVI
Retrograde color flow
turbulent or multiple color patterns seen within valve sinuses
Color-flow imaging
Patients presenting with CVVI do not have _____
venous obstruction
unceasing valvular insufficiency
due to valve damage
intermittent valvular insufficiency
function of venous dilatation
reversed flux of blood
CVVI
CEAP classificaion
clinical
etiologic
anatomic
pathphysiologic
most commonly primarily CVVI concern
Great saphenous vein
The greater saphenous vein is located in the saphenous compartment between ______ and ______.
superficial saphenous fascia
deep muscular fascia
Identification of the GSV below the knee is aided by the _____ sign in cross-sectional imaging
triangle sign
components of the triangle sign
gastrocnemius muscle
tibial bone
saphenous fascia
two major valves at or near the SFJ
terminal
preterminal
The terminal valve is located ____ cm from the actual SFJ
0.4
The preterminal valve is located ____ cm from the actual SFJ
3.1
______ and _____ valves in femoral vein influence SFJ flow
suprasaphenic
infrasaphenic
can occur distally to a normal terminal valve or even distally to both valves
perijunctional GSV reflux
common SFJ tributaries
superficial external pudendal
superficial circumflex iliac veins
landmark for saphenous ablation treatment
superficial inferior epigastric vein
identifies anterior accessory great saphenous vein in upper thigh
AAGSV and deep femoral vessels form a straight line perpendicular to transducer in cross sectional image
alignment sign
anterolateral in calf, crosses around knee to an anteromedial position in the thigh, and terminates at the SFJ
AAGSV
posterior to GSV in thigh and calf
PAGSV
calf segment of PAGSV
Leonardo vein/ posterior arch of GSV
within saphenous compartment in posterior calf parallel to sural nerves
small saphenous vein
most common SSV termination
popliteal vein via saphenopopliteal junction
cranial extension of SSV that communicates with GSV by terminating into posterior thigh circumflex vein
Vein of Giacomini
described by its superficial-deep vein connections and its distances from anatomic landmarks
perforating vein
embryologic remnants that course parallel to sciatic nerve in thigh
can function as a collateral pathway for the femoral vein
associated with Klippel-Trenaung syndrome
persistent sciatic veins
primarily a test of venous reverse flow (reflux) detection
venous valvular insufficiency
Function of lower extremity venous system
return blood from extermity back to heart and lungsW
What affects Lower extremity venous flow?
distal pumping
proximal resistance
gravity
Venous blood flow volume is affected by:
size and quantity of veins
Veins have valves to make venous flow ______.
unidirectional
3 types of disorders that affect lower extremity venous bicuspid valves
venous valve agenesis
venous valve damage
venous valve leakage
most common finding in women with varicose veins but no significant edema
segmental reflux
where segmental reflux starts
reflux source point
where segmental reflux ends
reflux drainage point
Over __% of population will develop CVI.
50
reticular veins are also known as _____
spider veins
ending of dilated little vessels
telangiectasias
veins with diameters greater than 3 mm
varicose veins
edema that affects fat tissue
lipedema
most prevalent sign of significant phlebopathology
intermittent edema
enlarged hypoechoic channels in thigh, lower leg, and foot
lymphatic obstruction
determines a numerical quantitative index applicable or time-rated treatment related patient follow
clinical severity score
relates daily activities to compressive therapy
disability score
Focused on improving quality of life
quality of life questionnaire
two major diagnostic goals of Duplex sonography with CVVI
to exclude deep venous obstruction or acute thrombosis
evaluate the function of venous valves or reflux detection
identifies location of reflux source, channel, and drainage of veins
pretreatment assessment/ mapping
marks skin following veins, documents patency of deep venous system and efficacy of superficial venous ablation or eradication
peritreatment ultrasonography
Endovenous thermal ablation is done by ____ or ____.
radio frequency
laser energy
After thermal ablation, the treated vein segment gradually shrinks and sonographically disappears over ___ months.
6-9
formal term for sclerotherapy
chemical ablation
foamed or liquid chemical injected into vein
chemical ablation
The deep veins are evaluated in ______ position.
reverse Trendelenburg
The sonographer should evaluate superficially CVVI with patient _____.
standing
Antegrade flow is _____ and ____ the baseline.
toward the heart
below
Retrograde flow is ____ and ____ the baseline.
abnormal, reflux
above
Normal flow in vein proximal to compression _____ during compression and _____ during decompression.
increase
stop
_______ is dependent on vein filling with blood and vein emptying with compression.
reflux time duration
maneuver used to test valves above and below the knee
parana maneuver
Normal vein
smooth thin-walled with obvious change in venous diameter, fully compressible, hypoechoic lumen
enlarged veins
incompressible
echogenic material within lumen
thrombus that is soft and deformable
acute DVT
vein diameters that are diminitive in caliber, rigid and nondeformable material, may appear as fibrous strands or webs within lumen
chronic post thrombotic changes
increase in collateral vein diameters, veins are completely compressible, some valve sinuses may appear prominent with thickened valve leaflets, may eventually become tortuous varicose or even aneurysmal
CVVI
Normal venous waveforms
spontaneous
phasic with respiration
unidirectional toward the heart
partial obstruction causes _____ flow and a lack of flow augmentation.
