Disclosure Joseph Zygmunt, Jr., RVT, RPhS

I disclose the following financial relationship(s):

•Employment: Covidien Inc.

Detecting Deep Venous Disease with Duplex Ultrasound Joseph Zygmunt, Jr. RVT, RPhS

IVC 2011

“Duplex Ultrasound has become the reference standard in assessing the morphology and hemodynamics of the lower limb veins”

Coleridge-Smith et al. Duplex Ultrasound Investigation of the Veins in Chronic Venous Disease of the Lower Limbs – UIP Consensus Document. Part I Basic Principles. Eur J Vasc Endovasc Surg 2006.

Cavezzi et al. Duplex Ultrasound Investigation of the Veins in Chronic Venous Disease of the Lower Limbs – UIP Consensus Document. Part II Anatomy. Eur J Vasc Endovasc Surg, 2006

“Duplex Ultrasound is the most significant contribution made to Phlebology in the last ten years” ~Dr. Hugo Partsch 2004

Deep Veins …….Some ask: Why Bother?

Deep Venous System

Examination of the deep venous system is considered an essential step in the evaluation of ANY phlebology patient

Primary system for venous return to the heart

Examination the superficial system only is inadequate

Evaluate for DVT – ( acute, sub-acute and chronic)

Evaluate for insufficiency (axial or segmental deep)

Change in Dogma -

Deep disease is no longer the “kiss of death”

Early intervention and clot load removal

IVUS

Iliac vein obstruction ubiquitous and often silent in general population

C3-C6 patients with primary and postthrombotic CVI - >90% with IVUS

Early restoration of iliac vein patency in the acute phase is becoming the norm to prevent post thrombotic syndrome

Lurie et al, Invasive treatment of deep venous disease,

a UIP consensus; Int Angiol 2010; 29:199-204

Anatomy : Deep System

Tibial

–Anterior –Posterior

Peroneal Gastrocnemius Popliteal

Anatomy : Deep System

Popliteal Femoral Vein (of the thigh)

– NOT SFV Deep (profunda)Femoris Common Femoral Vein External Iliac

Duplications in the FV and POP

can result in missed DVT

Patient Position

Hip slightly rotated

Supine (slight tilt on

table)

Incorrect positioning can lead to inaccurate assessment

Consider: ergonomics!

Deep System Diagnostic Criteria

Three complementary modes

Common Femoral Vein

Normal Findings – good compressibility

Split screen documentation

Femoral Vein

not superficial femoral vein

Popliteal Vein Note: vessel orientation

Post. Tibial and Peroneal Veins

Paired in calf

Anterior Tibial: omitted routinely

External Compression performed every 1-2 cm

along entire length of vein

90º to vein

(anterior and posterior

approach)

Don’t bounce the probe –

Use a slow deliberate

compression technique

Confirmation with other

modalities

Multiple Views to fully understand the pathology

DVT RT CFV

Spectral Doppler Spectral Doppler

Spontaneous flow Phasic flow with respiration (large veins)

cease with deep breath inspiration Flow also ceases with the Valsalva

maneuver Flow augmentation with distal compression Unidirectional flow (toward the heart) Non-pulsatile

Importance of contralateral CFV analysis

Valsalva:

“ a well performed Valsalva maneuver detects significant reflux in major veins until a competent valve is detected.….

Like descending venography, detection of reflux distal to competent valves may not be detected with these techniques”

Talbot, S Vascular Ultrasound Today 9(1): 1-28, 2004

A continuous venous waveform is abnormal – recommend study of proximal veins

Normal

phasic

Normal Color Doppler

Femoral Vein

thigh Venous Confluence

Color images in long axis to document patency of vein

Color Doppler Abnormal

Incomplete filling – no color = no flow

Case Study: Partial Compression

What about the spectral doppler?

Whats

going

On?

Rt CFV Continuous Flow

Walking Doppler

Venous Stenosis

Contralateral Comparison infra inguinal clues

Full Easy Compression Contralaterally

Report: What to document Transverse Gray Scale Spectral Wave Forms CFV, SFJ Right and Left CFV Prox, Mid, and Distal FV Pop V Pop V Post Tib V Peroneal V additional images as needed additional as per protocol additional as per protocol *iliacs, GSV, SSV, prox Profunda, gastrocs, soleals, ant tibs,

Perfs

ICAVL Imaging Standards 2010

Protocol: DVT

Deep Reflux vs Siphon affect?

Is deep reflux segmental or axial?

Thank You For Your Attention

joseph.zygmunt@covidien.com