What are the primary reasons for Venous vascular leg exam?

• Assess for DVT (Deep Vein Thrombosis)
• Evaluate the Saphenous veins for potential bypass conduit
• Evaluate for Venous Reflux

How do the deep veins course?

adjacent to major arteries and have the same names as the arteries (exception- IVC)

How much blood do the deep veins in the legs carry?

85% of blood volume

Name the deep veins in the pelvis?

Inferior Vena Cava (IVC)

Common Iliac Vein (CIV)

Internal Iliac Vein (IIV)

External Iliac Vein (EIV)

What is another name for the internal iliac vein?

Hypogastric vein

Name the deep veins in the thigh.

Common Femoral Vein (CFV)

Profunda Femoris Vein (PFV)

Femoral Vein (FV)

When does the external illiac become the common femoral

after it crosses the inguinal ligament

What is another name for the Profunda Femoris Vein?

Deep Femoral vein (DFV)

Where does the greater saphenous start and end?

starts at ankle

joins the common femoral at the groin

What was the Femoral vein previously known as?

Superficial Femoral Vein

Where is the Femoral vein?

What is the name of the vein that runs behind the knee?

Popliteal vein (Pop V)

When does the femoral vein become the popliteal vein?

when the femoral crosses the adductor canal

Where is the Small Saphenous vein (SSV) ?

Small Saphenous vein (SSV)

What was the Small Saphenous vein (SSV) previously known as?

Lesser Saphenous Vein (LSV)

Name the veins in the calf.

Popliteal vein (Pop V)

Gastrocnemius Veins

Anterior Tibial Veins (ATVs)

Posterior Tibial Veins (PTVs)

Peroneal Veins (Per. V)

All veins below the knee there are _____ veins to every one artery.

two

2 veins to every 1 artery

The Anterior Tibial Veins (ATVs) courses ________.

lateral

The Posterior Tibial Veins (PTVs) courses ________.

medial

The Peroneal Veins (Per. V) courses ________.

deep medial

Explain the course of the large saphenous vein.

GSV courses along the medial aspect of the leg from the ankle to the groin where it enters the deep system at the CFV (Saphenofemoral junction)

What is the difference between the deep and superficial veins?

superficial lie above the muscle

deep veins lie within muscle

Explain the course of the small saphenous vein.

SSV courses up the posterior aspect of the lower leg from the Achilles tendon region to the Popliteal vein confluence in the Popliteal Fossa

How many cases of DVT a year?

1 - 10 million

How many cases of Pulmonary Embolus a year?

600,000 cases

How many death a year from Pulmonary Embolus?

200,000 deaths

What are the reasons for a BLE?

Stasis - bedrest - lack of movement

hypercoagulability

vein wall injury - stab, gunshot, IV drugs

thrombofilia

hormone replacement

What are the Risk factors for DVT?

post - operative state

previous DVT

cancer

thrombophilia

• ATIII, protein C, protein S, deficiency, APC resistance
• Antiphospholipid antibody or lupus anticoagulant

trauma

pregnancy

high dose estrogen RX

Immobility (long car or plane ride)

Bed-rest > 4 days

Lower limb paralysis

What are the symptoms of a DVT?

• persistent leg pain with acute onset
• persistent leg swelling
• calf pain/tenderness
• if patients have above symptoms, 50% chance of DVT

Leg swelling will be ________ if a DVT is present.

Leg swelling will be unilateral if a DVT is present.

Why are DVTs have low sensitivity?

Many DVTs are clinically asymptomatic

Why are DVTs have low specificity?

Non-thrombotic disorders can cause the same clinical symptoms as DVT

What symptom has high positive predictive value for DVT?

Phlegmasia cerulea dolens

What is Phlegmasia cerulea dolens?

massive thigh and calf swelling

limb cyanosis

iIlio - femoral outflow obstruction

painful blue anemia

superficial thrombophlebitis

erythema / inflammation (swelling)

local tenderness

palpable cord or mass

usually more painful that DVT

What is the main problem with superficial thromboplebitis?

hurts like hell but probably will not throw an embolism unless proximal to the deep wein system.

What is the treatment with superficial thromboplebitis?

warm compress and aspirin

What should be looked for on a physical exam?

swelling

limb discoloration - venous insufficiency

stasis dermatitis, ulceration

varicose veins

palpable “cords” (STP-superficial thrombophlebitis)

What are the four parts o?f a Venous Duplex Techniques?

1.compressibility / coaptation of vein

2.visualization of thrombus

3.spectral Doppler - pos augmentation

4.color Doppler - wall to wall filling

What are the techniques used for a Venous Duplex Techniques?

Torso elevated 10-20 degrees - tilted bed

Leg rotated externally

Start at groin crease in transverse plane

What is coaptation?

close

phasic & spontaneous flow

site 1

site 2

site 3

site 4

site 5+

Why would you scan through the adductor canal?

