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ABSTRACT

OBJECTIVE: To determine various venous pathologies in the Lower Limb diagnosed by Doppler ultrasound.STUDY DESIGN: Cross sectional observational study

st stPLACE AND DURATION: At University Ultrasound Clinic, University of Lahore from 1 January to 1 July 2013.METHODOLOGY: Symptomatic Patients were selected from both sex and different provocative measures were used for the diagnosis of venous pathologies. Compression technique, echogenic contents and color Doppler were used for the diagnosis of deep vein thrombosis, Valsalva and augmentation techniques were used for chronic venous insufficiency, low frequency transducer was applied for deep located veins. Collected data from the examination was compared with Clinical, etiological, anatomical and pathological (CEAP) classification System.RESULTS: Among 100 patients 81% females and 19% males were diagnosed for different venous diseases i.e. chronic venous insufficiency and DVT with diverse presentation of venous reflux, dilated perforators, and varicose veins. DVT was observed in 9 Legs, (Left 55.5%, right 45.5%). Right and Left leg ratio for varicose veins was 1:2. Along with other sonographic signs of chronic venous insufficiency, dilated incompetent perforators observed in 51% of individuals.CONCLUSION: Doppler ultrasound is very effective in the assessment of lower limb peripheral veins amongst noninvasive examinations.KEY WORDS: Deep Vein Thrombosis, Varicose Veins, Chronic Venous Insufficiency, Flow Reflux, Incompetent Perforators.

HOW TO CITE THIS:Bacha R, Gilani SA, Fatima M, Malik SS, Manzoor I, Zaman S, Khadija S. Doppler Ultrasound in the Assessment of Lower Limb Peripheral Veins, Isra Med J. 2017; 9(5): 284-88.

This is an Open Access article distributed under the terms of the Creative Commons Attribution-NonCommercial 4.0 International License (http://creativecommons.org/licenses/by-nc/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

ORIGINAL ARTICLE ISRA MEDICAL JOURNAL | Volume 9 - Issue 5 | Sep - Oct 2017

INTRODUCTION

Doppler ultrasound is increasingly used in the investigations of the lower limb venous problems since last decades. It is cost effective, universally available, relatively rapid and noninvasive method of diagnostic imaging. It is therefore frequently used investigation of choice in the assessment of lower limb venous

1diseases. Historically the development of Doppler ultrasound resulted from the fact that insufficient information provided by other imaging devices and ultrasound is free of; complications related to puncture site, radiation and high-density contrast

2agent. The transition occurred since early 1990s from the 3invasive studies to vascular Doppler. The specificity and

sensitivity of Doppler ultrasound in the diagnosis of venous reflux is measured in study of inter-observers variation as 97.9%

4-6 and 99.5% respectively.Worldwide lower limb vascular disorders are common and consume significant proportion of resources. Approximately 10 to 15 percent of males and 20 to 25 percent of females have visible varicose veins. Doppler ultrasound is the most important noninvasive investigation in the assessment of vascular studies but operator dependency is its important drawback. It is therefore important for the operator to have immense study regarding the anatomy of the veins and normal anatomic

7variations to overcome this deficiency. Doppler ultrasound of the lower limb veins is mainly indicated in the diagnosis of Deep vein thrombosis (DVT) and chronic venous insufficiency (CVI). Some of the axillary conditions for which venous Doppler is indicated are; venous obstruction in symptomatic or high-risk asymptomatic individuals; reflux, primary and secondary varicose veins; skin discoloration and venous ulceration. It is also helpful in the evaluation of the causes of Swelling, Pain, Tenderness, burning sensation, itching, throbbing, Palpable cord and documentation of a source for pulmonary embolism (PE). Assessment of dialysis access; Venous mapping prior to surgical procedures; Evaluation of veins prior to venous access and. It is also used for the Follow-up of patients with known venous thrombosis near the anticipated end of anticoagulation

8-10 therapy to assess the presence of residual thrombus.

