venous incompetence

8/12/2019 Venous Incompetence

1/17

UPPER ABDOMEN

o Liver

Liver Normal

Liver Segments

Liver Pathology

Portal Hypertension

o Pancreas

Pancreas Normal

Pancreas Pathology

o

Biliary Gallbladder

GB Normal

GB Pathology

Biliary tree

Normal

Pathology

o Spleen

Spleen Normal

Spleen Pathology

o Vascularity

Normal

Pathology

o Appendix

Appendix Normal

Appendix Pathology

o Bowel

Bowel-Pathology

UROLOGY
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2/17

o Kidney

Kidney Normal

Kidney Pathology

o Bladder

Bladder Normal

Bladder Pathologyo Prostate

Prostate Normal

Prostate Pathology

GYNAECOLOGY

o Uterus

Uterus Normal

Uterus Pathology

o Ovaries

Ovary Normal

Ovary Pathology

OBSTETRIC

o 1st Trimester

1st trimester Normal

1st trimester Pathology

o 2nd Trimester

2nd trimester Normal

2nd trimester Pathology

o 3rd Trimester

3rd trimester Normal

3rd trimester Pathology

o Fetal heart Fetal Heart Normal

Fetal Heart Pathology

o Charts/tables

MUSCULOSKELETAL

o Upper limb

Shoulder

Shoulder Normal

Shoulder Pathology

Elbow

Elbow Normal

Elbow Pathology

Wrist

Wrist Normal

Wrist Pathology

Hand & Finger

Hand Normal

Hand Pathology
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3/17

o Lower limb

Hip/groin

Hip/Groin Normal

Hip/Groin Pathology

Knee

Knee Normal Knee Pathology

Ankle

Ankle Normal

Ankle Pathology

Foot

Foot Normal

Foot Pathology

VASCULAR

o Carotids

Carotids Normal

Carotids Pathology

o Leg arteries

Leg arteries Normal

Leg arteries Pathology

o DVT

Upper limb

Arm DVT Normal

Arm DVT Pathology

Lower limb

Leg DVT Normal

Leg DVT Pathologyo Varicose veins

CVI Normal

CVI Pathology

o Renal arteries

Renal arteries Normal

Renal arteries Pathology

SMALL PARTS

o Eye

Eye Normal

Eye Pathology

o Salivary glands

Submandibular Gland

Submandibular Gland Normal

Submandibular Gland Pathology

Parotid Gland

Parotid Normal

Parotid Pathology
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4/17

Sublingual Glands

Sublingual Normal

Sublingual Pathology

o Thyroid

Thyroid Normal

Thyroid Pathologyo Breast

Breast Normal

Breast Pathology

o Scrotal

Scrotal Normal

Scrotal Pathology

o Superficial lumps

Lumps Normal

Lumps Pathology

PAEDIATRICS

o Neonatal head

Neonatal Head Normal

Neonatal Head Pathology

o Neonatal hip

Neonatal Hip Normal

Neonatal Hip Pathology

o Pediatric Abdomen

Pylorus Normal

Pylorus Pathology

Intussusception

o Neonatal spine Neonatal spine normal

OTHER

o Normal

o Pathology

o FAST scan

o Join Now

o Renew Membership

o Member Benefits

o Welcome Members

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VENOUS INCOMPETENCE (Varicose vein)ULTRASOUND - Normal
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5/17

Venous Incompetence (VI) and Chronic Venous Insufficiency (CVI) are interchangable terms

FLOW DYNAMICS

NORMAL FLOW

In the normal cicumstance, the

superficial system drains the

subcutaneous tissues and periodically

empties into the deep system via

perforating veins.

Flow direction should always be:

1. Cephalad.

2. Superficial to deep.

Normal venous flow and valve movement,


6/17

Click image to enlarge.

INCOMPETENT FLOW

With distal augmentation, flow initially

goes cephalad. It then refluxes back

down the leg through the malfunctioning

valve.

An incompetent perforating veinalso

allows blood to flow from the deep veins

to the surface veins.

This combination of back pressure

causes dilation and tortuosity of the

veins (ie varicosites).

Incompetent valve & perforator leading to venous reflux.

