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been disappointing, and published long-term results are
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absent. Comparisons between liquid and foam sclerotherapy have been done, and the results strongly favor foam.
20,21
Ultrasound-guided sclerotherapy (USGS) with foam must
be considered as a completely new treatment of varicose
veins. Although it needs proper training and some skill, it is
simple, a ordable, and extremely e cient.
Sclerosing agents produce a lesion of the venous wall,
predominantly of the endothelium and, to a minor extent,
of the media. e reaction that follows depends on the concentration of the agent and on the duration of the contact. If
the venous diameter is greater than 3mm, injections of liquid do not achieve this aim and dilution with blood quickly
decreases their e cacy at short distances from the point of
injection. Injections of foam have the advantage of a total
lling of the vein, at least under 12mm diameter. Afurther
reduction in venous diameter can be obtained by leg elevation, compression with the hand, duplex probe or bandage,
and venous spasm. In very large veins, foam will oat over
blood and induce a lesion of the upper venous wall despite
apparent correct lling of the vein observed on duplex, thus
the importance of massaging and compression.
Making the foam is easy and quick. Based on the technique initially described by Tessari, it can be prepared with
20
two 5-cc syringes and a three-way stopcock.
Only detergent sclerosing agents can be used: Sotradecol and polidocanol at any desired concentration from 0.25% to 3%.
Microbubbles of foam sclerosing agents are hyperechogenic
and represent an excellent contrast medium for ultrasound
techniques. ey appear as a shadow within the lumen
early, and like a hyperechogenic mass later with an acoustic
shadow. Massaging the sclerosing agent to the desired part
of the varicose network with the duplex probe or the hand
is also very easily carried out. Progression from the varicose
clusters to the GSV and then to the SFJ is always visible,
provided a su cient volume has been injected. Venous
spasm usually is observed within minutes. e importance
of the initial spasm has been emphasized in several studies
22,23
and protocols.
Postsclerotherapy compression is mandatory: on the
varicose clusters for 48 hours, and then whole limb compression with 20- to 30-mm Hg thigh-high medical elastic
24
stockings.
ey must be worn during the daytime for at
least 15days. Patients must be examined both clinically and
with duplex at 7 to 15days.
e absolute risk of deep venous thrombosis is not con rmed. Afew cases have been reported:most of them are
gastrocnemius vein thrombosis, typically a er telangiectasia and reticular vein sclerotherapy. Most frequent complications are visual disorders. ese adverse reactions have
been observed also with liquid sclerosing agents, but their
incidence is much higher with foam; they can be estimated
25
ey are observed more
frequently in patients su ering from migraine with visual
aura. ey usually reproduce this aura. Researchers have
questioned the pathophysiology of this phenomenon but
have received no answer so far. e existence of a patent
foramen ovale is the most likely explanation, as has been the
liberation of toxic component associated with endothelial
cell destruction (endothelin).
All published results demonstrate an immediate e cacy
better than 80% in terms of immediate/primary venous
occlusion. Repetition of injections in case of initial failure
allows closure to approach 95% of e cacy with two to three
sessions. Early and midterm results demonstrate a recurrence rate of about 20%. e redo injections remain as simple as primary injections and at least as e cient.
R E F E R E N C E S
1. Takase S , Pascarella L , Bergan J , Schmid-Schönbein , GW .
Hypertension-induced venous valve remodeling, J Vasc Surg . 2004 .
39 : 1329–1334 .
2. Takase S , Pascarella L , Lerond L , Bergan JJ , Schmid-Schönbein GW .
Venous hypertension, in ammation, and valve remodeling , Eur J
Vasc Endovasc Surg . 2004 . 28 : 484–493 .
3. Pascarella L , Schmid-Schönbein GW , Bergan JJ . An animal model
of venous hypertension: e role of in ammation in venous valve
failure , J Vasc Surg . 2005 . 41 : 303–311 .
4. Pascarella L , Schmid-Schönbein GW , Bergan JJ . Microcirculation
and venous ulcers, Ann Vasc Surg . 2005 . 19 ( 6 ): 921–927 .
5. Mashiah A , Ross SS , Hod I . e scanning electron microscope in the
pathology of varicose veins, Isr J Med Sci . 1991 . 27 : 202–206 .
6. Travers JP , Brookes CE , Evans J, etal. Assessment of wall structure and
composition of varicose veins with reference to collagen, elastin, and
smooth muscle content , Eur J Vasc Endovasc Surg . 1996 . 11 : 230–237 .
