Hello, my name is Terrence Case. I'm the Program Director and Assistant Professor for the Vascular Sonography Program at Nova Southeastern University in Fort Lauderdale, Florida. I also chair the Products Committee of the Society for Vascular Ultrasound along with Billy Zhang and George Berdejo. This program is being supported by an unrestricted educational grant from the Radiology and Vascular Ultrasound Division of GE Healthcare in cooperation with TIP TV. I'll be providing a brief overview of the SVU Professional Performance Guidelines and then Paula Hegerich will provide a comprehensive presentation and demonstration entitled Duplex Evaluation of Chronic Venous Insufficiency. These guidelines were prepared by members of the Society for Vascular Ultrasound to provide a working template to aid vascular technologists and other vascular professionals. The purpose of this examination is to evaluate the deep and superficial venous systems for evidence of valvular incompetence. Common indications for this study include preoperative evaluation for venous insufficiency, venous ulcers, pain or feelings of heaviness in the lower extremity, visible varicose veins, and or pain, edema, and discoloration of the lower extremities. The most common contraindication for this examination include obesity, open draining ulcers, severe edema, or inability to stand for an extended length of time. The guidelines begin with an explanation of proper patient communication followed by the patient assessment and physical examination and the duplex examination for venous reflux. The guidelines continue with an explanation for a review of diagnostic exam findings, a presentation of exam findings, exam time recommendations, and suggestions for continuing medical education. For a comprehensive list of all SVU exam protocol guidelines, please visit our website at www.svunet.org. Thank you. My name is Paula Hegerich. I'm the manager of clinical marketing and training for Venous Medical Technology in San Jose, California. The lecture today is on duplex evaluation for venous insufficiency. There is an increased interest in assessing for chronic venous insufficiency as a direct result of all of the new, less invasive treatments for CVI. These techniques include endovenous laser, endovenous radiofrequency ablation, sclerotherapy, and microphlebectomy. All of these techniques require the use of ultrasound, first, to identify patients with venous insufficiency, second, to help direct the physician during the procedures, and lastly, post-operatively, to determine the success of the treatment and to rule out the presence of deep vein thrombosis. Let's start with the first slide. It is estimated that 25 million people in this country have symptomatic superficial venous insufficiency, but only 1.7 million seek treatment annually, therefore, 23 million go untreated. If you look at venous disease compared to all other vascular disease, for instance, peripheral arterial disease, coronary artery disease, you can see that venous reflux from this graph is much more prevalent than any other of the vascular diseases. What is venous reflux disease? Well, it is a progressive condition. It's caused by poor return of blood from the legs to the heart. Symptoms that a patient may have would be pain, varicose veins, leg heaviness and fatigue, swollen limbs, and ultimately skin changes and skin ulcers if gone untreated. Risk factors include multiple pregnancies because of extrinsic compression on the venous system in the pelvis, family history of disease seems to be quite prevalent, obesity, and standing professions, such as a hairdresser who stands all day for their work. How does venous reflux occur? Well, in a normal vein, we have valves, they're one-way valves, that open up and allow blood to go from the lower extremity back up to the heart. That happens with muscular contraction and or changes in interthoracic pressure. And on relaxation, the valve should close so that blood does not go in the retrograde fashion. When these valves are not working properly, we will have reflux or blood in the wrong direction and this causes increased venous pressure and ultimately this vein will become varicose or stretched because of all this increased pressure. Venous reflux, well, we're seeing here a dilated vein and you can see from this picture that these valves should come together and prevent the blood from going in the wrong direction. Well, when they don't come together properly, what happens is you have retrograde flow and increased venous pressure and the vein can become stretched and you can see on this picture a varicose vein on this patient's leg. How would a patient present with chronic venous insufficiency? Well, initially, they may present with just some edema. As the disease progresses, we might see evidence of varicose veins as we do on this leg. And as things get worse, you're going to start seeing discoloration at the ankle particularly and then ultimately, there may be a venous ulcer. When a patient presents, you should observe physical signs of venous disease and pay special attention to those locations when doing the examination. When we do the scan, the evaluation should be performed in a transverse and a longitudinal plane with the patient positioned to facilitate optimal access to these veins and we'll talk about those different