Doppler Ultrasound in the Assessment of Lower Limb Peripheral Veins1 2 3 4Raham Bacha , Syed Amir Gilani , Mehreen Fatima , Sajid Shaheen Malik ,

5 6 6Iqra Manzoor , Shah Zaman , Syeda Khadija

1. Senior Lecturer Department (UIRSMIT) FAHS2. Dean FAHS, University of Lahore Pakistan3. Senior lecturer of Biostatistician Faculty of Allied Health Sciences4. Head of Department (UIRSMIT) FAHS, 5. MSc Ultrasound6. MS Ultrasound, University of Lahore Pakistan

Correspondence to:Raham BachaSenior Lecturer Department (UIRSMIT) FAHSUniversity of Lahore PakistanE-mail: raham.bacha@rsmi.uol.edu.pk, dr.rahambacha@gmail.com

Received for Publication: 15-02-17Accepted for Publication: 13-11-17

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Combined Doppler US with compression US and different provocative techniques have optimal sensitivity and specificity for the diagnosis of deep vein thrombosis (DVT), chronic venous insufficiency (CVI), thrombophlebitis and possible causes of varicose veins. As ultrasound modalities are updating day by day so its diagnostic accuracy improves. Some of the meta-analysis shows that specificity and sensitivity was improved with time. It is therefore justified to publish data for the prevailing ultrasound modalities and techniques. The provision of this data makes easy for the future studies to compare the prevailing modalities and techniques with the old ones. It is an effort to evaluate the diagnostic capability with the improvement of Doppler ultrasound instrumentation and adoptability of new

11-15provocative techniques. This study was conducted to determine various venous pathologies in the Lower Limb diagnosed by Doppler ultrasound.

METHODOLOGY

stThis cross-sectional observational study was performed from 1 stJanuary to 1 July 2013, at the Ultrasound Clinic, University of

Lahore. A total of 107 symptomatic patients were enrolled in this study voluntarily, while the procedure was explained to human-subject and written informed-consent was obtained. Pre-approval was taken from the institutional review board (IRB) and ethical committee of the University of Lahore. Symptomatic patients were selected for various venous pathologies with CEAP (clinical etiologic anatomic pathophysiologic) method. All the patients with lower limb conditions related to venous system and classified with CEAP method were included. While other lower limb condition expectedly related to arterial system i.e. heart diseases, vascular brain diseases, peripheral obstructive artery disease, chronic liver disease, known kidney disease or any other chronic severe disease and pregnancy were excluded. This study was performed with high resolution linear transducer frequency ranging from 5 to 11MHz (esothe mylab 50) ultrasound systems. MS Excel 2013 was used for the collection and organization of data, SPSS IBM 16 version was used for the evaluation of data and graphs formation. The results were summarized in the form of graphs, tables and charts. Descriptive data is explained in the form of frequency, mean and standard deviation.Real-time images of the common femoral, deep femoral, femoral, popliteal, posterior tibial, anterior tibial and sometimes peroneal veins were obtained with different provocative measures and methods. The techniques applied study are Valsalva maneuver, compression, augmentation, examination of the vessel lumen with different frequencies and application of colour and power Doppler. We observed some of the venous pathologies with most certainty. Deep vein thrombosis (DVT); Ultrasound criteria for DVT are non-compressible vein with internal echo either no flow or minimal augmented flow through calf squeezing in case of recanalization. Chronic venous insufficiency (CVI); Reflux or retrograde flow in deep, superficial or perforating veins, causing distal venous pressure is termed as venous insufficiency. Long term venous outflow obstruction and or incompetence may

results in swelling or ulceration due to peripheral blood pooling, —which is a characteristic of post-phlebitic limb. The causes of

varicose veins were diagnosed with the use of different provocative techniques i.e. Valsalva distal compression and following of the varicose segment of vein proximally or communication with deep veins. Complex anatomic variation is present in the lower limb venous system, including a branch of small saphenous vein often extends to the thigh called Giacomini vein. It is also sometimes referring to as proximal thigh extension of the small saphenous vein which could be the cause of varicosity.