7. Gradman WS , Segalowitz J , Grundfest W . Venoscopy in varicose
vein surgery:Initial experience , Phlebology . 1993 . 8 : 145–150 .
8. Van Cleef IF , Desvaux P , Hugentobler JP, etal. Endoscopie veineuse ,
J Mal Vasc . 1991 . 16 : 184–187 .
9. Van Cleef JF , Desvaux P , Hugentobler JP, etal. Etude endoscopique
des re ux valvulaires sapheniens, J Mal Vasc . 1992 . 17 : 113–116 .
10. Ono T , Bergan JJ , Schmid-Schönbein GW , Takase S . Monocyte
in ltration into venous valves , J Vasc Surg . 1998 . 27 : 158–166 .
11. Satokawa H , Hoshino S , Igari T . Angioscopic external valvu-
loplasty in the treatment of varicose veins , Phlebology . 1997 .
12 : 136–141 .
12. Wilkinson LS , Bunker C , Edwards JC , Scurr JH , Coleridge Smith
PD . Leukocytes: eir role in the etiopathogenesis of skin damage
in venous disease , J Vasc Surg . 1993 . 17 : 669–675 .
13. Sarin S , Scurr JH , Coleridge Smith PD . Stripping of the long saphe-
nous vein in the treatment of primary varicose veins, Br J Surg . 1994 .
81 : 1455–1458 .
14. Dwerryhouse S, Davies B , Harradine K , etal. Stripping of the long
saphenous vein reduces the rate of reoperation for recurrent varicose veins:Five year results of a randomized trial , J Vasc Surg . 1999 .
29 : 589–592 .
15. Jones L , Braithwaite BD , Selwyn D , etal. Neovascularisation is the
principal cause of varicose vein recurrence:Results of a randomised
trial of stripping the long saphenous vein , Eur J Vasc Endovasc Surg
1996 . 12 : 442–445 .
16. Woodyer AB , Dormandy JA . Is it necessary to strip the long saphe-
nous vein?, Phlebology . 1986 . 221–224 .
17. Min RJ , Zimmet SE , Isaacs MN , Forrestal MD . Endovenous laser
treatment of the incompetent greater saphenous vein , JVIR . 2001 .
12 : 1167–1171 .
18. Lurie F , Creton D , Eklof B , etal. Prospective randomized study of
endovenous radiofrequency obliteration (Closure Procedure) versus
ligation and stripping in a selected patient population (EVOLVeS
Study) , J Vasc Surg . 2003 . 38 : 207–214 .
.
138 • PRIMARY SUPERFICIAL VENOUS INSUFFICIENCY
19. Morrison NM . Saphenous ablation:What are the choices, laser, or
https://t.me/med1917
RF energy?, Semin Vasc Surg . 2005 . 18 ( 1 ): 15–18 .
20. Tessari L , Cavezzi A , Frullini A . Preliminary experience with a new
sclerosing foam in the treatment of varicose veins , Dermatol Surg .
2001 . 27 : 58–60 .
20. Yamaki T , Nozaki M , Iwasaka S . Comparative study of duplex-guided
foam sclerotherapy and duplex-guided liquid sclerotherapy for the
treatment of super cial venous insu ciency, Dermatol Surg . 2004 .
30 ( 5 ): 718–722 ; discussion722.
21. Hamel-Desnos C , Desnos P , Wollmann JC , Ouvry P , Mako S ,
Allaert FA . Evaluation of the e cacy of polidocanol in the form
of foam compared with liquid form in sclerotherapy of the greater
saphenous vein:Initial results, Dermatol Surg . 2003 . 29 ( 12 ): 1170–
1175 ; discussion1175.
22. Frullini A , Cavezzi A . Sclerosing foam in the treatment of varicose
veins and telangiectases:History and analysis of safety and complications , Dermatol Surg. 2002 . 28 ( 1 ): 11–15 .
23. Barrett JM , Allen B , Ockelford A , Goldman MP . Microfoam
ultrasound-guided sclerotherapy of varicose veins in 100 legs,
Dermatol Surg . 2004 . 30 ( 1 ): 6–12 .
24. Barrett JM , Allen B , Ockelford A , Goldman MP . Microfoam
ultrasound-guided sclerotherapy treatment for varicose veins in a subgroup with diameters at the junction of 10mm or greater compared with a
subgroup of less than 10mm, Dermatol Surg . 2004 . 30 ( 11 ): 1386–1390 .