positions. We'll start with anatomy and pathophysiology review. I wanted to add this slide at the beginning of this lecture because I want to talk about the fact that there were a group of phlebologists from all over the country that got together and formed a consensus statement stating the new terminology for the venous system. Because people use terms inconsistently all over the board, they thought it would be important to write a paper, agree on the proper terminology, and publish that paper. So you may see in different texts different terminology and that's why I did a side-by-side slide here to discuss the different terms as we knew them and the new terminology. So to begin with, the femoral vein is now called the common femoral vein. The superficial femoral vein is now called the femoral vein and the reason for that is it is not a superficial vein and that was always a point of confusion. The greater and long saphenous vein are now called the great saphenous vein. The lesser or short saphenous vein is now called the small saphenous vein. The femoral veins are now grouped together as soleo and gastrocnemius veins. Dodd and Hunterian perforators, which are in the thigh, are now called the perforator of the femoral canal. Boyd's perforator are called the paratibial perforator and they're in the upper third of the calf. And the cockate perforators are now referred to as the posterior tibial perforator. Okay, we'll do the anatomy review of the deep venous system first. We'll start low in the leg because the blood flows from the foot up to the heart. So in the calf, we have the tibial veins and the gastrocnemius veins. Those veins join the popliteal vein at the back of the knee. And as the vein proceeds up the thigh, it becomes the femoral vein. And at the common femoral vein, we have the deep and the femoral vein. There is a confluence that joins the femoral vein. Now we'll discuss the superficial venous system. We have the great saphenous vein, previously known as the greater or long saphenous vein. And we have the saphenofemoral junction tributaries, which are the anterior accessory saphenous vein, previously known as the anterior lateral tributary, and the posterior accessory saphenous vein, previously known as the posterior medial tributary. The superficial venous system, we have, in addition, the small saphenous vein. And this was previously known as the lesser or the short saphenous vein. And we also have perforators that connect the superficial system to the deep system. Now we'll start with the great saphenous vein. The great saphenous vein courses from the medial ankle to the groin, and it joins the common femoral vein proximal at the saphenofemoral junction, which is a real important landmark. Now the great saphenous vein is bound anteriorly by the superficial fascia, and I'll point that out here in the diagram, and posteriorly by the deep fascia. So we see the great saphenous vein in cross-section here. And this is referred to as the saphenous eye. Now up at the saphenofemoral junction, we have several tributaries, but there are really three that are most important, especially when doing these endovenous procedures. We have the superficial epigastric vein, which is right here on this diagram. And we have the anterior accessory saphenous vein, which runs over the front of the thigh and joins the great saphenous vein. And the posterior accessory saphenous vein, again, joins the great saphenous vein. The reason these landmarks are important is because when we place our catheter for treatment for either laser or radiofrequency, we need to be distal to the superficial epigastric vein, and we usually want to be at about the level of the other tributaries, especially if they show reflux. And in this diagram, it's just an ultrasound image of the saphenofemoral junction, and I think it demonstrates nicely that just with a little movement of the ultrasound probe, vessels can appear differently. So in the first picture here, we have the number four is the great saphenous, and it joins the common femoral vein. We have the epigastric vein, which is number two, and we don't really see the vessel on number three, the anterior accessory. With just slight movement of our transducer, moving a little anterior and lateral, we can bring in that anterior accessory saphenous vein. And we can also have the great saphenous vein also in that picture. Now the anterior accessory saphenous vein, it connects with the saphenofemoral junction, and it empties the lateral venous system. It's a pretty large vein. It's thin-walled, and it's an important source of varicose veins. There's a relatively high incident of anterior accessory vein reflux in patients with great saphenous vein reflux. And after a stripping, it is a common source of reoccurrence. Here's just showing you an ultrasound image of that anatomy. Keep in mind that this is a right lower extremity. So as we know, when we're in a transverse view on the right leg, this, with a notch pointing toward the patient's right, this is lateral, and this is medial on this image. So here we have the common femoral vein. We have the great saphenous vein, which is going medial. And we have the anterior accessory saphenous vein, which goes lateral. In this image, we are looking at a left lower extremity. So if you recall that this side of the image would be