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Dr Ahmed Esawy
Tips Tricks
Peripheral Venous Duplex
Dr. Ahmed Esawy
MBBS M.Sc MD
Dr Ahmed Esawy
Varicose veins
DUPLEX US
Dr Ahmed Esawy
DEFINITION
• Varicose veins are veins that have become abnormally
enlarged and tortuous.
• The term “varicosities”, represent enlarged collaterals
(branches) of so-called saphenous venous system affected
by a disease called “superficial venous insufficiency of
lower extremities
• The term commonly refers to the veins on the leg
• although varicose veins can occur elsewhere i.e.
Abdominal Wall ,Anus , Vulva, Oesophagus.
• Varicose veins are bulging veins that are larger than spider
veins i.e. typically 3 mm or more in diameter.
Dr Ahmed Esawy
venous circulation uphill
Hemodynamics
• Gravity/hydrostatic pressure
Force of gravity , pressure of body weight & task of carrying blood
from bottom of body up to heart make legs primary location for varicose veins.
• Intra-abdominal pressure
• External Venous compression
left iliac vein compression by the right iliac artery, known as
May-Thurner syndrome (MTS).
compression of right iliac vein by the right iliac artery or
compression of the left iliac vein by the left iliac artery
Leg muscles pump the veins to return blood to the heart, against
the effects of gravity
Dr Ahmed Esawy
VARICOSE VEIN
primary varicose (superficial
system abnormally dilated tortous
, no history of DVT)
Intrinsic weakness of smooth
muscle media layer of vein wall
(hereditary, hormonal, endothelial
damage)
Intrinsic “leakiness” of valve
secondary varicose (deep system
2ry to obstruction or
incompetence )with ankle
oedema venous ulcer at ankle)
Post–thrombotic damage to valve
leaflets
Dr Ahmed Esawy
Reflux (most common)
Calf muscle pump dysfunction
muscle wasting
neuromuscular disease
deep fasciotomies
local vein valve failure within the muscle
fascia sheath
Venous obstruction
DVT / Post-thrombotic syndrome
Mass
artery
Venous valvular incompetence
Primary
Secondary
Congenital abnormalities (Klippel - Trenaunay - Weber Syndrome)
Impaired venous drainage
Varicose veins etiology
Dr Ahmed Esawy
Klippel - Trenaunay - Weber Syndrome:
Congenital absence of the deep veins
Causes numerous superficial varicosities and clusters of varicosities
Dr Ahmed Esawy
Varicosities color duplex
examination objectives
• 1-ascertian whether the deep or superficial system
is patent
• 2-identify,localize,grade reflux in deep and
superficial system
• 3-to determine the source of blood flow to varicose
segment , evaluation of cause of varicosities
• 4-to evaluate the potential benefits for occluding
the source of inflow to varicose segment
• 5- extent of post-thrombotic abnormalities
Dr Ahmed Esawy
VARICOSE VEIN
superficial system
Extra-axial
Deep system
Axial
Dr Ahmed Esawy
Varicose vein
Telangectasia
Dermis
Reticular vein
Perforators
Sup. fascia
Deep fascia
Deep vein
Superficial & Deep connections
Dr Ahmed Esawy
ColorSizeClassType
Red0.1-1 mmTelangectasia
/spiders
I
Violet1-2 mmVenul-ectasiaII
Blue2-4 mmReticular veinsIII
Blue3-8 mmNon-saphenous
varicose
IV
Blue7-8 mmSaphenous
varicose
V
varicose veins Classification
Dr Ahmed Esawy
deep venous system
incompetence
• an enlargement of the deep venous system,
which increases in standing position,
• consequently slow venous flow.
• Typical symptoms are restless legs, calf pain
during the night, and severe muscle cramps.
• The degree of dilatation can be measured easily
with M-mode during Valsalva maneuver.
Dr Ahmed Esawy
Evaluation of valvular competence in
the deep venous system
• evaluated in thrombosis with a swollen lower extremity.
• With valvular competence, no significant retrograde is
observed (a brief and low amplitude physiologic flow
reversal may occur prior to valve closure).
• With valvular incompetence, high amplitude flow
reversal will be observed during the entire period of
abdominal compression. A long waveform
corresponding to venous emptying will follow.
Dr Ahmed Esawy
Evaluation of valvular competence in the
deep venous system
At the level of the thigh
With the patient in decubitus,
the Doppler sampling volume is
placed within the femoral vein
and pressure is applied on the
abdomen or the patient is
asked to do a Valsalva
At the level of the calf
With the patient erect, muscular
compression should only result in
minimal flow reversal, again
related to normal valve closure.
Prolonged and large flow reversal
is suggestive of valvular
incompetence.
Dr Ahmed Esawy
Evaluation of valvular competence in the
deep venous system
qualitative assessment
On color Doppler
observing reversal of color-
saturation, corresponding to
forward and reversed flow
directions, especially during
functional maneuvers
Quantitative assessment
relative to the duration of flow
reversal can be obtained with
spectrum
Dr Ahmed Esawy
NORMAL VEIN VALVE
Dr Ahmed Esawy
Evaluation of valvular
competence in the
superficial venous system
Dr Ahmed Esawy
Dr Ahmed Esawy
Dr Ahmed Esawy
Veins have leaflet valves to prevent blood from flowing backwards
(retrograde flow).
the leaflets of the valves no longer meet properly allows blood to flow
backwards and they enlarge even more
this backflow will dilate the supple superficial veins making them tortuous
and dilated (varicose veins).
Valve damage Incompetence with reversal of flow, pooling and venous
hypertension.
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 adherence of valve
leaflets to the vein wall, rendering the valve useless.
Varicose veins (valvular)
Dr Ahmed Esawy
Dr Ahmed Esawy
B shows a varicose vein with a
deformed valve, abnormal blood flow,
and thin, stretched walls. The middle
image shows where varicose veins
might appear in a leg.
The illustration shows how a
varicose vein forms in a leg.
Figure A shows a normal
vein with a working valve and
normal blood flow.
Dr Ahmed Esawy
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:
Cephalad Superficial to deep.
Dr Ahmed Esawy
INCOMPETENT FLOW
With distal augmentation, flow initially goes cephalad. It then refluxes back down the
leg through the malfunctioning valve.
An incompetent perforating vein also 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).
Dr Ahmed Esawy
Varicose
veins
• Varicose veins are a common condition in the United States, affecting
up to 15 percent of men and up to 25 percent of women.
Dr Ahmed Esawy
For many people, varicose veins and spider veins a common, mild and medically
insignificant variation of varicose veins — are simply a cosmetic concern.
For other people, varicose veins can cause aching pain and discomfort
Dr Ahmed Esawy
Sometimes the condition leads to more serious problems.
Varicose veins may also signal a higher risk of other disorders of the circulatory system.
Dr Ahmed Esawy
Dr Ahmed Esawy
Dr Ahmed Esawy
different pathways of saphenous incompetence
Incompetence confined to the saphenous trunks at the two levels imaged by
ultrasonography would reveal an enlarged vein in the saphenous sheath at both levels
Dr Ahmed Esawy
different pathways of saphenous incompetence
Incompetence spills into a tributary vein, which is enlarged in the subcutaneous
space in the lower of the two levels imaged. In this case the saphenous vein is visible
but more normal in size at the lower imaging level
.
Dr Ahmed Esawy
different pathways of saphenous incompetence
Incompetence spills into a tributary vein, which is enlarged in the subcutaneous space in
the lower of the two levels imaged. In this case the saphenous vein is not visible at the
lower level
.