FIGURE - 1: GIACOMINI VEIN

FIGURE-2: DISTRIBUTION OF VARICOSE VEINS IN BOTH THE LEGS

FIGURE-3: GENDER FREQUENCY PARTICIPATED IN THIS RESEARCH

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RESULTS

A total of 107 symptomatic individuals of different ages, ranging from 20 years to 80 years with mean was 43.21±13.23 years were enrolled. Among them 3 were declared normal, 1 was with subcutaneous edema and enlarged inguinal lymph nodes suggested of elephantiasis, 1 patient with excessive subcutaneous fats and bulky muscle while one was with arteriosclerotic disease. The rest of 100 patients were evaluated for different sonographic signs of DVT and Chronic venous insufficiency. The diagnostic accuracy of US for lower limb venous study varies according to the expertise and technique used. Among100 individuals 81 (81%) males and 19 (19%) were females. DVT was diagnosed in 9% of the patients, Right and Left Leg ratio for DVT was 4:5, Male and Female percentage was 33% and 66% respectively (Figure-1). Chronic venous insufficiency was evaluated with the help of Valsalva maneuver at the sapheno-femoral junction, perforator incompetency and varicosity. Along with other signs of chronic venous insufficiency varicose veins were observed in 81%(14% bilateral, 37% Left, 29% Right, 1% within gastrocnemius muscle) (Figure-2). Estimated left and right leg ratio was 1:2. Blood flow reflux was found in 67% Sapheno-Femoral Junction (17% bilateral, 30% Left and 20% Right) (Figure-3). Dilatated, incompetent perforators found in 51% of individuals. The detail of incompetent perforators is given 1% had Left Boyd's and Hunter's perforator, 2% only Left Boyd's perforator, 9% Left Crocket's and Boyd's perforators, 1% Left Cockett's and Dodd's, 19% only Left Cockett's perforator, 1% Left Cockett's, Boyd's, Dodd's and Hunter's perforators while the. On the other side 4% had dilated Right Boyd's, 3% Right Cockett's and Boyd's, 8% only Right Cockett's and the rest of 1% has Right Dodd's perforator (Figure-4). Overall complaint of patients for left leg was more than right leg, Right and Left leg ratio, 3:4.

DISCUSSION

Doppler ultrasound provides non-Invasive method for the assessment of blood vessels. Gray scale along with spectral Doppler and color Doppler give us information regarding anatomic structure and detailed characteristics of blood flow

and direction. While keeping in view the objective and results of the study, it is logical to state that Doppler ultrasound has a pivotal role in the assessment of lower limb vein.A systemic review and meta-analysis concluded its sensitivity for detecting proximal DVT was 94.2% and for distal DVT was

1163.5%. and Pooled specificity was 93.8%. We selected patients with CEAP classification method for this study but 7 (6.5 %) were wrongly classified. The rest of 100 (93.4%) were diagnosed for different sonographic signs of DVT and Chronic venous insufficiency. Optimal sensitivity was achieved by the use of different provocative techniques. Compression sonography is sufficient for the diagnoses proximal DVT, color Doppler with distal augmentation was used to detect flow in the deep thigh and calf veins. In addition, Valsalva maneuver is used to evaluate venous insufficiency and proximal stenosis. Calf squeezing is used to augment flow and sudden release to assess reflux in the vein. We observed DVT at different locations, the thrombosed veins were evaluated for compression color/ power Doppler and distal augmentation. But all the techniques equally and effectively declared DVT. It is also observed that women are more susceptible to DVT as compared to man. occurrence of DVT is more evident in left leg than right leg. Another study aimed to determine the causes of varicose vein, valvular incompetence, incompetent perforating vein and deep vein thrombosis. Resulted in (50%) volvular incompetence, (27.5%) valvular incompetence combined with incompetent perforating vein, only incompetent perforating vein was observed in (16.3%), DVT in (5%), and. This study concluded that vascular Ultrasound is a safe and effective technique for evaluating lower limb varicose veins before planning the