medial, this side of the image would be lateral. So this is the common femoral vein, and this would be the great saphenous vein because it's going medial. And this would be the anterior accessory lateral saphenous vein because it goes in a lateral fashion. And below that are the two arteries. Now we'll discuss the posterior accessory saphenous vein. The posterior accessory saphenous vein incompetence is less common than anterior accessory saphenous vein incompetence. It also can be a large vessel and thin-walled. We can see that it goes by this diagram in a medial and posterior fashion from the great saphenous. And here we're looking at an image of the left lower extremity. Again, I'll just point out that this is the medial side of the image. This is lateral. And this is just showing compression of all these veins. So we see that they completely compress. So in this image, we have the common femoral vein. And because this is the medial side, this is the posterior accessory saphenous vein. And we have the great saphenous vein here and the two arteries. This is an image of the anterior accessory saphenous vein and posterior by ultrasound. Noting that this is the right lower extremity, this would be the lateral side of this image and this would be the medial side. So here we have the common femoral vein in cross-section and the anterior accessory going in a lateral and anterior fashion, the great saphenous lying right in the middle of these two vessels, and the posterior accessory saphenous vein going in a medial and posterior direction. Now we'll move on to the small saphenous vein. The small saphenous vein courses from the lateral ankle and it courses up the posterior calf and it joins the popliteal at what is called the sapheno-popliteal junction, which is the confluence of the popliteal vein. And this can be very variable in patients. And we will discuss the different variations that you might find on image. The proximal portion lies between the fascia, as does the great saphenous. We'll continue with the anatomy review. In the back of the leg, we have the gastrocnemius vein, which is the primary vein responsible for calf muscle pump. We have the crease behind the knee, which is the popliteal fossa. We have the popliteal vein and the small saphenous vein empties into this deep vein. And we have the sapheno-popliteal junction, which typically lies within five centimeters of the popliteal crease. Off of that vein, the small saphenous vein, we have the vein of Giacomini and the thigh extension, which continue right up the back of the thigh. The vein of Giacomini is a vein that connects the great saphenous vein with the small saphenous vein. It is found in approximately 70% of limbs. And if you look at this diagram, we see it coming off the small saphenous and it proceeds up the back of the thigh going medial until it joins about the upper third of the thigh to the great saphenous vein. In addition, we have the thigh extension vein. And although this isn't a great image, we see in cross-section the thigh extension vein and the small saphenous vein. Down here, we see the small saphenous vein in this image. And here, we see a longitudinal view of that vein. So we see the small saphenous vein come in here. We see it join the popliteal vein at the saphenopopliteal junction. And we see the thigh extension vein continuing up the back of the thigh. Here's just different variations of the small saphenous vein and its termination. So let's look at the first diagram here. This is the most common confluence with the popliteal vein that occurs. And that's the small saphenous vein. We see the vena jacomini in the thigh extension going up towards the thigh. And we see the small saphenous join the popliteal. Down here, we see the gastrocnemius veins join the popliteal just on their own right into that vein. In this diagram, we see the small saphenous vein coming towards the popliteal. But we see the gastrocnemius veins joining the small saphenous vein here. And then we see the vessels that go up towards the thigh, the vena jacomini in the thigh extension. Here the small saphenous vein does join the popliteal. But the diameter of this vessel is so small that on ultrasound, you may not think you're visualizing it. It appears that it just continues on up through the thigh. But you have to really concentrate on this area because this vessel can be very small. And it's just not large enough. And your settings may not be correct on your ultrasound machine to see it. And in this last picture, the small saphenous vein does not join the popliteal at all. Just an ultrasound image, longitudinal image of the small saphenous vein joining the popliteal vein. Down here, we would have the popliteal artery. Here's another longitudinal image with and without color. We see the small saphenous vein joining the popliteal vein. And here we see color. And I just want to point out the color bar here so you can become familiar with what is the correct direction of flow. We see that flow going away from the transducer is in blue. And in fact, this is going away from the transducer towards the head, towards the heart. And this is the correct direction of flow by color Doppler. Here's another image of showing reflux, actually, of the small saphenous vein. So again, we're looking at our color bar. We see that the correct direction