25. Guex JJ , Allaert FA , Gillet JL , Chleir F . Immediate and midterm
complications of sclerotherapy:Report of a prospective multicenter
registry of 12,173 sclerotherapy sessions , Dermatol Surg . 2005 .
31 ( 2 ): 123–128 ; discussion 128.
OVERVIEW:TREATMENT OF VENOUS INSUFFICIENCY • 139
17.
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ULTRASOUND EXAMINATION OF THE PATIENT
WITH PRIMARY VENOUS INSUFFICIENCY
Nicole Loerzel , Virginia Ratcli , Nisha Bunke-Paquette , and John J. Bergan
INTRODUCTION
Chronic venous insu ciency (CVI) is a common disorder whose manifestations include varicose veins and skin
changes such as venous dermatitis, hyperpigmentation,
lipodermatosclerosis, and chronic leg ulcers. e signs
and symptoms identifying CVI have been clearly demonstrated to be related to venous hypertension.
tors, such as age, gender, hormones, body posture, genetic
inheritance, and employment in standing occupations are
associated with the development of venous hypertension.
is, in turn, has been found to trigger vascular remodeling,
through a reorganization of extracellular matrix within the
venous parenchyma. is leads to the failure of vein valves.
Primary valve incompetence is the most important cause
of venous hypertension (70–80% of cases). Valve incompetence may be secondary to deep venous thrombosis (DVT)
or trauma in 18–25% and due to a congenital anomaly in
7
1–3% of cases.
e advent of duplex ultrasonography has provided the
physician with practical information to assess varicose veins,
deep veins, thrombotic states, postthrombotic obstruction,
and incompetent perforating veins.
8
examination is an essential diagnostic tool in the evaluation
and treatment of venous disorders. Precision anatomical
vein mapping and identi cation of patterns of venous re ux
are essential to determine therapeutic options.
E Q U I P M E N T
e duplex ultrasound system should be able to detect
9
blood ow rates as low as 6 cm/s.
is can be done by
dedicated high resolution vascular scanners with Color/
Power-Doppler functions and pulsed-wave Doppler. Linear
transducers in the range of 4–7 MHz are used.
rior vena cava (IVC), pelvic veins, and deep veins in obese
patients may be imaged with 3-MHz transducers.
1,2
Several fac-
3,4
5,6
Duplex ultrasound
7
e infe-
With advances in technology, duplex systems have
become smaller, more transportable, and more operator
friendly. Miniaturized devices feature transducers designed
with advanced architecture that allow a single probe to
image across a greater range of depths within an application
and across applications. e transducer for peripheral vascular examinations operates from 5–10 MHz and provides resolution from skin surface to 7cm in depth. e technology
incorporates power Doppler sonography, tissue harmonic
imaging, and direct connectivity to a personal computer.
Additional materials needed for a complete examination include a warm room, acoustic gel, towels, handled step
stools, and a comprehension worksheet.
CLINICAL EXAMINATION
e clinical examination and complete medical history,
will help determine the need for venous duplex ultrasound
evaluation. Data concerning family and personal venous
history, symptoms, clinical ndings, and previous venous
treatments should be elicited.
Limbs should be classi ed into one of seven CEA P classes
of increasing severity designated C
to C 6 (see Table17.1)
0
and identi ed as symptomatic (S)or asymptomatic (A).
Common symptoms associated with CVI are leg idling,
heaviness, and sensation of itching and swelling; important
signs to consider are skin hyperpigmentation, varicose veins,
corona phlebectatica, venous dermatitis, lipodermatoclerosis, active ulcers, and/or scars from previous ulceration. e
term “chronic venous disease” (CVD) is used for the full
spectrum of signs and symptoms associated with classes C
, and the term “CVI” is used for classes C 4 toC 6 . 11
to C
6
A history of previous DVT or pulmonary embolism
provides information regarding etiology. e method of
diagnosing DVT always should be recorded. e anatomic
distribution and the pathophysiology within the CEAP system are revealed by the ultrasound examination.