Dr Ahmed Esawy
Diagram of the pathways of reflux
Reflux begins at the saphenofemoral junction (SFJ)
and extends down the great saphenous vein (GSV) to
the thigh.At this point the reflux spills into a varicose
tributary (point A)
The incompetent tributary then refills the GSV at a lower
level (point B) and leads to an additional segmental
incompetence of the GSV.
The GSV between the takeoff and reentry of the
tributary is not incompetent.
If this segment of GSV is visible to Doppler
ultrasonography , it is probably traversable and a single
access (near point C) may be all that is required for
treatment of both the higher and lower segments
If this segment is not visible, two punctures are needed
(near points A and C) to treat both incompetent
segments of the GSV.
Dr Ahmed Esawy
B-mode appearance of varicose
veins and perforators
• Varicose veins are relatively easy to identify on the B-
mode image.
• They appear as single or multiple dilated tortuous
vessels that vary randomly in diameter .
• They are superficial and may be located in the thigh as
well as the calf.
• The main trunk supplying varicose areas, such as the
LSV in the thigh, may be dilated but often has a
reasonably even caliber and is frequently not visible on
the skin surface.
Dr Ahmed Esawy
• Occasionally a large localized dilation can be seen in
the main trunk, called a varix.
• Sometimes the supplying vein may appear reasonably
small, but reflux is demonstrated with color and
spectral Doppler.
• The easiest way of locating perforators is to run the
transducer steadily along the trunk of the superficial
vein in transverse section.A break in the fascia will be
seen on the B-mode image as the perforator runs
between the subcutaneous and subfascial areas .
Dr Ahmed Esawy
Normally, the vein is 4 mm in diameter. Veins >7 mm have a
high incidence of reflux.
Reflux can occur in smaller veins but is usually clinically
unimportant.
Peripheral to the takeoff of incompetent tributary veins, the
caliber of the vein often decreases.
Conversely, the caliber of the GSV generally increases at the
level of a significant incompetent perforator vein
careful search should be made at points of GSV dilatation for
this important source of reflux
Dr Ahmed Esawy
Incompetent
GSV
normal
GSV
Dr Ahmed Esawy
GSV standing
GSV supine
Dr Ahmed Esawy
A- the long saphenous vein (V) lies in The superficial compartment ,bounded by deep
muscular fascia (upward arrow) and the saphenous fascia (downward arrow)
long saphenous vein
Dr Ahmed Esawy
B-the short saphenous vein (V) is also bounded by the deep fascia (upward arrow)
and saphenous fascia (downward arrow). The medial gastrocenemius muscle (MG)
and lateral gastrocenemius (LG) are shown on this image of the right leg
Dr Ahmed Esawy
Longitudinal scan of a sapheno-femoral junction. The
superficial long saphenous vein (LSV) joins the deep
superficial femoral vein (SFV) to form the deep common
femoral vein (CFV)
Dr Ahmed Esawy
The blue in the long saphenous vein shows flow towards the heart.
The blood velocity waveform shows flow towards the heart as the thigh is
squeezed and the flow continues in the same direction as the squeeze is released.
A normal sapheno-femoral junction
on squeeze/ release.
Dr Ahmed Esawy
Anterior accessory great veins
Dr Ahmed Esawy
Interfascial Veins
GSV Egyptian Eye
Leaflets of the Valve
Dr Ahmed Esawy
SFJ Pre-terminal Valve
/ Terminal Valve
Pre-Terminal Valve
Saphenous Ligament
Dr Ahmed Esawy
Reflux of the Pre-Terminal Valve (Color ) ;
while the terminal Valve appeared Competent (NO color)
Dr Ahmed Esawy
GSV normal diameter and Huge Varicosities “Large tributary”
Dr Ahmed Esawy
compensatory Anterior accessory GSV
Hypo plastic GSV
Dr Ahmed Esawy
Duplicated GSV
Dr Ahmed Esawy
Echogenic lining
Sclerosed vein
Sluggish Flow by B-Mode
Dr Ahmed Esawy
Thrombosed GSV
Dr Ahmed Esawy
Transverse image of tortuous
dilated varicose veins
Dr Ahmed Esawy
Reflux
Retrograde Reversed flow due to Delayed
closure of the valve
1ry or 2ry
CUT off Values of NORMAL LIMIT 0.5
seconds
Dr Ahmed Esawy
Reflux
Velocity Volume
( Venous Filling index >
2ml/sec)
Duration
Dr Ahmed Esawy
Superficial Venous reflux types
Isolated
ostial
reflux
SFJ
SPJ
combined ostial
,perforating
reflux.
perforating
reflux
GSV SSV
reflux
Dr Ahmed Esawy
Evaluation of valvular competence in the
superficial venous system: evaluation of
varicose veins while patient erect
Dr Ahmed Esawy
examined Reflux sites
deep thigh Veins
CFV
Deep Femoral Vein
Proximal & Distal SFV
perforating
vein
deep Veins
Proximal & Distal Popliteal Vein
Gastrocnemius Veins
Posterior Tibial Veins
Anterior Tibial Veins
Superficial Veins
Sapheno-femoral Junction
Great Saphenous Vein *GSV (Thigh /upper & lower leg)
Sapheno-popliteal junction (SPJ)
Small Saphenous Vein *SSV (mid leg)
Dr Ahmed Esawy
• the duration and volume of reflux can be evaluated
with spectrum analysis or with color duplex but last
is more expedient method
Dr Ahmed Esawy
venous reflux grading
grade1 reflux
defined as
retrograde
venous flow
that lasts only
for 0.5-2
seconds
grade1V reflux reversed
flow persist as long as
valsalva effort is
maintained
grade11 reflux lasts
slightly longer for 2-
3 seconds
grade111 reflux produces prominent reversed flow
phase that persists 4-6 seconds
< 0.5 sec NO reflux
Dr Ahmed Esawy
Augmentation of flow toward the heart
is seen in both instances (velocities
mapped below the x-axis).
However,upon release of external
compression, flow directed toward the
feet is seen in incompetent segments
(velocities above the xaxis).
Dr Ahmed Esawy
Relationship Between Reflux
and SV diameter is present
• The normal limit of the calibre of
GSV 5 mm and SSV 3 mm in upright
• Sudden caliber change of the
vessels is an important marker of
regurgitant flow within that segment
Dr Ahmed Esawy
• Perforating veins with diameters
greater than 3.5 mm can also be
taken as a sign of significant reflux
Dr Ahmed Esawy
Competent vein
Incompetent vein
Dr Ahmed Esawy
Spectral Doppler evaluation shows persistent retrograde flow beyond 0.5 second in
the great saphenous vein suggestive of venous reflux. Retrograde flow can be seen
up-to 3 seconds in (A) and 4 seconds in (B).
Dr Ahmed Esawy
Normal flow pattern of the saphenous vein
during Valsalva: flow stops during the
maneuver; there is a very short, physiological
reflux peak caused by the closing of the valve
Dr Ahmed Esawy
Dr Ahmed Esawy
Reflux tips &tricks
• Length of refluxed segment to 1.5m
• Distal compression is standard for forward flow
• But proximal compression or valsalva can be
used but will demonstrate reverse flow as far
as the first comptent valve so underlying
incomptent valve is missed
• Reflux seen by color and spectrum
• Reflux make turbulance as result of forward
and reverse flow appear together
Dr Ahmed Esawy
During Valsalva maneuver there
is abnormal reversal blood flow
demonstrated by the change
to red. This is secondary to the
development of venous
insufficiency due to previous DVT.