NORMAL VEIN VALVE
http://www.ultrasoundpaedia.com/uploads/53003/ufiles/venous-incomp/venous%20incomp%20normal/incompetent.gifhttp://www.ultrasoundpaedia.com/uploads/53003/ufiles/venous-incomp/venous%20incomp%20normal/incompetent.gifhttp://www.ultrasoundpaedia.com/uploads/53003/ufiles/venous-incomp/venous%20incomp%20normal/incompetent.gifhttp://www.ultrasoundpaedia.com/normal-varicose-veins/http://www.ultrasoundpaedia.com/uploads/53003/ufiles/venous-incomp/venous%20incomp%20normal/incompetent.gifhttp://www.ultrasoundpaedia.com/normal-varicose-veins/http://www.ultrasoundpaedia.com/uploads/53003/ufiles/venous-incomp/venous%20incomp%20normal/incompetent.gifhttp://www.ultrasoundpaedia.com/normal-varicose-veins/http://www.ultrasoundpaedia.com/uploads/53003/ufiles/venous-incomp/venous%20incomp%20normal/incompetent.gifhttp://www.ultrasoundpaedia.com/uploads/53003/ufiles/venous-incomp/venous%20incomp%20normal/incompetent.gifhttp://www.ultrasoundpaedia.com/uploads/53003/ufiles/venous-incomp/venous%20incomp%20normal/incompetent.gif


7/17

Normal venous valve.

A video clip of a normal vein valve (LS) A video clip of a normal vein valve (TS)

LEG VEIN ANATOMY

Nomenclature

For a comprehensive document on the international consensus of leg vein

labelling.

REF: Journal Of Vascular Surgery, Special Communication, 2005. (215kB PDF file)

We recommend reviewing this thorough document.

Importantly, to avoid confusion, the 'Long Saphenous' is now the 'Great Saphenous'.
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What are Varicose veins?

Below is a basic outline of the anatomy and function of the veins and what constitutes venous

incompetence. Be aware however that there are numerous anatomical variations.

Valves

The veins contain a series of valves along their course, preventing retrograde flow back down the

leg. These valves operate like two plastic doors opening up the leg. If back pressure is applied,

they swing closed, pushing against each other, blocking reverse flow down the leg.

If functioning normally, it is a competent valve. If blood is able to pass backwards though the

valve, it is deemed incompetent.

Depending on the extent of incompetence, this backflow will dilate the supple superficial veins

making them tortuous and dilated(varicose veins).

Causes include:

Familial factors with 'lax' veins. These distend slightly allowing the valve leaflets to no longer

oppose each other.

Injury or thrombosis. Both of these can lead to adherance of valve leaflets to the vein wall,

rendering the valve useless.

The Deep Veins

Are the primary route for returning blood to the heart. They collect the venous blood from all the draining

muscular and superficial veins.

In the lower limb the deep veins are: (from groin to ankle)

Common Femoral Vein (CFV)

Superficial Femoral Vein (SFV)- also called just the Femoral Vein.

Popliteal vein (POPV)

Anterior tibial (ATV)

Posterior tibial (PTV

Peroneal veins (Per V)


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The latter 3 are calf veins that generally run in pairs (venous commantantes)

Click here for a diagram of leg deep vein anatomy.

The Superficial Veins

There are 2 main superficial veins draining the subcutaneous tissue of the lower leg:

The Great Saphenous vein (GSV)runs from the medial malleolus, up the medial aspect of the

leg, draining into the CFV at the groin as the Sapheno-femoral junction (SFJ).

The Short Saphenous vein (SSV)runs up the posterior midline of the calf. It may drain into the

proximal POPV above the knee crease as the Sapheno-Popliteal junction (SPJ). Commonly

however, it may continue up the posterior thigh as the Giacomini vein. This will terminate either

into the mid/distal SFV or ascend to drain into the proximal LSV.

Incompetence of the SFJ and SPJ are the two primary sources of varicose veins.

Sapheno-femoral Junction

The termination of the Great Saphenous Vein (GSV) into the Common Femoral vein (CFV) in the

groin.

Is the primary source of venous incompetence and varices of the lower limb.
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Sapheno-Femoral Junction Anatomy

Deep Veins

Common femoral vein (CFV)

Superficial femoral vein (SFV)

Proffunda femoris vein (Proffv)

Superficial Veins:

Long (Great) Saphenous vein

(LSV)

Medial accessory saphenous vein

(MASV)

Lateral accessory saphenous

vein (LASV)

Insert caption here

Sapheno-popliteal junction

The termination of the Short Saphenous Vein (SSV) into the Popliteal vein (POPV) in the popliteal

fossa.

The SPJ is absent in 25% of the population, continuing up the posterior thigh as the Giacomini

vein.

Only 15% of people have a midline SPJ. The remaining junctions are medial/lateral, often via a

gastrocnemius vein.
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Diagram of transverse calf showing the 'eye-like' fascia containing the

SSV.Insert caption here

The Short Saphenous Vein may terminate in the Giacomini

vein with no Sapheno-popliteal junction.

Alternatively it may divide, with a normal SPJ and a Giacomini

vein (as in this case).