10
0.s
140
Table17.1 CEAP CLASSIFICATION OF CVD ANDCVI 17
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CLASS SIGNS OF VENOUS DISEASE
Class 0
Class 1 (A,S)
Class 2 (A,S)
Class 3 (A,S)
Class 4 (A,S)
Class 5 (A,S)
Class 6 (A,S)
No visible or palpable signs of venous disease (only
symptoms)
Telangiectasias or Reticular Veins
Varicose Veins
Edema
Skin changes ascribed to venous disease (e.g.,
pigmenta tion, venous eczema, lipodermatosclerosis)
Skin changes as de ned above with healed ulceration
Skin changes as de ned above with active ulceration
INDICATIONS FOR DUPLEX
EVALUATION
Its generally accepted that all patients presenting with varicose veins, skin changes associated with chronic venous
insu ciency, edema, leg ulceration (CEAP clinical stages
2–6) should undergo duplex ultrasound evaluation. Duplex
scanning is also indicated to further evaluate patients with
venous symptoms (CEAP clinical stage 0), venous malforma-
12
tions and for post-treatment surveillance.
It is the authors
opinion that select patients with telangiectactic or reticular
veins (CEAP clinical stage 1) should also be scanned for
underlying venous insu ciency. Patients who have extensive reticular veins and/or telangiectasias, especially located
in the inner thighs, medial or lateral malleolus or associated
with corona phlebectasia are more likely to have underlying
venous insu ciency than patients with minimal or isolated
spider veins. e Edinborough Vein Study showed there
was a signi cant trend between grade of telangiectasias
and re ux in the GSV (upper and lower segments) in the
13,14
limbs of 1092 subjects.
Engelhorn demonstrated either
greater or small saphenous vein re ux in 46% of patients
15
with CEAP 1 telangiectasias.
Other clinical signs such as
corona phlebectasia, as de ned as fan-shaped intradermal
telangiectases in the medial and sometimes lateral portions
of the ankle and foot has been associated with an increased
16
prevalence of GSV re ux.
Additionally, risk of underlying
incompetence in the calf perforators by duplex ultrasound
is 4.4 times greater in patients with corona phlebectasia.
16
Patients who have failed spider vein treatment should also
be evaluated for an underlying source of venous re ux.
ULTRASOUND EXAMINATION
Table17.2 SUMMARY OF IMPORTANT CHANGES IN
NOMENCLATURE OF LOWER EXTREMITY VEINS
OLD TERMINOLOGY NEW TERMINOLOGY
Femoral Vein
Super cial Femoral Vein
Deep Vein of the thigh
Greater/Long Saphenous
Vein
Smaller/Short Saphenous
Vein
Sural Veins
Dodd’s Perforator
Boyd’s Perforator
Sherman’s Perforator
(24cm)
Cockett’s Perforators
when the patient is supine.
Common Femoral Vein
Femoral Vein
Profunda Femoris Vein
Great Saphenous Vein
Small Saphenous Vein
Solcal Veins
Gastrocnemius Veins
Medial Gastrocnemius Vein
Lateral Gastrocnemius Vein
Intergemellar Vein
Perforator of the Femoral Canal
Paratibial Perforator (upper third
of the leg)
Paratibial Perforator (middle third of
the leg)
Posterotibial Perforators
8,18,19
It is further recommended that
the patient stand for several minutes prior to a duplex examination, allowing for equilibration of the venous system. e
standing examination of the lower extremity venous system
has become the standard of care and the supine examination
should be considered inadequate. If the patient is physically
unable to stand or if the history reveals a tendency to fainting
because of vasovagal response, the examination may need to
be modi ed with the patient in the semi-upright position.
VEIN MAPPING.
Transverse rather than longitudinal scans, and continuous
scanning are performed in order to provide a clear mapping
of the venous system. is can be recorded on a premade data
sheet simultaneously with the venous re ux examination
(see Figure 17.1). Patency usually is assessed by compression
of the vein, and re ux is detected on release. e augmentation of ow, distal compression, and release of thigh and
7
should be done sharply and quickly. Automated rapid
calf
in ation/de ation cu s are cumbersome but may be used
for this purpose, and o er the advantage of a standardized
8,20
stimulus.
e Valsalva maneuver is a reverse ow augmentation stimulus and is best used for the saphenofemoral
junction (SFJ) because a competent valve at that level will
render the test useless on more distal segments.
19,25
In 2002, an international interdisciplinary consensus committee on venous anatomical terminology proposed a revision and extension of the Terminologia Anatomica of the
lower extremity venous system (see Table17.2).
e ultrasound examination is carried out with the patient
standing in an upright position.
challenging venous valves and maximally dilates the leg veins.