Longitudinal image of the duplicated
superficial femoral veins (blue)
demonstrates that the blood flows in
the normal direction towards the groin
in the resting state.
Venous incompetence in duplicated superficial femoral veins.
Dr Ahmed Esawy
Prblem in quantifying reflux as in this example .the LSV
was very large (8) mm in diameter but the duration of
reflux (0.9) is shorter
blood flow during reflux is probably very significant due to
the size of the vein
it should be noted that volume flow calculation are not
routinely used in venous examination
Dr Ahmed Esawy
B: venous reflux (R) of 2 s duration is seen across SFJ
A. venous reflux of 0.55 s duration is recorded across the SFJ following distal
augmentation
Dr Ahmed Esawy
Spectral and color Doppler-US image shows the velocity and duration of the reflux
in a collateral from the GSV.
Dr Ahmed Esawy
A : partial incompetence of a venous valve is demonstrated by an area of
retrograde flow (arrow) between the two valve cusps
B : Spectral Doppler demonstrated trickle or low velocity reflux in the popliteal
vein following distal augmentation (S)
Dr Ahmed Esawy
NO reflux with Valsalva
Dr Ahmed Esawy
Reflux of 0.5 sec duration
Dr Ahmed Esawy
1.3 sec duration
Dr Ahmed Esawy
Prolonged duration with Valsalva
Dr Ahmed Esawy
Spectral and color Doppler-US image shows the velocity and duration of
the reflux in an incompetent perforator in the calf area.
Dr Ahmed Esawy
NO REFLUX SEVERE REFLUX
Dr Ahmed Esawy
SPJ incompetence
Distal augmentation
flow toward heart
Following squeeze release
retrograde flow in SSV
Dr Ahmed Esawy
B mode and color Doppler-US: Reflux in the saphenofemoral junction and in a
tributary vein from the pelvis
Dr Ahmed Esawy
Incompetent SFJ
Mickey Mouse view
LSV is very large ,small branches are
Dividing from junction
LSV (L) ,anterolateral branch (arrow)
SFV=V
SFA=A
Dr Ahmed Esawy
CFV proximal LSV=S SFJ=J
Superior tributary is seen draining to the LSV ,just proximal to the junction (arrow)
.it is aften not possible to image the CFV distal to the SFJ in the same plane
B . An image of an abnormally large SFJ (J) which was found to be incompetent
Dr Ahmed Esawy
Transverse image of the left popliteal fossa showing an abnormally large
sapheno-popliteal junction (arrow) ,proximal SSV (S) ,popliteal vein (V) and
popliteal artery (A) .note that the junction is located to the medial side of the
popliteal vein in this example but its position can vary
Dr Ahmed Esawy
Longitudnal image of the popliteal fossa demonstrating a dilated saphenopopliteal
junction and Proximal SSV .there is small deep vein (arrow) jioning the SSV at the
level of the junction (J) to the popliteal vein (PV) .the popliteal artery (PA) is shown
below the vein .it is not always possible to see the junction in this plane or this clarity
,especially if it lies to the medial or lateral side of the popliteal vein
Dr Ahmed Esawy
• A large incompetent upper thigh perforator. The large
perforator joins the deep superficial femoral vein (SFV) to the
superficial long saphenous vein (LSV). On release of a thigh
or calf squeeze, blood would flow from the deep vein through
the incompetent perforator into the superficial system.
Dr Ahmed Esawy
An incompetent long saphenous vein.
There is normal forward flow on squeezing the lower thigh (SQ),
but the flow reverses when the squeeze is released (REL).
The reverse flow persists for more than two seconds, indicating
significant incompetence.
Dr Ahmed Esawy
Greater saphenous vein valvular incompetence.
Dilated vein with forward flow at rest.
Dr Ahmed Esawy
Greater saphenous vein valvular incompetence.
Flow reversal in the arch and proximal vein during Valsalva
Dr Ahmed Esawy
Reversed Color Flow
Dr Ahmed Esawy
B-Mode and color Doppler-US images showing incompetent collaterals that were
responsible for the varicose veins that the patient presented in the physical exam
Dr Ahmed Esawy
• Important dilatation of the femoral vein during Valsalva
the diameter of the vein nearly doubles
• Measurement should be made carefully, applying only minimal pressure
with the probe, so that the dilatation of the vein is not hindered.
Dr Ahmed Esawy
diameter of the common femoral vein in the groin
of > 14 mm at rest (patient lying down)
and of > 20 mm after Valsalva is to be considered
as an important
degree of deep venous insufficiency, and seems to
correlate well with the typical clinical symptoms.
Dr Ahmed Esawy
• The region of most interest in examining varices
is the cross of the great saphenous vein. On this
image we see the typical configuration; excellent
vascular filling in Power Doppler mode
Dr Ahmed Esawy
• Dilatation of the cross during Valsalva, with
clear visualization of the closed valve.
Dr Ahmed Esawy
• Characteristic image of incompetent valve of the saphenous cross.
• Color Doppler: dilatation of the cross, reverse flow, turbulent flow (color
mosaic).
• Pulsed Doppler: reversal of the flow direction.
Dr Ahmed Esawy
• Reflux in the saphenous vein: pulsed Doppler shows initially
a turbulent, but later on a more "stable" flow pattern. The
spectral spread of velocities is made very clear by using
color spectral display.
Dr Ahmed Esawy
• Reflux in the V saphena magna: because Color Doppler
gives color-coded directional information in real time, the
reflux at the cross can easily be observed in real time.
Confirmation is registered with pulsed Doppler.
Dr Ahmed Esawy
• There are a lot of anatomical variations of the greater saphenous vein,
which can be doubled or can have large side branches (anterolateral and
posteromedial). There can be reflux in a side branch, with a normal distal
trunk. The image shows reflux in a superficial side branch, because there
is a valve on the main trunk just below the bifurcation; the valve is closing
normally
Dr Ahmed Esawy
• Chronic reflux gives dilatation and tortuous deformity
of the superficial veins, with typical "cork screw"
appearance; infra-valvular aneurysms are also
common.
Dr Ahmed Esawy
Color Doppler-US image of an incompetent collateral that drained into the GSV
in the thigh area.
collateral
GSV
Dr Ahmed Esawy
• Enlargement of the vein is not always present, especially in
the early stages of disease.
• Saphenous vein: diameter of only 3 mm (patient standing,
Valsalva), with clear demonstration of reflux.
Dr Ahmed Esawy
• The popliteal fossa should also be evaluated in case of
varices. Lesser saphenous vein (VSP) and gastrocnemius
veins (GCNM) are frequently incompetent. They should be
studied with the patient standing.
Dr Ahmed Esawy
• Cross section of the popliteal fossa: dilatation of
the lesser saphenous vein in case of
incompetence.
Dr Ahmed Esawy
• Characteristic reflux flow pattern of the saphena parva in
standing position. Distal compression causes augmentation
of the flow, and release of the pressure gives immediately
reversal of the flow direction.
Dr Ahmed Esawy
The normal sapheno-femoral junction showing
complete color fill-in across the vein lumen
Dr Ahmed Esawy
• A normal valve in the superficial femoral vein.