On many patients, this approach provides an excellent acoustic window to the FV and SFA in the adductor canal. However, you must compress from the posterior thigh

What is the Valsalva Maneuver?

During inspiration, diaphragm moves downward and increases intra-abdominal pressure.

IVC is compressed and venous outflow is temporarily reduced or stopped.

Flow resumes during exhalation

*bearing down like you are pooping stops slows blood flow

If there is no close and back filling during valsalva maneuver what does this mean?

reflux

Flow direction display

Traditionally, the Doppler waveform has been displayed below baseline

This is not necessary with duplex ultrasound systems.

Continuous venous flow in CFV?

proximal obstruction

Respiratory phasicity may not be present due to:

Shallow breathers, (patients with pulmonary embolus-PE).

Patients who are lying supine.

Patients who have their arms raised and hands behind their head.

Spinal cord injured patients due to reduced abdominal muscle tone.

Proximal DVT or extrinsic venous compression.

Where is cardiac activity most influential?

thoracic vessels.

Explain cardiac influence in the lower extremities

Cardiac influence is usually not apparent or is reduced in the lower extremities

Pulsatile flow due to congestive heart failure

Where should you begin with Calf imaging?

at the ankle

Which vessel should be identified first in the calf?

PTV

What plain are the calf vessels imaged?

You may use color Doppler in transverse plane, but it’s not as good as in long view

What are some methods to improve calf vein visualization?

Leg dependent position

Maximum vein dilation

****Don’t expect spontaneous flow

What is the leg dependent position?

reverse trndenburg

When do we examine the anterior tibial veins?

Don’t bother !

Too tedious

Too small

They’re rarely involved unless there is extensive DVT in other vessels

Explain the importance of Gastroc vein thrombosis.

May be clinically important if thrombus extends to popliteal vein.

So, determine the extent of thrombus

What should you do if the patient has tenderness in her calf?

If the patient is symptomatic (tenderness), look for muscular vein thrombosis

Why must you augment most of the time in the calf?

Flow in calf veins is usually not spontaneous, you often must augment flow by squeezing the calf or ankle.

Explain the most important perspective of bilateral lower extremity exam

thrombus anywhere from the popliteal to the iliac veins is life threatening.

****Calf vein DVT may cause PE but thrombus is too small to be fatal.

What is the Criteria for Venous Thrombosis?

Absence of vein compressibility

Visualization of thrombus

Vein distention

Abnormal Doppler signals

Reduced / absent augmentation

Reduced / absent color filling

What is the sonographic appearance of acute DVT?

vein distended

somewhat hypo-echoic

no collaterals

maybe free floating

Tail!!!!!!!!!!

Acute DVT CFV

What must you do if PTV or peroneal vein thrombus is detected?

You must look carefully in the distal pop vein for propagation. It’s a difficult region to image.

What will eventually happen with chronic?

vein will eventually open back up & flow again

What are the symptoms of chronic DVT?

echogenic thrombus - more echogenic then acute

vein smaller than artery

presence of collaterals

recannalization

constricted vein

What us a Baker's cyst?

Synovial lining and fluid bulge into the popliteal space.

May dissect into calf muscles or along intermuscular septums

What is another name for a baker's cyst?

Synovial cyst

What should you do to confirm a baker's cyst?

Rule out calf hematoma by demonstrating communication with joint space

How do you tell the difference between a Calf hematoma and a baker's cyst?

absence of joint space communication helps differentiate from Baker’s cyst

Calf hematoma

Lymphedema

What is the sonographic appearance of a Lymphedema?

“Ant farm” appearance

What is Lymphedema?

Lymphedema refers to swelling that generally occurs in one of your arms or legs. Sometimes both arms or both legs swell.

Lymphedema is most commonly caused by the removal of or damage to your lymph nodes as a part of cancer treatment. It results from a blockage in your lymphatic system

Lymphedema

Where are Lymph nodes commonly seen?

Commonly seen in the groin region.

When are lymph nodes commonly seen?

Kidney-shaped and can be swollen in the presence of systemic infection, malignancy,

What should be done when lymph nodes are seen?

Should be measured in three dimensions and reported.

What is May Thurner Syndrome?

May-Thurner syndrome (MTS) is caused when the left iliac vein is compressed by the right iliac artery.

Why is May Thurner syndrome dangerous?

increases the risk of deep vein thrombosis (DVT) in the left extremity

VENOUS

acute onset SX

limb swelling

persistent pain calf/thigh

local tenderness

palpable “cord”

chest pain/SOB

ARTERIAL

progressive SX

intermittent pain when walking

foot/limb coolness

limb pallor

gangrene, tissue necrosis

Venous Insufficiency/
Venous Incompetence/ Venous Reflux

Primary

Congenital absence or defect of valves

Secondary

Post- phlebitic: valves damaged by venous thrombosis, and/or chronic outflow obstruction

How many valves are there in the IVC?

0

How many valves are there in the CIV?

0

How many valves are there in the EIV?