continuous
arterial, venous, or fistula like flow causes
recanalization
neovascularization
inflammation
Reflux duration of saphenous vein valves
55 m/s
Reflux duration of deep femoropoliteal veins
less than 1sw
Reflux duration of perforating vein valves
less than 350 ms
transducer emits infrared light and detects signal reflected from blood within cuteaneous vessels
venous photoplethysmography
Normal FT
longer than 25 seconds
Normal venous FR
less than 2mL
Normal RV%
less than 20-35%
very low VV
calf venous thrombosis
chronic obstruction
high VV
abnormally high venous pooling because of larger or numerous veins
FT shorter than 10 seconds
severe reflux
FT shorter than 25 seconds
mild to moderate reflux
FR greater than 2 mL/s
venous insufficiency
RV% greater than 20-35%
increased ambulatory venous pressures
can show small superficial vessels upt o 1 cm in the skin; demonstrates subcuteaneous veins with a diameter or 0.5 to 2 mm
near-infrared imaging
______ is one of the most prevalent diseases.
CVVI
Within which of the following positions can a true saphenous vein be determined?
a. deep muscular fascia
b. subdural lipid layer
c. saphenous fascia
d. anterior vascular compartment
c
Which of the following is aligned with the deep system?
a. anterior accessory saphenous vein
b. great saphenous vein
c. posterior accessory saphenous vein
d. small saphenous vein
a
Into which of the following vessels does the small saphenous vein terminate?
a. popliteal vein
b. gastrocnemius vein
c. distal femoral vein
d. any of the above
d
What is the term for genetically absent venous valves that me complete or localized, creating reflux at any time under any conditions?
venous valve agenesis
What is an important factor that has correlation with reflux probability?
venous diameter
What are other causes of leg edema that may mimic venous obstruction or valvular insufficiency?
a. lymphatic obstruction
b. cardiac disorders
c. lipedema
d. all of the above
d
What is the area of phlebology that includes primarily visual signs of venous insufficiency?
aesthetic phlebology
A patient presents to the vascular lab with visible spider veins. Based on this information, what woul this patient’s clinical CEAP classification likely be?
C1
A patient presents to the vascular lab with chronic bilateral leg swelling. Upon duplex assessment of the venous system, the deep system was found to be unremarkable, although a reflux was demonstrating in the bilateral great saphenous veins. What is the most likely CEAP classification for this patient?
C3EpAsPr
Before assessing the venous system for insufficiency/reflux, which of the following should be performed?
a. evaluation of the deep venous system for obstruction or thrombosis
b. evaluation of the arterial system for atherosclerotic development
c. mapping of the superficial venous system
d. auscultation for bruits in the lower extremitiies
a
To best demonstrate valvular incompetence, which position should the patient be examined in?
standing
When performing an examination for CVVI, patency and flow characteristics should be documented at all of the following locations EXCEPT:
a. common femoral vein
b. femoral vein
c. popliteal vein
d. anterior tibial vein
d
Which technique should be used to quantify reflux flow patterns?
spectral Doppler
Pathologic flow or reflux occurs during _____ of an automatic cuff when the cuff is distal to the site of insonation./
decompression
Which of the following describes the proper use of an automatic cuff compression device?
a. rapid inflation from 70 to 80 mm Hg of pressure, held for a few seconds and then released quickly
b. paced inflation from 70 to 80 mm Hg of pressure, then released quickly
c. rapid inflation from 120 to 150 mm Hg with immediate rapid deflation
d. gradual inflation and deflation of the cuff with the patient’s respiratory cycle
a
What is the major advantage of using hand compression instead of automatic cuff inflators?
adaptability to unusual venous segments
Which of the following is NOT a pitfall in measuring reflux?
a. high persistence resulting in false-positive color flow findings
b. high velocity scale or PRF setting affecting color flow sensitivity
c. low wall filter settings allow visualization of low-velocity venous flow
d. gain settings too high altering the sensitivity of spectral Doppler
c
After thermal ablation of a vein, what do the sonographic findings include?
potentially sonographically absent, fibrosed, or recanalized veins at different locations along the vein length
Valvular reflux time as measured on a spectral Doppler display are typically considered abnormal when greater than how many seconds?
