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I LOVE Venous Insufficiency Exams




You might be asking yourself, how can love and venous insufficiency be in the same sentence?




Well initially, when I learned about venous insufficiency studies, I thought they were sooo tedious and definitely did not like them. However, as I scanned them more and fully learned the superficial and perforating veins anatomy, I got more and more comfortable and in some strange way, I now love performing them.


I hope this blog answers any of the questions you currently have about this exam and helps you love them as much as I do, or at least like them a little more :)


Note: this protocol/criteria will likely vary from facility to facility, below is what I personally do, this can serve as a baseline for those of you that currently do not have a protocol in place.


 

Position


The exam should be performed standing or reverse Trendelenburg position.

By Saltanat ebli - Own work, CC0, https://commons.wikimedia.org/w/index.php?curid=25416738

 

Protocol


First perform a complete DVT study

Compression, Color Doppler, PW Doppler:

  • CFV

  • SAPHENOFEMORAL JUNCTION

  • FV PROX

  • FV MID

  • FV DISTAL

  • POP V.

  • PTVs

  • PERONEAL V.

  • GASTROCNEMIUS V.

Once the vessels above have been imaged, return to the groin and start evaluating the superficial system (GSV and SSV).


GSV PROX, MID, DISTAL THIGH

  • Dual screen compression and diameter measurement at each level.

  • Color Doppler with and without Valsalva maneuver at each level.

  • PW Doppler with Valsalva maneuver at each level.


SSV PROX

  • Color Doppler with and without Valsalva maneuver or augmentation

  • PW Doppler with Valsalva maneuver or augmentation


Perforators:

Throughout your study be observant: look for any incompetent perforators. They can be seen in transverse coursing between the deep and superficial system. Obtain diameter measurements and augmentations of perforators, measuring any significant reflux.


Knowing your vascular anatomy is a MUST in order to provide quality diagnostic images.

Look at the diagrams below for a little anatomy recap :)

Fig 3. Superficial and perforating veins of the leg. From Mozes G, Gloviczki P. New discoveries in anatomy and new terminology of leg veins: clinical implications. Vasc Endovasc Surg 2004;38:367-74121
Fig 4. Deep veins of the leg. From Mozes G, Gloviczki P. New discoveries in anatomy and new terminology of leg veins: clinical implications. Vasc Endovasc Surg 2004;38:367-74.121




TIP: one of the best ways to learn vascular anatomy, for me, was drawing it out!


Research has shown that those that spend some minutes in their day creating art/crafts have actually decreased levels of cortisol! Cortisol is the biological indicator correlated to stress. Hence, the lower your cortisol levels are the less stressed out you are!


This is a WIN-WIN! Go grab a pencil and a paper and get to it, you future Da Vinci you ;) .

 

Technique


Valsalva is usually more successful in imaging reflux above the knee. If the patient cannot perform valsalva, you can press with your hand the pelvic region for a few seconds and achieve valsalva that way.


Distal Augmentation is usually more successful in imaging reflux below the knee. An augmentation is done by squeezing the patient's calf and quickly letting it go or you can use an augmentation device (if your facility has one).


TIP: With advanced disease it can be difficult to distinguish between the GSV from tributaries – if that occurs, measure the diameter of the larger branches and indicate on your worksheet “the GSV was lost at ___ segment due to varicose vein clusters”.


 

Criteria


Venous Reflux Grading:

  • Grade 1: 0.5 – 1 sec

  • Grade 2: 2 – 3 sec

  • Grade 3: 3 – 6 sec

  • Grade 4: greater than 6 sec


If incompetent:

The SFJ must measure 5.5 mm or greater in diameter. The proximal GSV must measure 5.5 mm or greater in diameter. The small SSV must measure 5.0 mm or greater in diameter.


If incompetent, Perforators must measure 3.5 mm or greater in diameter. Perforator reflux of greater than 350 ms duration must be measured and documented.



 

I hope you all enjoyed my very first blog!


Many more to come,

Daryan Garcia, B.S, RDMS, RVT


P.S. Feel free to share your thoughts, your feedback is truly valuable.


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