Sensitivity and speci city in detecting re ux are increased in
examinations performed with the patient standing rather than
ULTRASOUND EXAMINATION OF THE PATIENT WITH PRIMARY VENOUS INSUFFICIENCY • 141
17
18
is position elicits re ux by
R E F L U X
e presence of vein re ux through incompetent vein valves
is the most important pathologic nding in CVI. Re ux is
measured during the release phase of the ow augmentation
maneuver and during the closed epiglottis apneic phase of
the Valsalva maneuver (see Figure17.2). It should be noted
Right
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Left
Femoral Vein
SFJ
1.08 cm
GSV
58 cm;
48 cm;
0.36 cm
Figure17.1 is data entry form outlines the saphenous veins and the relevant deep veins. Re uxing veins are added in heavy black lines and selected
vein diameters are recorded. Location of PVs and aneurysms can be added and distance from the oor indicated.
0.41 cm
34 cm;
0.22 cm
Vein of Giacomini
22 cm; 0.76 cm
AP 2.2 × LL 1.9 cm
that retrograde back ow is present in normal vein valves
immediately before their closure, but a cuto value of 500 ms
de nes pathologic re ux in the saphenous veins. e value
of 350 ms is used in perforator veins (PVs) and 1,000ms for
18,21
femoropopliteal veins.
Time of day is a relative consen-
sus regarding the position for re ux determination.
SFJ 1.19 cm
Posterior
Accessory
Venous
Aneurysm
16 cm; 0.6 cm
10 cm; 0.8 cm
Anterior
Accessory
Anterior
Arch
36 cm; 0.65 cm
19 cm; 0.46 cm
“Reentry” PV
SPJ
0.80 cm
SSV
and deep femoral veins are identi ed (see Figure 17.3).
e SFJ also known as the con uence of super cial inguinal veins, is complex and highly variable. It includes the
great saphenous vein (GSV), pudendal veins, and super cial epigastric and super cial circum ex iliac veins (see
17,22
Figure 17.4A).
Imaging of the pudendal veins is particularly important in cases of pelvic congestive syndrome,
in which vulvar varicosities and pudendal re ux can be
THE SAPHENOFEMORAL JUNCTION
With the patient standing and the transducer gently applied
in the groin, the SFJ, common femoral vein, femoral vein,
observed.
important cause of this syndrome.
the femoral vein is recorded. e SFJ is usually the location
23
Incompetence of the ovarian veins is the most
24
e diameter of the SFJ at the con uence of the GSV and
AB
Figure17.2 Flow augmentation maneuvers elicit re ux in incompetent veins. Re ux is de ned as retrograde out ow measured during the release
phase of the augmentation maneuver and the Valsava maneuver’s closed epiglottis apneic phase for the SFJ only. Figure17.2 (A)demonstrates
examination of a normal GSV. In contrast, Figure17.3 (B)demonstrates an incompetent GSV with re ux duration greater than 3 seconds.
142 • PRIMARY SUPERFICIAL VENOUS INSUFFICIENCY
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Figure17.3 A transverse scan of the SFJ is displayed. Major anatomic landmarks to be noted are femoral vein, femoral artery, SFJ diameter, GSVs.
25
of the terminal valve.
as subterminal, is also identi able (see Figure17.4B).
More distally another valve, known
25
e Valsalva and thigh/calf compression-release maneuvers de ne the presence of re ux at the saphenofemoral
junction as well as in the femoralvein.
T H E G S V
e GSV is scanned from the groin in proximal-to-distal
direction.
In the thigh, the GSV lies within the saphenous compart-
17
ment (see Figure17.5).
e super cial fascia and the muscular
fascia de ne the saphenous compartment and provide the typical ultrasound image of an Egyptian eye (see Figure17.5C).
25
Anterior and posterior accessory veins are o en
identi ed in the thigh (see Figure17.6). ese veins are
o en incompetent and receive re ux from the saphenous
17
vein.
Varying patterns of re ux through the di erent components of the SFJ and GSV system have been documented.
Classi cation of abnormal, re uxing venous patterns has
been a di cult task because of the anatomic variability of the vascular structures involved. In 2005 a panel
of experts proposed a new classi cation of GSV re ux
describing the di erent types and extent of GSV insu -
26,27
ciency (Figure17.7).