Dr Ahmed Esawy
Reflux occurring at the sapheno-femoral junction on
colour Doppler. (a) forward flow; (B) reverse flow
Dr Ahmed Esawy
B-Mode and Color Doppler-US images that show reflux in sapheno-popliteal
junction and in the small saphenous vein
Dr Ahmed Esawy
• Incompetent calf perforating vein
Dr Ahmed Esawy
Perforating Veins
Dr Ahmed Esawy
Perforating Veins
Dr Ahmed Esawy
Most incompetent perforating veins are located on
the medial side of the leg (see diagram).
The Cockett veins are the most common
incompetent veins.
Dr Ahmed Esawy
• Method to scan transversly to calf or
lower thigh and the see perforators
• Calf vein incompetence is difficult or
impossible to assess so if dilated
mean incomptence
• Judicious compression on varices
will show course of vein and reflux
Dr Ahmed Esawy
Perforating Veins
> 3 mm thickness Retrograde flow Traverse fascial plane
Dr Ahmed Esawy
Perforating veins evaluation:
patient erect. With compression of the calf, forward flow (blue, away from the
transducer) is detected in the greater saphenous vein (top), SFV (bottom), and
one perforating vein between them —. Because of its spiral configuration, the entire
length of the perforating vein cannot be visualized on a single 2D image
Dr Ahmed Esawy
Perforating veins evaluation: patient erect.
Following removal of the tourniquet, high amplitude reflux (red,
towards the transducer) is noted through the perforating vein —
towards the saphenous vein. No reflux is seen in the SFV
(absence of red saturation).
Dr Ahmed Esawy
perforator incompetence
• isolated perforator incompetence at
distal thigh but also occur in calf
from branches of ant or post arch
vein
Dr Ahmed Esawy
In those selected cases where
hemodynamic correction of varicose
veins (CHIVA) is considered,
detection of incompetent perforating
veins is essential.
Dr Ahmed Esawy
• In search of pathological perforating veins, the saphenous
vein is scanned over the whole length in transverse section.
Perforating veins, which form the communication between the
deep and superficial systems, are easy to detect this way.
Dr Ahmed Esawy
• Perforating vein coming through the fascia.
Dr Ahmed Esawy
• Dynamic demonstration of flow in two directions
(normally only flow from superficial to deep) using
Color Doppler.
Dr Ahmed Esawy
• Pulsed Doppler confirmation of bidirectional flow
in the incompetent perforating vein.
Dr Ahmed Esawy
• Recurrence of varicosis after surgery occurs in most cases in the groin,
or at the level of perforating veins, which become incompetent.
• This image shows recurrence at the level of the former sapheno-
femoral junction; reflux is demonstrated using Color Doppler
Dr Ahmed Esawy
VARICOSITY
DISTRIBUTIONS
Dr Ahmed Esawy
• Varicose patterns on the leg often
indicate the source of the problem
• Determining the source of the
varicosities is important for treatment
Dr Ahmed Esawy
• junctional tributaries are often the
site of varicosities
• Saphenous nerve close contact
with the GSV below the knee
Dr Ahmed Esawy
Zone of Influence
of GSV
Varicose Veins
Terminal and subterminal valves at the SFJ
Leaks cause VV
Often causes varicosities in the tributaries
Zone of influence GSV medial aspect
Dr Ahmed Esawy
Varicose Veins
GSV Reflux
medial aspect
Dr Ahmed Esawy
Varicose Veins
Anterior Circumflex (ATL) Reflux
varicose areas on the anterior aspect of the thigh and lateral calf supplied from
incompetence of the anterolateral vein from the saphenofemoral junction . The main
proximal trunk of the LSV can be competent or incompetent in this situation.
Dr Ahmed Esawy
Varicose Veins Pudendal
Reflux
Dr Ahmed Esawy
Zone of Influence of
SSV and VG
The saphenopoliteal junction is often the origin
of reflux in the SSV
The excess blood volume entering the SSV from the
deep system causes varicosities to form in
tributary braches that course along the posterior
Calf
Reflux in the VG often leads into the GSV and
varicosities often occur in the posterior thigh
Dr Ahmed Esawy
Varicose Veins
Small Saphenous Reflux
varicosities to form in tributary braches that course along the posterior Calf
Dr Ahmed Esawy
Varicose Veins
Varicosities of the Vein of Giacomini
Dr Ahmed Esawy
Zone of Influence of
LSVS
The network of abnormal reticular vein
demonstrate reflux
A focal source of reflux often can not be found
with ultrasound
Spider veins often occur along the lateral aspect
of the thigh and calf
Large varicosities can occur
Dr Ahmed Esawy
Varicose Veins
Lateral Subdermic Venous System
Dr Ahmed Esawy
unusual distributions
Varicose at the anterior aspect of the calf or lateral aspect of
the thigh . The supply is frequently from varicose branches of
the LSV or SSV, depending on the location of the varicose
areas.
varicose veins running along the lateral aspect of the thigh
and calf can be related to isolated perforators located on the
lateral aspect of the upper thigh.
Dr Ahmed Esawy
Varicose veins in the lower posterior and posteromedial thigh
can be supplied by the Giacomini vein.
In this unusual situation, blood flows in a loop, across an
incompetent saphenopopliteal junction and up the Giacomini
vein, which then feeds the superficial varicosities running down
the leg. This is a ‘paradoxical’ situation, in which the thigh
veins are filled by ‘anti gravitational’ flow, but in fact the flow will
eventually make its way down into the calf via the incompetent
veins, in the correct gravitational direction
unusual distributions
Dr Ahmed Esawy
In some patients, it may be impossible to clearly
define the source of the varicose veins
especially if they are very small, are diffusely
distributed and generally run into very small superficial
tributaries.
Dr Ahmed Esawy
RECURRENT
VARICOSE
VEIN
Dr Ahmed Esawy
Possible causes of LSV recurrences
Incomplete Ligation SFJ
Neo-vascularization (cavernoma)
Incomplete stripping of the LSV trunk in the thigh
(Remnants of GSV)
Duplicated GSV
incomplete removal of incompetent Thigh or calf perforators
failure to differentiate lesser from greater saphenous
vein incompetence (incompetence of the SSV)
Incompetent tributaries
Secondary varicose veins
Dr Ahmed Esawy
Possible causes of SSV recurrences
• incomplete ligation of the
saphenopopliteal junction
• lncompetent Giacomini vein
• Incompetent perforators
• LSV incompetence
• Diffuse varicosities in the popliteal
fossa
Dr Ahmed Esawy
Difficulty in competency assess
• the assessment of patients with venous ulcers.
• continuous high-volume flow (hyperemic flow) in the
superficial and deep veins due to infection.
• The high-volume flow toward the heart can lead to a
reduction in reflux duration
• The leg can be reassessed when the hyperemia
subsides (by antiobiotic therapy).
Dr Ahmed Esawy
Saphenous pulsation on duplex may be a marker
of severe chronic superficial venous insufficiency
Duplex tracing of a typical saphenous pulse (SP) waveform
Etiology may be AV connections (arterial varices)
Dr Ahmed Esawy
SUPERFICIAL
PHLEBITIS
Dr Ahmed Esawy
Color Doppler examination is frequently carried out to see if
there is thrombus, or to evaluate the extension of the thrombus
in the deep system.
Example: thrombosis of the greater saphenous vein with
extension of the thrombus (arrows) in the femoral vein
Dr Ahmed Esawy
• Due to inflammatory infiltration of the surrounding
subcutaneous fat, a hyperechoic halo is visible
around the inflamed vein in case of phlebitis
Dr Ahmed Esawy
A marked inflammatory hyper-vascularization is always visible
around the inflamed part of the vein, with hypertrophic
arterioles which are not visible in normal conditions.