22treatment course.The involvement of right and left leg in varicosity was estimated as (2:3). Robertson, L, et al, 2012; worked on a sample of 1456 for the incidence of chronic venous disease in the Edinburgh Vein Study. They estimated the overall incidence of C2 varicose veins was 18.2% (15.2%-21.6%), giving an annual incidence rate of 1.4% (1.1%-1.7%), with incidence rates similar in men and women: the 13-year age-adjusted incidence of varicose veins was 15.2% (10.4%-20.0%) in men and 17.4% (13.1%-21.7%) in women. They also estimated that the incidence of varicose veins increased consistently with age from 9.8% in those aged 18 to 34 years to 25.7% in those aged 55 to 64 years. The 13-year incidence of CVI was 9.2%, and the annual incidence rate was 0.7%. The incidence of CVI was similar in men and women and increased consistently with age. Participants with a family history of venous disease were more likely to develop C2 varicose veins. Obesity was associated with the development of CVI: the 13-year incidence was 6.1% in those who were of normal weight and 23.6% in obese participants, with an age-adjusted odds ratio of 3.58.A study on the incidence of varicose veins and CVI resulted in no significant difference between male and female although favored association with increasing age. Association with positive family history and body mass index was also appreciated with CVI. Our results of chronic venous insufficiency agree with international study.The sensitivity of Doppler ultrasound is estimated in proximal

FIGURE-4: DVT INVOLVEMENT REGION AND SIDE OF THE LOWER LIMB

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and distal veins as; proximal sensitivity (96%), distal sensitivity (75%) and specificity (94%). Optimal reliability is achieved with

23, 24the use of different provocative measures. Compression US alone is probably the appropriate technique for the identification of simply proximal DVT. Although the probability of DVT is low to optimum specificity and reduce false positive results color Doppler should be used. In recent studies, high sensitivity is recorded, probably due to development in machines technologies and expertise. Vascular study done with old modalities shows dramatically low sensitivity and specificity. similarly compression ultrasonography is the simplest technique, whereas Doppler ultrasound techniques are more challenging and therefore more likely result in greater reporting variability.A study was done on the contribution of perforating veins in chronic venous insufficiency, it was revealed that dilated incompetent perforating veins is a late complication of varicose veins. Dilatation and incompetency of the perforating vein was observed in close relation with the post-thrombotic syndrome. Incompetent perforators was estimated in 84% of post-thrombotic syndrome after short period of follow up. We observed venous insufficiency with reflux at various anatomical regions, matching international studies.Form the above studies it is concluded that Doppler ultrasound is considered as the gold standard among noninvasive examinations, because it allows identifying and locating pathophysiological alterations (remodeling), obstructions or refluxes, both in the deep venous system and in the superficial venous system. Over the last two decades, phlebography is replaced Doppler ultrasound.

CONCLUSION

Doppler ultrasound is very effective in the assessment of lower limb peripheral veins amongst noninvasive examinations

RECOMMENDATIONS

It is recommended to use different provocative measures just as Valsalva maneuver, Compression sonography, distal and proximal augmentation. Patient positioning, proper exposure, sonographer expertise and machine design technologies are also accounted for the overall reliability of Doppler ultrasound. The operator dependency could be overcome by educating and updating the operator's knowledge.

CONTRIBUTION OF AUTHORS:Bacha R: Study Designed, Data collection.Gilani SA: Conceived Idea, Final proofingMalik SS: Data CollectionFatima M: Data AnalysisMazoor I: Proof reading, compilationZaman S; Data collection, Proof readingKhadija S: Proof reading

Disclaimer: None.Conflict of Interest: None.

Source of Funding: None.

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