of flow would be in blue, going towards the heart with augmentation. And in this image, we see the presence of reflux by color Doppler because the blood flow is, by our color bars, going towards the transducer or away from the head. We'll continue on with anatomy and pathophysiology of the perforating veins. As we said, the perforating veins are veins that connect the deep and the superficial system. They course through the deep fascia. In this particular diagram, it's showing an abnormal situation. We see the deep system over here to the left. We see a valve that's competent and closes properly. We see the flow going from the deep system to the superficial system. And that is not the correct direction. We see that the valve cusps are not closing. So what happens is if the blood goes retrograde through the perforator into the superficial vein, we're going to have increased pressure in that superficial vein. And ultimately, that vein will stretch. And those valves will also become incompetent. Now perforator anatomy, we have many, many perforators in the leg. But there are really only a few that are clinically important to us with our imaging and also with treatment. We have the direct, which are the ones that we are most concerned about. And they connect with the major deep veins. And they're relatively consistent in their anatomical location, meaning we have given them names. You have many indirect perforators. And they connect with the muscle venous sinusoids. And their anatomic distribution can be very irregular. And many of those perforators are not named. Now via dissection and radiologic studies, we have identified the clinically significant groups. And those groups of perforating veins are in the foot, in the medial calf. Those are the most important perforating veins, in the lateral calf, and in the thigh. Now the thigh and calf perforators usually have one to three valves, and all are located beneath the deep fascia. So here we see what happens when we walk, and the muscle pumps. As the muscle contracts, and this is in a normal situation, the valve in the deep vein that's distal to that area will close. And as the muscle contracts, the blood will be pushed up through the deep system, and it will also push blood in through the perforator. If the perforator is functioning properly, that valve will shut, and there will not be retrograde flow into the superficial vein. On relaxation, it allows the valve distal in the deep system to open, the valve above will close, and flow will go from the superficial vein through the perforator into the deep system. Now we're looking at diagrams where it's an abnormal situation. So on muscle relaxation, there's not a lot of pressure in the system, so it won't be quite as apparent if the perforator is not functioning properly. So here we have the first diagram. We have muscle relaxation. We do have flow going retrograde into the deep system, and we see flow from superficial vein to deep system, and we see flow from superficial to deep. With the muscle contraction, that puts additional pressure on the venous system, so the blood is being pushed up through the deep system and forced through an incompetent perforator and into the superficial system. And as that superficial system becomes more stretched, we can actually palpate what's called a blowout on the skin. So if the patient stands up, and there's increased pressure, especially down at the ankle level, a physician can actually palpate that area and know where there is an incompetent perforator just by physical exam. Medial calf perforators. The most clinically significant of these perforator groups are the posterior tibial, which were formerly known as the cockat, and the paratibial, which were formerly known as the boid. We have three perforators located at the posterior medial border of the tibia. Usually, these are the posterior tibial perforators, and they are generally 6 centimeters, 13.5 centimeters, and 18.5 centimeters from the tip of the medial malleolus. These drain the lower leg into the posterior tibial veins. An important thing to remember is that they connect the posterior arch vein, which is a tributary of the great saphenous vein and not the great saphenous vein proper, with the posterior tibial veins. So in this diagram, we see the posterior arch vein here. Coming up, we see where it joins the great saphenous. The great saphenous is above it. And we see these perforators down here coming into the posterior tibial vein. And we have the paratibial perforators, and they lie medial, just below the knee. And they do connect with the great saphenous vein and the posterior tibial veins, and sometimes branches of the gastrocnemius veins. So they're located up higher here after the posterior arch vein joins the great saphenous. So that would be above that level. It's where this green circle is. The lateral calf perforators, they do exist. They can be important, especially if a patient has an ulcer in that area. On most examinations, we don't examine them with ultrasound unless there is some clinical indication to do so. Generally, they are located five to seven sonometers and 12 to 14 sonometers from the lateral ankle. And they connect into the small saphenous vein. They connect the small saphenous vein with the peroneal veins. Here's just a picture, an ultrasound image of a