Dr Ahmed Esawy
A typical low-resistance inflammatory flow is seen in these tiny arterioles.
.
Dr Ahmed Esawy
Sonographic triade of superficial phlebitis
hyperechoic halo
small arterioles around the vein
low-resistance flow

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4 peripheral venous duplex pt 4 varices dr ahmed esawy

  • 1. Dr Ahmed Esawy Tips Tricks Peripheral Venous Duplex Dr. Ahmed Esawy MBBS M.Sc MD
  • 2. Dr Ahmed Esawy Varicose veins DUPLEX US
  • 3. Dr Ahmed Esawy DEFINITION • Varicose veins are veins that have become abnormally enlarged and tortuous. • The term “varicosities”, represent enlarged collaterals (branches) of so-called saphenous venous system affected by a disease called “superficial venous insufficiency of lower extremities • The term commonly refers to the veins on the leg • although varicose veins can occur elsewhere i.e. Abdominal Wall ,Anus , Vulva, Oesophagus. • Varicose veins are bulging veins that are larger than spider veins i.e. typically 3 mm or more in diameter.
  • 4. Dr Ahmed Esawy venous circulation uphill Hemodynamics • Gravity/hydrostatic pressure Force of gravity , pressure of body weight & task of carrying blood from bottom of body up to heart make legs primary location for varicose veins. • Intra-abdominal pressure • External Venous compression left iliac vein compression by the right iliac artery, known as May-Thurner syndrome (MTS). compression of right iliac vein by the right iliac artery or compression of the left iliac vein by the left iliac artery Leg muscles pump the veins to return blood to the heart, against the effects of gravity
  • 5. Dr Ahmed Esawy VARICOSE VEIN primary varicose (superficial system abnormally dilated tortous , no history of DVT) Intrinsic weakness of smooth muscle media layer of vein wall (hereditary, hormonal, endothelial damage) Intrinsic “leakiness” of valve secondary varicose (deep system 2ry to obstruction or incompetence )with ankle oedema venous ulcer at ankle) Post–thrombotic damage to valve leaflets
  • 6. Dr Ahmed Esawy Reflux (most common) Calf muscle pump dysfunction muscle wasting neuromuscular disease deep fasciotomies local vein valve failure within the muscle fascia sheath Venous obstruction DVT / Post-thrombotic syndrome Mass artery Venous valvular incompetence Primary Secondary Congenital abnormalities (Klippel - Trenaunay - Weber Syndrome) Impaired venous drainage Varicose veins etiology
  • 7. Dr Ahmed Esawy Klippel - Trenaunay - Weber Syndrome: Congenital absence of the deep veins Causes numerous superficial varicosities and clusters of varicosities
  • 8. Dr Ahmed Esawy Varicosities color duplex examination objectives • 1-ascertian whether the deep or superficial system is patent • 2-identify,localize,grade reflux in deep and superficial system • 3-to determine the source of blood flow to varicose segment , evaluation of cause of varicosities • 4-to evaluate the potential benefits for occluding the source of inflow to varicose segment • 5- extent of post-thrombotic abnormalities
  • 9. Dr Ahmed Esawy VARICOSE VEIN superficial system Extra-axial Deep system Axial
  • 10. Dr Ahmed Esawy Varicose vein Telangectasia Dermis Reticular vein Perforators Sup. fascia Deep fascia Deep vein Superficial & Deep connections
  • 11. Dr Ahmed Esawy ColorSizeClassType Red0.1-1 mmTelangectasia /spiders I Violet1-2 mmVenul-ectasiaII Blue2-4 mmReticular veinsIII Blue3-8 mmNon-saphenous varicose IV Blue7-8 mmSaphenous varicose V varicose veins Classification
  • 12. Dr Ahmed Esawy deep venous system incompetence • an enlargement of the deep venous system, which increases in standing position, • consequently slow venous flow. • Typical symptoms are restless legs, calf pain during the night, and severe muscle cramps. • The degree of dilatation can be measured easily with M-mode during Valsalva maneuver.
  • 13. Dr Ahmed Esawy Evaluation of valvular competence in the deep venous system • evaluated in thrombosis with a swollen lower extremity. • With valvular competence, no significant retrograde is observed (a brief and low amplitude physiologic flow reversal may occur prior to valve closure). • With valvular incompetence, high amplitude flow reversal will be observed during the entire period of abdominal compression. A long waveform corresponding to venous emptying will follow.
  • 14. Dr Ahmed Esawy Evaluation of valvular competence in the deep venous system At the level of the thigh With the patient in decubitus, the Doppler sampling volume is placed within the femoral vein and pressure is applied on the abdomen or the patient is asked to do a Valsalva At the level of the calf With the patient erect, muscular compression should only result in minimal flow reversal, again related to normal valve closure. Prolonged and large flow reversal is suggestive of valvular incompetence.
  • 15. Dr Ahmed Esawy Evaluation of valvular competence in the deep venous system qualitative assessment On color Doppler observing reversal of color- saturation, corresponding to forward and reversed flow directions, especially during functional maneuvers Quantitative assessment relative to the duration of flow reversal can be obtained with spectrum
  • 16. Dr Ahmed Esawy NORMAL VEIN VALVE
  • 17. Dr Ahmed Esawy Evaluation of valvular competence in the superficial venous system
  • 20. Dr Ahmed Esawy Veins have leaflet valves to prevent blood from flowing backwards (retrograde flow). the leaflets of the valves no longer meet properly allows blood to flow backwards and they enlarge even more this backflow will dilate the supple superficial veins making them tortuous and dilated (varicose veins). Valve damage Incompetence with reversal of flow, pooling and venous hypertension. 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 adherence of valve leaflets to the vein wall, rendering the valve useless. Varicose veins (valvular)
  • 22. Dr Ahmed Esawy B shows a varicose vein with a deformed valve, abnormal blood flow, and thin, stretched walls. The middle image shows where varicose veins might appear in a leg. The illustration shows how a varicose vein forms in a leg. Figure A shows a normal vein with a working valve and normal blood flow.
  • 23. Dr Ahmed Esawy 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: Cephalad Superficial to deep.
  • 24. Dr Ahmed Esawy INCOMPETENT FLOW With distal augmentation, flow initially goes cephalad. It then refluxes back down the leg through the malfunctioning valve. An incompetent perforating vein also 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).
  • 25. Dr Ahmed Esawy Varicose veins • Varicose veins are a common condition in the United States, affecting up to 15 percent of men and up to 25 percent of women.
  • 26. Dr Ahmed Esawy For many people, varicose veins and spider veins a common, mild and medically insignificant variation of varicose veins — are simply a cosmetic concern. For other people, varicose veins can cause aching pain and discomfort
  • 27. Dr Ahmed Esawy Sometimes the condition leads to more serious problems. Varicose veins may also signal a higher risk of other disorders of the circulatory system.
  • 30. Dr Ahmed Esawy different pathways of saphenous incompetence Incompetence confined to the saphenous trunks at the two levels imaged by ultrasonography would reveal an enlarged vein in the saphenous sheath at both levels
  • 31. Dr Ahmed Esawy different pathways of saphenous incompetence Incompetence spills into a tributary vein, which is enlarged in the subcutaneous space in the lower of the two levels imaged. In this case the saphenous vein is visible but more normal in size at the lower imaging level .