2
What is the main purpose for venous photophlethysmography of the lower limb?
screening for detection of reflux
What can the use of a tourniquet during venous PPG testing help determine?
deep versus superficial vein reflux
A patient presents to the vascular laboratory for evaluation of valvular incompetence. A venous PPG examination is performed. The results of the examination demonstrate a venous refill time (VRT) of 10.5 seconds without the use of a tourniquet and 22 seconds with the use of a tourniquet. What do these findings demonstrate?
presence of superficial venous reflux
What is air plethysmography useful for?
quantification of chronic venous insufficiency
Using APG, increased ambulatory pressures suggestive of the inability to empty the calf veins owing to poor or nonfunctional calf muscle pump and indicated with which of the following?
a. residual volume greater than 20-35%
b. low venous volume
c. venous filling rate less than 2 mL/s
d. venous filling time greater than 25 seconds
a
Which of the following is an emerging technology that may help with guidance of venous access, phlebotomy, and injection sclerotherapy?
a. venous photoplethysmography
b. near-infrared imaging
c. air plethysmography
d. radio frequency imaging
b
Chronic venous insufficiency is a term used to describe venous insufficiency due to venous ______ or _______ insufficieny.
obstruction
chronic venous
Along with the great and small saphenous veins, the vascular technologist must also be familiar with the posterior and anterior ______ saphenous veins.
accessory
Saphenous veins are within a saphenous _____, readily identifying them on ultrasound. This structure gives the saphneous veins their distinctive ____ appearance.
compartment
fascia eye
The landmark to identify the anterior accessory saphenous vein is the ________, which is a vertical line perpendicular to the transducer surface that runs through the femoral artery and vein
alignment sign
Veins that pierce the saphenous fascia and drain into another major vein are known as _____ veins.
perforating
The triangle formed by the gastrocenemius muscle, the tibial bone, and great saphenous vein used to identify the GSV below the knee is known at the ______
angle sign
The tributary of the GSV near the saphenofemoral junction that is commonly used as a landmark for the venous ablation catheter is the _______ vein.
superficial epigastric
The confluence of the small saphenous vein and the deep venous system is _____, terminating into the popliteal vein, femoral vein, or other deep or perforating veins.
variable
Normal venous valves allow for _____ flow direction, whereas incompetent valves permit _______ flow or reflux.
antegrade
retrograde
Prevalence of venous reflux tends to increase with the severity of _________ and with increasing _____.
CEAP classification
age
Visual signs of abnormal venous pressures, such as spider veins or skin changes, are the primary basis for _____ classification.
CEAP
Temporary leg swelling at the end of a working day, after prolonged standing, or as result of leg positioning, may represent _____.
phleboedema
Cardiac disease, arterial disease, sympathetic tone, or lipid disorders are all differential diagnoses for _____.
edema
A skin change that results in a cluster of veins and skin changes, usually at the ankle, is ______.
coronal phlebactia
A patient with open skin ulcers, CVVI as major cause of clinical manifestations, and affecting superficial and perforating veins with a pathologic combination of pathophysiology would have a CEAP classification of _____.
C6EpAsPro
Duplex Doppler ultrasonography has two major diagnostic goals for CVVI: first is to rule out ______ and the second is the evaluation of ______ (reflux detection).
deep venous obstruction
valvular insufficiency
A concise duplex ultrasound evaluation designed for patients at risk or with a high probability of having CVVI is a ______ examiantion.
screening
An invasive diagnostic method to detect venous thrombosis, congenital venous malformations, or valvular function is _____.
venography
A CVVI treatment option that uses a foamed or liquid chemical agent injected directly into the vein is termed _____.
thermal ablation
Patient positioning for evaluation for venous disease typically starts with the patient in ______ position for evaluation of deep veins, whereas a _____ position is recommended for evaluation of CVVI.
reverse Trendelenburg
standing
If acute DVT is detected on initial assessment of a patient with suspected CVVI, the continuation of the CVVI is ______.
not recommended
When using proper compression techniques, abnormal veins proximal to the site of compression would demonstrate ______ flow during compression and ______ flow during decompression.
increased
retrograde
The most reproducible methods of compression include an automatic cuff and the “_____” maneuver
parana
Reflux time measurement should be performed with _____ Doppler with the vein in a sagittal image.
spectral
When performing a screening examination for CVVI, the scan can be interrupted after finding ____ level(s) of saphenous or nonsaphenous abnormality.
1
Evaluation of the femoropopliteal veins, deep calf veins, and entire superficial system (saphenous and nonsaphenous veins) would be appropriate in the ______ diagnosis of CVVI.
definitive
During thermal ablation treatment of CVVI, selection of incision site; insertion of needles, introducers, guide wires and catheters; and placement of tumescent anesthesia are all performed under ________.
ultrasound guidance
During postablation follow-up, the most important ultrasound documentation should be of the ____ veins to assure patency.
deep
To optimize detection of reflux, system settings, such as gain, scale/PRF, and persistence, should be adjusted to detect ______.
low flow states
In the diagnosis of CVVI, the measurement of reflux _____ is commonly preferred to measurement of peak reverse velocity or reflux volume flow rate.
time
In venous photoplethysmography, a PPG transducer is placed on the _____ aspect of the calf and venous _____ time is measured after the patient performs 5-10 foot flexion maneuvers.
medial
refill
Air plethysmography is a recommended technique for _______ of chronic venous insufficiency.
quanitification
In APG studies, patient performance of a series of maneuvers is _______ in obtaining reliable results.
paramount
A patient with a filling time (FT) of greater than 25 seconds, filling rate (FR) of less than 2 mL/s, and a residual volume (RV) of less than 20% would be considered ______ with respect to CVVI.
normal
