URR lower extrem venous eval for insufficiency

Question 1

what is venous insufficiency

Answer 1

-chronic swelling of lower legs and ankles (NOT FEET), brawny discoloration in the gaitor zone, visible spider veins, palpable varicosities
-most common complication of DVT
-most common venous disease of the extrems
-most commonly occurs at the saphenofemoral junction at the groin
-varicosities are most commonly tributaries of the great saphenous vein

Question 2

what is primary venous insufficiency

Answer 2

-most common type
-incompetent valves in the superficial system
-intact deep venous system
-pregnancy and obesity will increase the risk of developing varicose veins
-oral contraceptive increase the risk of varicose vein formation
-can be hereditary - risk significantly increases when one or both parents have varicose veins
-more common in females

Question 3

what is secondary venous insufficiency

Answer 3

incompetence of the superficial system caused by an obstructed or incompetent deep system

Question 4

exclusion of pathology in deep system, confirms diagnosis of what

Answer 4

primary varicosities

Question 5

how does blood flow after muscle contraction in normal person

Answer 5

-muscle contraction causes the deep veins to empty as the flow moves toward the heart and pressure in the deep system drops
-pressure in the superficial system should decrease during muscle contraction as flow moves through the perforators and increase as the muscle relaxes and reduces outflow in the perofrators
-the drop in pressure allows for normal flow form the superficial vein through the perforators to the deep system
-as the muscle relaxes the deep veins refill and pressure increases in the deep veins to reduce the flow through the perforators

Question 6

physiology of secondary varicose veins?

Answer 6

-an obstructed deep system will have increased pressure due to decreased outflow and blood pooling; muscle contraction will not efficiently empty the deep veins and the decrease in pressure is minimalized; the smaller the drop in pressure decreases the pressure gradient across the perforators and limits superficial system outflow
-once the pressure in the deep system continuously exceeds the pressure in the superficial system, perforators will dilate and valve incompetence occurs
-incompetent perforators allow flow from the deep system into the superficial system with muscle contraction; flow moving into instead of out of the superficial system leads to increased pressure in the superficial system during muscle contraction that will decrease when the muscle relaxes (opposite of normal flow during muscle contraction/relaxation)
-w/ chornic increase in deep system pressure, the superficial system will also dilate and valves become ineffective at managing proper flow direction

Question 7

what is venous hypertension?

Answer 7

-venous pressure is significantly increased w/ stranding
-calf muscle pumps blood in all directions and is ineffective for reducing venous pressure in calf
-edema, hyperpigmentation and ulceration can occur

Question 8

signs and symptoms of venous insufficiency

Answer 8

-edema
-tightness of the skin
-stasis dermatitis
-hyperpigmentation
-heaviness in the legs
-muscle cramps
-swelling of the calf and ankle, but NOT in the feet, when legs are in a dependent position; usually worsens as day progresses
-aching pain after standing or sitting w/ legs dependent
-walking relieves symptoms if no deep vein obstruction
-if deep vein obstruction present, walking causes claudication due to rapid increase in pressure in the deep and superficial veins caused by decreased outflow
-venous claudication results in severe cramping and burning feeling in the legs w/ exercise that is relieved by elevating the legs
-varicosity formation

Question 9

what is stasis dermatitis

Answer 9

common inflammatory skin disease; usually the earliest cutaneous sequela of chronic venous insufficiency w/ venous hypertension; causes discoloration of the ankle and calf

Question 10

what is hyperpigmentation

Answer 10

brawny discoloration of the distal 1/3 of the calf (gaitor zone- area just above medial malleolus)

Question 11

other words for varicosity formation?

Answer 11

-telangiectasia
-spider veins
-varicose veins

Question 12

if ulcer formation happens in the medial ankle it is usually related to what?

Answer 12

GSV disease

Question 13

if ulcer formation happens in the lateral ankle it is usually related to what?

Answer 13

SSV disease

Question 14

risk factors for venous insufficiency?

Answer 14

-female
-pregnancy
-oral contraceptive use
-age
-obesity
-fam hx
-personal hx
-job that requires standing still for extended periods of time on regular basis

Question 15

how to do CW for venous insufficiency

Answer 15

-exam performed in warm room, patient in reverse trendelenburg position or standing w/ body weight supported on contralateral leg
-first identifty CFA and document waveform
-angle medially for CFV
-prox augmentation used to stop flow and when compression is released, flow should continue toward the heart
-if valve immediately distal to probe is competent, flow reversal will be noted w/ compression during prox augmentation
-if reflux suspected at the saphenofemoral junction, place a tourniquet 10 cm distal to area to compress the GSV; perform distal augmentation; if reflux present, the deep system is incompetent
-if reflux stops w/ application of the tourniquet, the GSV is incompetent
-saphenopop junction is evaluated in the manner to distinguish pop and small saphenous vein reflux

Question 16

limitations of CW doppler?

Answer 16

-cannot be certain which vein you are evaluating
-cannot evaluate duplicated systems; fem veins are commonly duplicated
-difficult to differentiate deep veins from superficial veins and superficial veins from perforators due to lack of range resolution
-standardization of the protocol is difficult

Question 17

duplex eval for insufficiency?