  • 32. Dr Ahmed Esawy different pathways of saphenous incompetence Incompetence spills into a tributary vein, which is enlarged in the subcutaneous space in the lower of the two levels imaged. In this case the saphenous vein is not visible at the lower level .
  • 33. Dr Ahmed Esawy Diagram of the pathways of reflux Reflux begins at the saphenofemoral junction (SFJ) and extends down the great saphenous vein (GSV) to the thigh.At this point the reflux spills into a varicose tributary (point A) The incompetent tributary then refills the GSV at a lower level (point B) and leads to an additional segmental incompetence of the GSV. The GSV between the takeoff and reentry of the tributary is not incompetent. If this segment of GSV is visible to Doppler ultrasonography , it is probably traversable and a single access (near point C) may be all that is required for treatment of both the higher and lower segments If this segment is not visible, two punctures are needed (near points A and C) to treat both incompetent segments of the GSV.
  • 34. Dr Ahmed Esawy B-mode appearance of varicose veins and perforators • Varicose veins are relatively easy to identify on the B- mode image. • They appear as single or multiple dilated tortuous vessels that vary randomly in diameter . • They are superficial and may be located in the thigh as well as the calf. • The main trunk supplying varicose areas, such as the LSV in the thigh, may be dilated but often has a reasonably even caliber and is frequently not visible on the skin surface.
  • 35. Dr Ahmed Esawy • Occasionally a large localized dilation can be seen in the main trunk, called a varix. • Sometimes the supplying vein may appear reasonably small, but reflux is demonstrated with color and spectral Doppler. • The easiest way of locating perforators is to run the transducer steadily along the trunk of the superficial vein in transverse section.A break in the fascia will be seen on the B-mode image as the perforator runs between the subcutaneous and subfascial areas .
  • 36. Dr Ahmed Esawy Normally, the vein is 4 mm in diameter. Veins >7 mm have a high incidence of reflux. Reflux can occur in smaller veins but is usually clinically unimportant. Peripheral to the takeoff of incompetent tributary veins, the caliber of the vein often decreases. Conversely, the caliber of the GSV generally increases at the level of a significant incompetent perforator vein careful search should be made at points of GSV dilatation for this important source of reflux
  • 38. Dr Ahmed Esawy GSV standing GSV supine
  • 39. Dr Ahmed Esawy A- the long saphenous vein (V) lies in The superficial compartment ,bounded by deep muscular fascia (upward arrow) and the saphenous fascia (downward arrow) long saphenous vein
  • 40. Dr Ahmed Esawy B-the short saphenous vein (V) is also bounded by the deep fascia (upward arrow) and saphenous fascia (downward arrow). The medial gastrocenemius muscle (MG) and lateral gastrocenemius (LG) are shown on this image of the right leg
  • 41. Dr Ahmed Esawy Longitudinal scan of a sapheno-femoral junction. The superficial long saphenous vein (LSV) joins the deep superficial femoral vein (SFV) to form the deep common femoral vein (CFV)
  • 42. Dr Ahmed Esawy The blue in the long saphenous vein shows flow towards the heart. The blood velocity waveform shows flow towards the heart as the thigh is squeezed and the flow continues in the same direction as the squeeze is released. A normal sapheno-femoral junction on squeeze/ release.
  • 43. Dr Ahmed Esawy Anterior accessory great veins
  • 44. Dr Ahmed Esawy Interfascial Veins GSV Egyptian Eye Leaflets of the Valve
  • 45. Dr Ahmed Esawy SFJ Pre-terminal Valve / Terminal Valve Pre-Terminal Valve Saphenous Ligament
  • 46. Dr Ahmed Esawy Reflux of the Pre-Terminal Valve (Color ) ; while the terminal Valve appeared Competent (NO color)
  • 47. Dr Ahmed Esawy GSV normal diameter and Huge Varicosities “Large tributary”
  • 48. Dr Ahmed Esawy compensatory Anterior accessory GSV Hypo plastic GSV
  • 50. Dr Ahmed Esawy Echogenic lining Sclerosed vein Sluggish Flow by B-Mode
  • 52. Dr Ahmed Esawy Transverse image of tortuous dilated varicose veins
  • 53. Dr Ahmed Esawy Reflux Retrograde Reversed flow due to Delayed closure of the valve 1ry or 2ry CUT off Values of NORMAL LIMIT 0.5 seconds
  • 54. Dr Ahmed Esawy Reflux Velocity Volume ( Venous Filling index > 2ml/sec) Duration
  • 55. Dr Ahmed Esawy Superficial Venous reflux types Isolated ostial reflux SFJ SPJ combined ostial ,perforating reflux. perforating reflux GSV SSV reflux
  • 56. Dr Ahmed Esawy Evaluation of valvular competence in the superficial venous system: evaluation of varicose veins while patient erect
  • 57. Dr Ahmed Esawy examined Reflux sites deep thigh Veins CFV Deep Femoral Vein Proximal & Distal SFV perforating vein deep Veins Proximal & Distal Popliteal Vein Gastrocnemius Veins Posterior Tibial Veins Anterior Tibial Veins Superficial Veins Sapheno-femoral Junction Great Saphenous Vein *GSV (Thigh /upper & lower leg) Sapheno-popliteal junction (SPJ) Small Saphenous Vein *SSV (mid leg)
  • 58. Dr Ahmed Esawy • the duration and volume of reflux can be evaluated with spectrum analysis or with color duplex but last is more expedient method
  • 59. Dr Ahmed Esawy venous reflux grading grade1 reflux defined as retrograde venous flow that lasts only for 0.5-2 seconds grade1V reflux reversed flow persist as long as valsalva effort is maintained grade11 reflux lasts slightly longer for 2- 3 seconds grade111 reflux produces prominent reversed flow phase that persists 4-6 seconds < 0.5 sec NO reflux
  • 60. Dr Ahmed Esawy Augmentation of flow toward the heart is seen in both instances (velocities mapped below the x-axis). However,upon release of external compression, flow directed toward the feet is seen in incompetent segments (velocities above the xaxis).
  • 61. Dr Ahmed Esawy Relationship Between Reflux and SV diameter is present • The normal limit of the calibre of GSV 5 mm and SSV 3 mm in upright • Sudden caliber change of the vessels is an important marker of regurgitant flow within that segment
  • 62. Dr Ahmed Esawy • Perforating veins with diameters greater than 3.5 mm can also be taken as a sign of significant reflux
  • 63. Dr Ahmed Esawy Competent vein Incompetent vein
  • 64. Dr Ahmed Esawy Spectral Doppler evaluation shows persistent retrograde flow beyond 0.5 second in the great saphenous vein suggestive of venous reflux. Retrograde flow can be seen up-to 3 seconds in (A) and 4 seconds in (B).
  • 65. Dr Ahmed Esawy Normal flow pattern of the saphenous vein during Valsalva: flow stops during the maneuver; there is a very short, physiological reflux peak caused by the closing of the valve
  • 67. Dr Ahmed Esawy Reflux tips &tricks • Length of refluxed segment to 1.5m • Distal compression is standard for forward flow • But proximal compression or valsalva can be used but will demonstrate reverse flow as far as the first comptent valve so underlying incomptent valve is missed • Reflux seen by color and spectrum • Reflux make turbulance as result of forward and reverse flow appear together
  • 68. Dr Ahmed Esawy During Valsalva maneuver there is abnormal reversal blood flow demonstrated by the change to red. This is secondary to the development of venous insufficiency due to previous DVT. Longitudinal image of the duplicated superficial femoral veins (blue) demonstrates that the blood flows in the normal direction towards the groin in the resting state. Venous incompetence in duplicated superficial femoral veins.