Furthermore, using this classi cation system, Chastanet and Pittaluga have demonstrated
that the more extensive the GSV re ux, the more it was
positively correlated with increasing age and advanced
28
clinical stage.
Younger patients were more likely to have
non-saphenous varicose veins with less advanced clinical
signs. Older patients were more likely to have incompetence at the saphenofemoral junction and GSV re ux to
theankle.
Diameters of the GSV, should be measured with
B-mode ultrasound in transverse section at several levels. ese measurements should be recorded at proximal,
middle, and distal regions and especially at diameter variation locations. e term “super cial venous aneurysms”
has been proposed for segmental dilations of the GSV and
29
small saphenous vein (SSV).
e term “varicosities” refers
to more elongated and dilated super cial veins. e level,
distance from the heel pad or oor, and anteroposterior
and laterolateral diameters of venous aneurysms should be
29
recorded.
Intersaphenous veins are o en present as communica-
tions between the GSV andSSV.
Figure17.4 ( A) e SFJ includes the GSV, the super cial iliac circum ex, the super cial epigastric, and the pudendal veins. (B)Illustration of the
SFJ with its valves. Modi ed from the De Venarum Ostiolis of Jeronimus Fabricius ab Aquapendente, Venice, 1603. TV, Terminal valve; PTV,
preterminal valve; SSV, suprasaphenic valve; ISV, infrasaphenic valve. (Adapted from Reference25.)
ULTRASOUND EXAMINATION OF THE PATIENT WITH PRIMARY VENOUS INSUFFICIENCY • 143
A
Supercial
Circumex
Iliac Vein
Anterior
Accessory
Vein
Supercial
Epigastric
Junction
GSV
B
Vein
SSV
TV
ISV
Pudendal
Vein
PTV
Posterior
Accessory
Vein
A
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SAPHENOUS CONPARTMENT
C
SUPERFICIAL
COMPARTMENT
DEEP
COMPARTMENT
B
SN
MUSCLE
DERMIS
ASV
GSV
FV
FA
ASV
(ASV = ACCESSORY SAPHENOUS VEINS)
SL
*
SAPHENOUS
FASCIA
SAPHENOUS
COPARTMENT
MUSCULAR FASCIA
MF
Figure17.5 ( A) e saphenous compartment (SaphC) is bound super cially by the saphenous fascia (SF) and deeply by the muscular fascia (MF).
It contains the saphenous veins (SV) and the saphenous nerve (SN). e accessory saphenous veins (ASV) lie external to this compartment, close
to the dermis (D). SC, Super cial compartment; DC, deep compartment. (Adapted from Reference 17.) (B)Axial section from a cadaveric limb.
e GSV enclosed in the saphenous compartment is clearly visualized. MF, Muscular fascia; SL saphenous ligament. (Adapted from Reference 25.)
(C)Sonography of the GSV at mid thigh. e hyperechoic saphenous fascia (SF) and muscular fascia (MF) de ne the saphenous compartment in
which the GSV courses.
T H E S S V
e SSV is an important and o en overlooked cause of
super cial venous insu ciency. e SSV usually empties in
e posterior leg should be carefully interrogated prior
to venous treatment, due to the variability in its anatomy
and proximity to nerves and arteries. e patient should
stand and facing opposite the examiner. e knee should
be slightly bent, heel on the ground and weight bearing on
the opposite limb. e study of the SSV starts at the popliteal fossa by identi cation of the saphenopopliteal junction
(SPJ). Compression-release of the calf provides information
concerning junctional re ux. If re ux is present in the SSV,
the diameter of the small saphenous vein should be mea-
12
sured 3cm distal to the SPJ and at mid-calf.
to the popliteal vein directly or via the gastrocnemius vein,
but there are many anatomic variations in its points of connection to the poplitealvein.
A thigh extension (TE), also known as the cranial exten-
30
sion of the SSV, is present in the majority of limbs.
It can
be identi ed between the biceps femoris and semimembra-
17
nous muscles.
e TE of the SSV may give rise to vein of
Giacomini, that connects with the GSV in the posteriome-
17
dial aspect of the thigh.
In the calf, the SSV courses within
a duplication of the super cial fascia similar to the GSV in
19
the saphenous compartment.
AB
Figure17.6 (A) SFJ in the longitudinal view. (B) e SFJ in transverse view will demonstrate the presence of accessory saphenous veins.