0

How many valves are there in the FV?

4

How many valves are there in the Pop?

2

How many valves are there in the PTV?

10

How many valves are there in the ATV?

10

How many valves are there in the ATV?

10

What are the 3 pump systems in the lower extremities?

Foot pump

Thigh pump

Calf veno-motor pump

What is the foot pump responsible for?

primes the calf pump

Thigh pump

Calf veno-motor pump

What is the thigh pump responsible for?

ejects thigh blood volume

What is the Calf veno-motor pump responsible for?

major ejection

Facilitates venous return to heart

Reduces the effect of hydrostatic pressure

Reduces venous pooling

Is dependent on competent valves and muscle contraction

What are the veins in the calves?

PTV’s

Peroneals

ATV’s

Gastrocs

Soleal sinuses

Greater & Small Saphenous

Perferators

How does the Veno-motor Pump work?

Muscle contraction squeezes blood upward, valves prevent return

What is the efficiency of the calf veno-motor pump is dependent upon?

1)The ability of the calf skeletal muscles to contract.

2)The competency of the venous valves.

3)The patency of outflow veins.

What can cause perforators?

Increased deep vein intraluminal pressure may cause perforators

What is a perforator?

shunt venous blood from Superficial to deep system) to dilate and become incompetent.

What are the Venous insufficiency symptoms?

Recurrent swelling (walking all day)

Varicose veins-Spider veins

Venous claudication - tired achy legs at end of day

Stasis dermatitis - pigment stain from leak

Ulceration

What is Stasis dermatitis ?

pigment stain from leak

What is Venous claudication?

tired achy legs at end of day

Explain the Flow patterns in upper extremities- central veins

Cardiac pulsatility is usually apparent and pronounced.

Respiratory variation occurs, but flow during inspiration INCREASES, due to changes in thoracic pressure.

subclavian

What is the difference between a midline and a Picc catheter?

midline ends in the subclavian before the cephalic

picc ends just outside the heart in the SVC

What are the Indications for UE venous duplex?

Pain and swelling in arm or neck

PE

Dilated SF veins of the arm or shoulder

Palpable cord in arm (SVT)

Infusion difficulty with indwelling catheters

Pre-op assessment for hemodialysis access placement

What are the Deep Veins of the upper extremity?

SVC

Innominate

Subclavian

Axillary

Brachial

Radial

Ulnar

What are the superficial Veins of the upper extremity?

Basilic

Cephalic

Median cubital

What is the Patient position for evaluation of proximal veins?

Supine for maximum venous filling

Normal upper venous flow

What are the normal characteristics of upper venous flow?

respiratory phasicity

cardiac influence

Infraclavicular Subclavian Vein

What will alleviate transient axillary vein compression?

Abduct arm to alleviate transient axillary vein compression

Arm veins

Use compression- release method

Pulsatile- phasic flow may be absent

Very superficial veins need standoff

Assess flow direction in all proximal veins

Bilateral comparison of proximal veins for waveform symmetry

Waveform assessment priority for prox veins

What is the rule about when an artery bifurcates?

before venous anastomosis

What is important when looking for reflux?

augmentation

If the vein is above the artery, where are you?

popliteal

What does continuous flow in the common femoral vein indicate?

proximal thrombosis

WHat is the easiest vein the identify below the knee?

posterior tibial

How do you find the peroneal veins?

posterior and deep to the PTV

If calf is swollen due to venous instruction what is involved?

popliteal

Where does DVT usually originate in the calf?

Soleal vein

Where is the soleus located?

small sinus that drains into PTV & Perotoneal

What does the gastrocnemius vein drain?

head of calf

drains into popliteal

What does poor augmentation indicate?

obstruction between transducer & augmentation

recanalization GSV with residual fibrous band is also called?

scaring

What is sub acute?

between acute and chronic

What is the treatment for a free floating thrombus?

NO AUGMENTATION!!!!!!!!!!!!

heprin/lebenen shot immediately

What will lymphedema cause with augmentation?

difficult augmenatation

What is progressive sx?

cholesterol problems

smoking

BP issues

What causes foot/limb coolness

limb pallor

gangrene

tissue necrosis

lack of arterial flow

The venous system is a ____ pressure system?

low

The rule for valves is

more distal more valves

What will venous obstruction in illiac, femoral or popliteal vein cause

sweeling & venous swelling

Why is dilated perforators a problem?

when veins stretch valves cannot "touch" and fully shut anymore

What is Paget–von Schrötter disease?

is a form of upper extremity deep vein thrombosis(DVT), in the axillary or subclavian veins.

What else is Paget–von Schrötter disease called?

"effort-induced thrombosis"

How many veins and arteries for the brachial, radial & ulnar?

2 veins

1 artery

Where does the basilic dump into?

axillary or brachial

What should be done when there is a thrombus in the basilic vein?

document how far it is from deep system

What is upper extremity exam not as accurate as the lower extremity exam?

confidence & volume