Venous Incompetence Ultrasound -Protocol
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*** NOTE: A comprehensive thorough scan can take an hour to complete. ***

Role of Ultrasound

To identify the source and course of varicosities in the lower limb.

To assess these veins pre-operatively as a cause for:

o Venous ulcers

o Lower limb oedema

o Venous ezcema

o Self image

Limitations

Ideally the scan should be performed with the patient erect or as upright as possible. Some

patient will have difficulty with this.

Markedly oedematous legs or open ulcers will impede scan quality.

Equipment Selection

Use of a medium to high frequency(7-10MHZ)linear array probe is preferrable to visualise the

superficial veins.

You may need to resort to a lower frequency probe to assess the deep veins, depending on the

patient's body habitus.

Doppler settings should be low PRF and low wall filter with medium to high persistance.

Set the u/s machine to display triplex- usually, when spectral doppler is on, there is a

'simultaneous' option

Patient position
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Ideally the scan should be performed with the patient erect or as upright as possible. Some

patient will have difficulty with this, occasionally becoming faint or weary.

Use of a tilt table will make the scan easier for both you and the patient.

Position the patient on their back. Gently flex their knee and externally rotate their leg with their

unaffected leg kept straight to take the majority of their weight.

Scanning Technique

DEEP VEINS

Post thromotic syndrome in patients with a past history of DVT can lead to deep venous incompetence.

Deep venous incompetence or current DVT is important to exclude as a cause for the patients symptoms.

1. Begining at the groin in transverse, identify the common femoral vein(CFV) at the point where it

bifurcates into the superficial femoral vein(SFV) and proffunda femoris vein(PFV).Check

compresibility in transverse and image in longitudinally with colour flow.

2. The external iliac vein (and often CFV) do not have valves so need not be checked for

incompetence.

3. Check the competency of the SFV proximally:In longitudinal, using colour and spectral doppler.

Ask the patient to strain down and make a fat tummy. If incompetent, flow reversal will be evident

throughout the strain. NOTE: Due to valve spacing you can get up to 0.5 seconds of reversed

flow in deep veins.

4. Check the patency and competency of the SFV distally: If the SFV was incompetent proximally,

valsalva can be used again, otherwise a short, firm squeeze of the proximal calf (called

Augmentation) should be used.

5. Check the patency and competency of the Popliteal vein(POPV). Place the probe transversely in

the popliteal fossa at the knee crease. The POPV and artery will be easily seen (Be cautious not

to mistake the several muscular veins in the area for the POPV). Check it's competency as per

the distal SFV.
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THE GREAT SAPHENOUS VEIN (GSV)

Sometimes referred to as the Long Saphenous vein (LSV).

Follow from the Sapheno-femoral junction (SFJ) groin to the ankle using distal augmentation to

assess for incompetence.

If there are changes in competence, note the distance from landmarks such as the groin or knee

crease.

THE SHORT SAPHENOUS VEIN

Similar to the GSV, in longitudinal, follow the SSV from the Sapheno-Popliteal Junction (SPJ) in

the knee crease, down the midline of the calf.

Use distal augmentation to assess for incompetence.

If there are changes in competence, note the distance from landmarks such as the malleoli or

knee crease.

The Sural nerve runs parallel to the SSV from mid calf down to the heel. If the SSV is

incompetent, make note in the report if the Sural nerve is in intimate contact with the vein. They

can be confused one for the other in surgery.

PERFORATING VEINS

A perforating vein joins the superficial veins to the deep veins. By definition a perforating vein must

breech the fascia between the superficial fat and the muscle fascia.

In transverse, scan in a methodical patternup and down the medial calf. Begin with the toe of the probe

on the Tibia and do vertical sweeps until you reach the SSV.

Flow should always be superficial to deep (competent).

If flow is observed deep to superficial, the vein is incompetent. Any incompetent perforating veins (IPVs)

or competent perforators >3mm should be noted in the report.
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Click image to enlarge

Common Perforators

The most common perforating veins are shown. The

'Cocketts' are by far the most common. These are medial,

paratibial in the distal 2/3 of the lower leg.

Basic Hard Copy Imaging

A CVI study should include the following minimum images:

CFV bifurcation

SFV proximal and distal demonstrating patency and competency

POPV demonstrating patency and competency

SFJ demonstrating patency and competency
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SPJ (if present) demonstrating patency and competency

Any incompetent perforators noting their diameter, depth and position relative to a surface

landmark

Any significant or atypical junctions of varices to the 'normal' system

Any incidental pathology such as thrombus, Bakers cyst or popliteal aneurysm.

Anatomy

Nomenclature

Scan protocol

Scan Technique

Perforating veins
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