  • 69. Dr Ahmed Esawy Prblem in quantifying reflux as in this example .the LSV was very large (8) mm in diameter but the duration of reflux (0.9) is shorter blood flow during reflux is probably very significant due to the size of the vein it should be noted that volume flow calculation are not routinely used in venous examination
  • 70. Dr Ahmed Esawy B: venous reflux (R) of 2 s duration is seen across SFJ A. venous reflux of 0.55 s duration is recorded across the SFJ following distal augmentation
  • 71. Dr Ahmed Esawy Spectral and color Doppler-US image shows the velocity and duration of the reflux in a collateral from the GSV.
  • 72. Dr Ahmed Esawy A : partial incompetence of a venous valve is demonstrated by an area of retrograde flow (arrow) between the two valve cusps B : Spectral Doppler demonstrated trickle or low velocity reflux in the popliteal vein following distal augmentation (S)
  • 73. Dr Ahmed Esawy NO reflux with Valsalva
  • 74. Dr Ahmed Esawy Reflux of 0.5 sec duration
  • 75. Dr Ahmed Esawy 1.3 sec duration
  • 76. Dr Ahmed Esawy Prolonged duration with Valsalva
  • 77. Dr Ahmed Esawy Spectral and color Doppler-US image shows the velocity and duration of the reflux in an incompetent perforator in the calf area.
  • 78. Dr Ahmed Esawy NO REFLUX SEVERE REFLUX
  • 79. Dr Ahmed Esawy SPJ incompetence Distal augmentation flow toward heart Following squeeze release retrograde flow in SSV
  • 80. Dr Ahmed Esawy B mode and color Doppler-US: Reflux in the saphenofemoral junction and in a tributary vein from the pelvis
  • 81. Dr Ahmed Esawy Incompetent SFJ Mickey Mouse view LSV is very large ,small branches are Dividing from junction LSV (L) ,anterolateral branch (arrow) SFV=V SFA=A
  • 82. Dr Ahmed Esawy CFV proximal LSV=S SFJ=J Superior tributary is seen draining to the LSV ,just proximal to the junction (arrow) .it is aften not possible to image the CFV distal to the SFJ in the same plane B . An image of an abnormally large SFJ (J) which was found to be incompetent
  • 83. Dr Ahmed Esawy Transverse image of the left popliteal fossa showing an abnormally large sapheno-popliteal junction (arrow) ,proximal SSV (S) ,popliteal vein (V) and popliteal artery (A) .note that the junction is located to the medial side of the popliteal vein in this example but its position can vary
  • 84. Dr Ahmed Esawy Longitudnal image of the popliteal fossa demonstrating a dilated saphenopopliteal junction and Proximal SSV .there is small deep vein (arrow) jioning the SSV at the level of the junction (J) to the popliteal vein (PV) .the popliteal artery (PA) is shown below the vein .it is not always possible to see the junction in this plane or this clarity ,especially if it lies to the medial or lateral side of the popliteal vein
  • 85. Dr Ahmed Esawy • A large incompetent upper thigh perforator. The large perforator joins the deep superficial femoral vein (SFV) to the superficial long saphenous vein (LSV). On release of a thigh or calf squeeze, blood would flow from the deep vein through the incompetent perforator into the superficial system.
  • 86. Dr Ahmed Esawy An incompetent long saphenous vein. There is normal forward flow on squeezing the lower thigh (SQ), but the flow reverses when the squeeze is released (REL). The reverse flow persists for more than two seconds, indicating significant incompetence.
  • 87. Dr Ahmed Esawy Greater saphenous vein valvular incompetence. Dilated vein with forward flow at rest.
  • 88. Dr Ahmed Esawy Greater saphenous vein valvular incompetence. Flow reversal in the arch and proximal vein during Valsalva
  • 90. Dr Ahmed Esawy B-Mode and color Doppler-US images showing incompetent collaterals that were responsible for the varicose veins that the patient presented in the physical exam
  • 91. Dr Ahmed Esawy • Important dilatation of the femoral vein during Valsalva the diameter of the vein nearly doubles • Measurement should be made carefully, applying only minimal pressure with the probe, so that the dilatation of the vein is not hindered.
  • 92. Dr Ahmed Esawy diameter of the common femoral vein in the groin of > 14 mm at rest (patient lying down) and of > 20 mm after Valsalva is to be considered as an important degree of deep venous insufficiency, and seems to correlate well with the typical clinical symptoms.
  • 93. Dr Ahmed Esawy • The region of most interest in examining varices is the cross of the great saphenous vein. On this image we see the typical configuration; excellent vascular filling in Power Doppler mode
  • 94. Dr Ahmed Esawy • Dilatation of the cross during Valsalva, with clear visualization of the closed valve.
  • 95. Dr Ahmed Esawy • Characteristic image of incompetent valve of the saphenous cross. • Color Doppler: dilatation of the cross, reverse flow, turbulent flow (color mosaic). • Pulsed Doppler: reversal of the flow direction.
  • 96. Dr Ahmed Esawy • Reflux in the saphenous vein: pulsed Doppler shows initially a turbulent, but later on a more "stable" flow pattern. The spectral spread of velocities is made very clear by using color spectral display.
  • 97. Dr Ahmed Esawy • Reflux in the V saphena magna: because Color Doppler gives color-coded directional information in real time, the reflux at the cross can easily be observed in real time. Confirmation is registered with pulsed Doppler.
  • 98. Dr Ahmed Esawy • There are a lot of anatomical variations of the greater saphenous vein, which can be doubled or can have large side branches (anterolateral and posteromedial). There can be reflux in a side branch, with a normal distal trunk. The image shows reflux in a superficial side branch, because there is a valve on the main trunk just below the bifurcation; the valve is closing normally
  • 99. Dr Ahmed Esawy • Chronic reflux gives dilatation and tortuous deformity of the superficial veins, with typical "cork screw" appearance; infra-valvular aneurysms are also common.
  • 100. Dr Ahmed Esawy Color Doppler-US image of an incompetent collateral that drained into the GSV in the thigh area. collateral GSV
  • 101. Dr Ahmed Esawy • Enlargement of the vein is not always present, especially in the early stages of disease. • Saphenous vein: diameter of only 3 mm (patient standing, Valsalva), with clear demonstration of reflux.
  • 102. Dr Ahmed Esawy • The popliteal fossa should also be evaluated in case of varices. Lesser saphenous vein (VSP) and gastrocnemius veins (GCNM) are frequently incompetent. They should be studied with the patient standing.
  • 103. Dr Ahmed Esawy • Cross section of the popliteal fossa: dilatation of the lesser saphenous vein in case of incompetence.
  • 104. Dr Ahmed Esawy • Characteristic reflux flow pattern of the saphena parva in standing position. Distal compression causes augmentation of the flow, and release of the pressure gives immediately reversal of the flow direction.
  • 105. Dr Ahmed Esawy The normal sapheno-femoral junction showing complete color fill-in across the vein lumen
  • 106. Dr Ahmed Esawy • A normal valve in the superficial femoral vein.