144 • PRIMARY SUPERFICIAL VENOUS INSUFFICIENCY
Mapping
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igh or calf
tributary
Type 1 Type 2a
Isolated Suprafascial
reux
Incompetent
tributary or
perforator
+/–
reentry
perforator
Incompetent
tributary or
perforator
Reentry
perforator
reentry
perforator
Incompetent
tributary or
perforator
+/–
Incompetent
tributary or
perforator
Reentry
perforator
Type 2b Type 2c Type 2d
Isolated Suprafascial reux
Incompetent
tributary
Reentry
perforator
Type 3a Type 3b Type 4a Type 4b Type 5
Mixed reux with junctional
competence
Mixed reux with junctional
incompetence
SAV reux with junctional
incompetence
Figure17.7 In 2005, a panel of experts proposed a new classi cation to he used in a prospective multicenter study testing the A.S.V.A.L. (selective
ablation of varicose veins in local anesthesia) method. e classi cation reports ve major types of saphenofemoral re ux.
roughout the entire examination, compression-release
maneuvers ser ve to elicit re ux in the various venous segments
should be recorded. Many authors have observed a correlation between an enlarged perforating vein diameter and
incompetence. One study reported that perforating diameters of 3.5mm or larger in the calf and thigh were associated
PERFORATINGVEINS
with re ux in more than 90% of cases.
31
Re ux is assessed by manual compression and release
PVs penetrate anatomic layers (see Figure 17.8). Communicating veins, such as intersaphenous veins, connect veins
17
within the same anatomic layer.
One of the innovations of the new Terminologia
Anatomica of the venous system of lower limbs is the complete elimination of eponyms such as the Boyd, Sherman,
and Cockett perforators. Descriptive terms designating
17
location have been adopted.
A classi cation of them is
shown in Table17.3. No doubt, all the eponyms will persist.
During the examination, the location of each perforator
is recorded by measuring its distance (in centimeters) from
the oor. e diameter (in centimeters) of each perforator
maneuvers. Blood ow direction and duration following
the compression must benoted.
It has been suggested that an outward (toward the super cial veins) blood ow of duration greater than 350ms, following manual distal compression, de nes a PV as incompetent.
Perforators can be distinguished as exit and reentry
veins. Exit veins are re uxing perforators usually associated with clusters of varicose veins and/or important skin
7
changes, such as hyperpigmentation.
Reentry perforators usually are found distal to major
varicose veins and clusters. eir blood ow direction is
inward (toward the deep veins) and they are not pathologic
7
ULTRASOUND EXAMINATION OF THE PATIENT WITH PRIMARY VENOUS INSUFFICIENCY • 145
Table17.3 PERFORATING VEINS 19
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MAIN GROUPS SUBGROUPS
Foot perforators Medial foot PV
Ankle Perforators Anterior Ankle PV
Leg Perforators Medial Leg PV
A
Knee Perforators Medial Knee PV
igh Perforators Medial igh PV
B
Plantar foot PV
Dorsal foot PVs or intercapillary veins
Plantar PV
Medial Ankle PV
Lateral Ankle PV
Paratibial PV
Posterior Tibial PV
Anterior Leg
Lateral Leg
Posterior Leg
Medial Gastrocnemius
Lateral Gastrocnemius
Intergemellar PV
Para-achillean PV
Suprapatellar PV
Lateral P.V
Infrapatellar PV
Popliteal Fossa
PV of the femoral canal
Inguinal PV
Anterior thigh PV
Lateral thigh PV
Posterior igh PVs
Pudendal PV
C
Figure17.8 PVs penetrate anatomic layers (A). Distal limb compression
rather than proximal (B and C) elicits re ux. Re ux is measured on the
release phase of the augmentation maneuver and is detected as outward
ow (B)whose duration is greater than in incompetent exit perforators.
Reentry perforators show little or no outward ow following distal
compressions(C).
but merely competent. 7 Skin changes are not seen adjacent
to reentry perforatingveins.
Incompetent perforators usually are observed at the
medial thigh, middle and distal third of the leg, and middle
7,9
third of the calf.
Scanning of the lateral aspect of the lower limb also is
recommended. e lateral venous system that is seen on the
lateral aspect of the thigh and the leg can show varicosities
and important exit and reentry perforators. ese are not as
well characterized as the medial perforatingveins.