Answer 17

-after DVT has been ruled out, the deep veins should be evaled for insufficiency
-superficial veins are evaled w/ patient in the upright position to increase hydrostatic/gravitational pressure to fill veins w/ blood; varicosities will become more visible
-if patient unable to stand for the exam they may be evaled in the reverse trendelenburg position
-GSV should be evaled w/ patient bearing weight on contralateral leg
-SSV should be evaled w/ leg in the dependent position; patient can be seated w/ foot resting on your lap
-measure the GSV diameter at the SFJ, prox thigh, mid thigh, at the knee, prox, mid, and dist calf
-depth of the GSV may be requred when considering endovenous ablation
-if vein too superficial, it can cause complications w/ thermal injury during the procedure
-measure SSV diameter at the prox, mid, and dist calf
-saphenous veins lie btwn the deep and superficial fascia of the leg
-tributaries are fount outside the superficial fascia
-anterior accessory vein and vein of giacomini area usually easily identified and can be assessed for size and reflux
-if perforators are identified in the calf, they should be assessed for size and reflux
-may see one or more intersaphenous veins connecting the small and great saphenous veins in the calf
-SSV perforators connect to the gastrocnemius or peroneal veins
-perforator diameter > 4 mm usually demonstrate reflux

Question 18

benefits of using doppler?

Answer 18

-color can be helpful for eval multiple veins in the same view
-can eval the GSV and one of its superficial tributaries simultaneously
-helps to identify the presence and timing of the reflux to identify recirculating reflux
-a minimum of 30 secs between testing sites is recommended
-a manual compression, valsalva maneuver, or rapid cuff inflator

Question 19

what is the rapid cuff inflator

Answer 19

-provides consistent augmentation for each vessel
-most reproducible and consistent results
-cuff placed distal to the area of interest
-cuff pressure varies w/ hydrostatic pressure and is applied quickly, held for a few seconds, and released quickly
-reversal of flow is assessed after release of the augmentation compression
-veins distal to the cuff can also be evaled but flow reversal would be documented during the compression part of the augmentation

Question 20

what is the normal response in veins prox to augmentation point

Answer 20

increase in flow toward the heart with no retrograde flow before flow normalizes

Question 21

what is the abnormal response in veins prox to the augmentation point

Answer 21

increase in flow toward the heart, then retrograde flow occurring toward the feet
-duration of reflux denotes the severity
-deep veins > 1.0 sec reflux
-superficial veins > .5 sec reflux
-perforators > .5 sec reflux

Question 22

normal response in veins distal to augmentation point

Answer 22

venous flow ceases at onset of valsalva or compression with no flow reversal

Question 23

abnormal response in veins distal to the augmentation point

Answer 23

venous flow reversal occurs at the onset of the valsalva maneuver or compression
-duration of reflux denotes the severity

Question 24

valsalva maneuver can be used to perform prox augmentation to assess reflux BUT if the valve at the saphenofemoral junction is competent what happens

Answer 24

reflux is not able to be demonstrated in lower portions of the GSV if it is present

Question 25

what is a varicose vein

Answer 25

abnormal vein that is dilated with valves that do not close properly which leads to reflux

Question 26

how to measure GSV

Answer 26

in trans plane from inner wall to inner wall

Question 27

what is the saphenopopliteal junction (SPJ)

Answer 27

junction of the SSV and pop vein
-insufficiency is common at this location but not as common as the SFJ

Question 28

if flow occurs at the onset of the valsalva, what must be measured?

Answer 28

duration of reflux flow

Question 29

during perforator reflux augmentation maneuver is used to eval the dilated perforating vessel, when the calf is squeezed what should happen?

Answer 29

NO FLOW should be seen moving from the deep to the superficial system
-if the perforator is competent, flow will stop with augmentation and then flow toward the deep system on release

Question 30

what are false negatives

Answer 30

-patient evaluated in supine position
-partial obstruction
-collateralization
-paired veins
-duplicated venous system

Question 31

what are false positives

Answer 31

-high persistence settings may result in false positive color flow findings
-extrinsic compression-tumor, clothing, muscle contraction
-PVD-poor inflow, poor outlfow
-COPD
-probe pressure

Question 32

aftercare post ablation?

Answer 32

-class 2 compression stockings 30-40 mmHg w/ daily ambulation of at least 30 mins
-follow up on exam should be performed 2 weeks after the procedure to confirm contraction/occlusion of the GSV and continued absence of thrombus in the deep system

Question 33

post ablation US exam

Answer 33

-venous occlusion w/ internal echogenicity and incompressibility should be seen within days of the procedure
-eval the treated veins and deep veins with US immediately after treatment to confirm the patency of the deep system
-risk of DVT post ablation is very low
-assess the distance of the end of the treated segment from the SFJ junction (if prox GSV treated) or SPJ (if SSV treated)
-GSV should be <2mm diameter and no DVT present in deep vessels

Question 34

post ablation coagulation usually occurs when

Answer 34

within 10-20 secs after radiofrequency or laser applied

Question 35

what is lymphedema?

Answer 35

-common differential diagnosis for lower extrem edema
-caused by abnormal lymphatic system
-causes extensive swelling that includes swelling of the feet
-chronic venous insufficiency normally does not include foot swelling, stops at the ankle
-most commonly affects a unilateral extrem because the most common cause is surgical removal of lymph nodes as a part of cancer treatment
-it is also associated with radiation therapy of the affected extrem
-elephantitis is a complication of lymphedema
-severe cases can develop into lymphangiosarcoma

Question 36

what is primary lymphedema

Answer 36

caused by congenital malformation of system or impaired transport of the lymphatic fluid

Question 37

what is secondary lymphedema

Answer 37

-related to injury, obstruction or damage to the lymphatic system
-common causes include wounds, burns, cancer treatment (#1 in US), filariasis (#1 in world)

Question 38

what is the stemmer sign

Answer 38

-significant edema of the lower extrem that causes a skin fold at the base of the second toe
-confirmed by trying to pinch the skin but the skin is too tight to allow pinching