  • 107. Dr Ahmed Esawy Reflux occurring at the sapheno-femoral junction on colour Doppler. (a) forward flow; (B) reverse flow
  • 108. Dr Ahmed Esawy B-Mode and Color Doppler-US images that show reflux in sapheno-popliteal junction and in the small saphenous vein
  • 109. Dr Ahmed Esawy • Incompetent calf perforating vein
  • 112. Dr Ahmed Esawy Most incompetent perforating veins are located on the medial side of the leg (see diagram). The Cockett veins are the most common incompetent veins.
  • 113. Dr Ahmed Esawy • Method to scan transversly to calf or lower thigh and the see perforators • Calf vein incompetence is difficult or impossible to assess so if dilated mean incomptence • Judicious compression on varices will show course of vein and reflux
  • 114. Dr Ahmed Esawy Perforating Veins > 3 mm thickness Retrograde flow Traverse fascial plane
  • 115. Dr Ahmed Esawy Perforating veins evaluation: patient erect. With compression of the calf, forward flow (blue, away from the transducer) is detected in the greater saphenous vein (top), SFV (bottom), and one perforating vein between them —. Because of its spiral configuration, the entire length of the perforating vein cannot be visualized on a single 2D image
  • 116. Dr Ahmed Esawy Perforating veins evaluation: patient erect. Following removal of the tourniquet, high amplitude reflux (red, towards the transducer) is noted through the perforating vein — towards the saphenous vein. No reflux is seen in the SFV (absence of red saturation).
  • 117. Dr Ahmed Esawy perforator incompetence • isolated perforator incompetence at distal thigh but also occur in calf from branches of ant or post arch vein
  • 118. Dr Ahmed Esawy In those selected cases where hemodynamic correction of varicose veins (CHIVA) is considered, detection of incompetent perforating veins is essential.
  • 119. Dr Ahmed Esawy • In search of pathological perforating veins, the saphenous vein is scanned over the whole length in transverse section. Perforating veins, which form the communication between the deep and superficial systems, are easy to detect this way.
  • 120. Dr Ahmed Esawy • Perforating vein coming through the fascia.
  • 121. Dr Ahmed Esawy • Dynamic demonstration of flow in two directions (normally only flow from superficial to deep) using Color Doppler.
  • 122. Dr Ahmed Esawy • Pulsed Doppler confirmation of bidirectional flow in the incompetent perforating vein.
  • 123. Dr Ahmed Esawy • Recurrence of varicosis after surgery occurs in most cases in the groin, or at the level of perforating veins, which become incompetent. • This image shows recurrence at the level of the former sapheno- femoral junction; reflux is demonstrated using Color Doppler
  • 125. Dr Ahmed Esawy • Varicose patterns on the leg often indicate the source of the problem • Determining the source of the varicosities is important for treatment
  • 126. Dr Ahmed Esawy • junctional tributaries are often the site of varicosities • Saphenous nerve close contact with the GSV below the knee
  • 127. Dr Ahmed Esawy Zone of Influence of GSV Varicose Veins Terminal and subterminal valves at the SFJ Leaks cause VV Often causes varicosities in the tributaries Zone of influence GSV medial aspect
  • 128. Dr Ahmed Esawy Varicose Veins GSV Reflux medial aspect
  • 129. Dr Ahmed Esawy Varicose Veins Anterior Circumflex (ATL) Reflux varicose areas on the anterior aspect of the thigh and lateral calf supplied from incompetence of the anterolateral vein from the saphenofemoral junction . The main proximal trunk of the LSV can be competent or incompetent in this situation.
  • 130. Dr Ahmed Esawy Varicose Veins Pudendal Reflux
  • 131. Dr Ahmed Esawy Zone of Influence of SSV and VG The saphenopoliteal junction is often the origin of reflux in the SSV The excess blood volume entering the SSV from the deep system causes varicosities to form in tributary braches that course along the posterior Calf Reflux in the VG often leads into the GSV and varicosities often occur in the posterior thigh
  • 132. Dr Ahmed Esawy Varicose Veins Small Saphenous Reflux varicosities to form in tributary braches that course along the posterior Calf
  • 133. Dr Ahmed Esawy Varicose Veins Varicosities of the Vein of Giacomini
  • 134. Dr Ahmed Esawy Zone of Influence of LSVS The network of abnormal reticular vein demonstrate reflux A focal source of reflux often can not be found with ultrasound Spider veins often occur along the lateral aspect of the thigh and calf Large varicosities can occur
  • 135. Dr Ahmed Esawy Varicose Veins Lateral Subdermic Venous System
  • 136. Dr Ahmed Esawy unusual distributions Varicose at the anterior aspect of the calf or lateral aspect of the thigh . The supply is frequently from varicose branches of the LSV or SSV, depending on the location of the varicose areas. varicose veins running along the lateral aspect of the thigh and calf can be related to isolated perforators located on the lateral aspect of the upper thigh.
  • 137. Dr Ahmed Esawy Varicose veins in the lower posterior and posteromedial thigh can be supplied by the Giacomini vein. In this unusual situation, blood flows in a loop, across an incompetent saphenopopliteal junction and up the Giacomini vein, which then feeds the superficial varicosities running down the leg. This is a ‘paradoxical’ situation, in which the thigh veins are filled by ‘anti gravitational’ flow, but in fact the flow will eventually make its way down into the calf via the incompetent veins, in the correct gravitational direction unusual distributions
  • 138. Dr Ahmed Esawy In some patients, it may be impossible to clearly define the source of the varicose veins especially if they are very small, are diffusely distributed and generally run into very small superficial tributaries.
  • 140. Dr Ahmed Esawy Possible causes of LSV recurrences Incomplete Ligation SFJ Neo-vascularization (cavernoma) Incomplete stripping of the LSV trunk in the thigh (Remnants of GSV) Duplicated GSV incomplete removal of incompetent Thigh or calf perforators failure to differentiate lesser from greater saphenous vein incompetence (incompetence of the SSV) Incompetent tributaries Secondary varicose veins
  • 141. Dr Ahmed Esawy Possible causes of SSV recurrences • incomplete ligation of the saphenopopliteal junction • lncompetent Giacomini vein • Incompetent perforators • LSV incompetence • Diffuse varicosities in the popliteal fossa
  • 142. Dr Ahmed Esawy Difficulty in competency assess • the assessment of patients with venous ulcers. • continuous high-volume flow (hyperemic flow) in the superficial and deep veins due to infection. • The high-volume flow toward the heart can lead to a reduction in reflux duration • The leg can be reassessed when the hyperemia subsides (by antiobiotic therapy).
  • 143. Dr Ahmed Esawy Saphenous pulsation on duplex may be a marker of severe chronic superficial venous insufficiency Duplex tracing of a typical saphenous pulse (SP) waveform Etiology may be AV connections (arterial varices)
  • 145. Dr Ahmed Esawy Color Doppler examination is frequently carried out to see if there is thrombus, or to evaluate the extension of the thrombus in the deep system. Example: thrombosis of the greater saphenous vein with extension of the thrombus (arrows) in the femoral vein
  • 146. Dr Ahmed Esawy • Due to inflammatory infiltration of the surrounding subcutaneous fat, a hyperechoic halo is visible around the inflamed vein in case of phlebitis
  • 147. Dr Ahmed Esawy A marked inflammatory hyper-vascularization is always visible around the inflamed part of the vein, with hypertrophic arterioles which are not visible in normal conditions.
  • 148. Dr Ahmed Esawy A typical low-resistance inflammatory flow is seen in these tiny arterioles. .
  • 149. Dr Ahmed Esawy Sonographic triade of superficial phlebitis hyperechoic halo small arterioles around the vein low-resistance flow