ULTRASOUND MAPPING OF
VENOUSULCER S
Venous ulcers usually are associated with varicose veins and
re uxing perforators located in the immediate vicinity of
the ulcerated area. Asuper cial network of enlarged and
dilated veins o en can be observed underneath the ulcer
32
(see Figure 17.9).
e description and the documenta-
tion of re ux in these veins can help to indicate a particular
32–34
therapeutic approach.
D E E P V E I N S
e ultrasound examination also must include the deep
veins. Femoral and popliteal veins usually are studied with
35
the patient in supine position.
Patency is assessed by distal
compression. Irregularities of the vascular wall may appear
as hyperechoic areas and always should be noted in patients
with super cial re ux and a clinical history suggestive of
previous DVT or pulmonary embolism. Sural, anterior
tibial, posterior tibial, and peroneal veins are imaged while
the patient is in the sitting position, usually starting from
35
the ankle and proceeding toward the knee.
Compression
and ow augmentation maneuvers assess their patency
146 • PRIMARY SUPERFICIAL VENOUS INSUFFICIENCY
Proximal
v
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ein
Distal
vein
Subcutaneous
layer
Subfascial
layer
Perforating
Figure17.9 A network of varicose veins and incompetent perforators is o en identi ed in the vicinity of venous ulcers usually beneath theulcer.
and presence of re ux. Deep vein abnormalities must be
recorded.
DISCUSSION
Duplex ultrasound sonography represents the best choice
7–9
in evaluation of venous re ux in lower limbs.
is test is
noninvasive, generally acceptable to the patient, and inexpensive. It provides direct imaging, localization, and extent
of venous re ux with a surprisingly high sensitivity (95%)
36
and speci city (100%).
Duplex ultrasound ndings correlate with the angio-
scopic observation of incompetent vein valves in advanced
37
chronic venous insu ciency.
As demonstrated by Yamaki
etal., high peak re ux velocities (>30cm/s), re ux duration
greater than 3 s, and an enlarged valve annulus measured
vein
Table17.4 MAJOR INTERROGATION POINTS FOR
VENOUS REFLUX EXAMINATION
INTERROGATION POINTS
Femoral vein
Saphenofemoral junction
Great saphenous vein
Accessory veins (anterior and posterior)
Popliteal vein-gastrocnemius Veins
Small saphenous vein
igh Extension
Vein of Giacomini
Intersaphenous veins
Medial thigh PVs
Leg PVs
Ankle PVs
Perforating
vein
by duplex ultrasonography at the SFJ are closely related to
angioscopically deformed and incompetent terminal valves
37
(Type III and Type IV valves).
In contrast, duplex ultrasound PV identi cation and
characterization have shown to be more di cult and less
36
accurate.
Lower sensitivity rates (51%) have been reported
indicated in Table 17.4. ese serve as basic guidelines
because the interested vascular ultrasonographer must trace
out duplicated veins and note re ux in major tributaries,
such as the accessoryveins.
when the number of perforators identi ed by ultrasound,
ascending phlebography (AP), and subfascial endoscopic
36
perforator surgery (SEPS) were compared.
C O N C L U S I O N
Duplex ultrasound sonography is the optimal diagnostic
modality for assessment of lower extremity re ux. Insights
into pathology, proper technique, and uniform testing
9
are essential.
A clear graphic notation of signi cant vein
diameters, anomalous anatomy, super cial venous aneurysms, PVs, and presence and extent of re ux should always
be recorded during the examination. e most important
interrogation points for the venous re ux examination are
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2. Bergan JJ , Pascarella L , Schmid-Schenbein GW . Pathogenesis of primary chronic venous disease:Insights from animal models of venous
hypertension . J Vasc Surg . 2008 . 47 ( 1 ): 183–92 . Review.
3. Criqui MH , Denenberg JO , Bergan J , Langer RD , Fronek A . Risk
factors for chronic venous disease:the San Diego Population Study .
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4. Evans CJ , Fowkes FG , Ruckley CV , Lee AJ . Prevalence of varicose
veins and chronic venous insu ciency in men and women in the
general population:Edinburgh Vein Study , J Epidemiol Community
Health . 1999 . 53 ( 3 ): 149–153 .
5. Takase S , Pascarella L , Bergan JJ , Schmid-Schonbein GW .
Hypertension induced venous valve remodeling, J Vasc Surg . 2004 .
39 ( 6 ): 1329–1334 .
R E F E R E N C E S
ULTRASOUND EXAMINATION OF THE PATIENT WITH PRIMARY VENOUS INSUFFICIENCY • 147
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