perforator. So we see the superficial vein up here. We see the fascia. We see this vessel cut right through the fascia. And we also see it join the posterior tibial veins. And if you notice on this image, there's a lot of numbers on here. And when we take these pictures, we like to indicate on the picture where this particular perforator is. So when we go back, we know exactly its location. So this is 12 sonometers up from the medial malleolus and eight sonometers back from the tibial border. Okay, moving forward, we've got the thigh perforators. Now they are simply called the femoral canal perforators. They were formerly called the Dodd and the Hunterian. Usually they're seen 15 sonometers proximal to the knee and middle 1 3rd of the medial thigh. So this area, 15 sonometers from the knee, and it can be anywhere from the mid to upper thigh, you would find that second femoral canal perforator. And those perforators connect to the great saphenous vein, the great saphenous vein to the femoral vein. Just an example of an image. We've got the great saphenous vein here. We see the perforator. Here's the fascia. We see the perforator cut right through the fascia. So we're moving on to the venous insufficiency examination. Before beginning this examination, it's good to just take a look at the patient's legs and kind of get an idea visually what kinds of issues that they're having. Because if you don't look at the patient's leg, you may miss like an anterior accessory saphenous vein. So it's just really important to look at their presentation, if they have an ulcer, where that ulcer is, and just kind of make a note of all that. And sometimes if you aren't finding it as you work from proximal to distal, sometimes it's important just to go backwards. Start where you know there's a problem and walk your way back until you can figure out what vessel it joins. So the venous insufficiency exam consists of assessing the deep venous system. So you wanna make sure there's no clot in the common femoral, the femoral, the popliteal, tibial veins, or the gastrocnemius veins. And you also wanna look at reflux in the deep system, at the common femoral, femoral, and popliteal veins. And what's clinically significant is any reflux that is greater than one second. We're gonna look at the superficial veins and we're gonna assess for reflux in the great saphenous, the saphenofemoral junction, the accessory saphenous veins, and the small saphenous vein. And if clinically indicated, we're going to look at the perforating veins. So in reflux evaluation of the superficial venous system, we'd like to position the patient standing with all the weight on the opposite leg. You can use something like a walker for them to hold their balance. But if it's not possible and not all patients can be assessed standing up, we recommend using a steep reverse Trendelenburg. You wanna evaluate multiple sites for reflux, especially near perforators or significant branches. So here's just a couple examples. This is a platform that somebody designed so that the sonographer can be upright while they image. So it's an ergonomically correct situation and the patient can stand and also have something to, someplace to place their arms so that they don't lose their balance. And this is a setup I used in my laboratory where I placed the patient in severe reverse Trendelenburg or steep reverse Trendelenburg. And I was able to sit to do the exam. And I also put a pillow under the foot of the leg that wasn't being examined. And that took the weight off of the leg that was being imaged at that time. And in addition, I had the luxury of having an automatic inflate system. You see the cuff here on the calf and you could inflate and deflate with a foot pedal. So it was an easy exam to do just with one person in the room. In addition, I wasn't always leaning over and having to do different augmentation and straining my back. So it really worked nicely for me. The patients were very comfortable, but we were, the patient was in a position steep enough so that we were able to fill the veins to the max. Reflex examination of the venous system initially, especially when you're up at the saphenofemoral junction, you're probably gonna wanna use a Valsalva maneuver instead of distal augmentation, but either works well. If the patient is unable to perform a good Valsalva maneuver, distal augmentation would be your next choice. And as you move down the leg, you want to use distal augmentation for the remainder of the great saphenous. And in this area, retrograde flow after augmentation, a normal valve closure time is less than 0.5 seconds. So anything greater than a half a second is considered to be clinically significant. Another important thing to remember is you want to optimize your image. You want to use a good ultrasound machine. You wanna use a transducer that is appropriate for where you're imaging. So if you're gonna be looking at the deep system, you wanna use a frequency of seven megahertz or less, but for the superficial veins, you wanna use a higher frequency, 10 megahertz or greater. You wanna optimize your color and your Doppler because we know that flow is very slow in the venous system so we want to put our setups at about five to 10 centimeters per second. We wanna use a low wall filter and we wanna maintain the shallowest depth during the procedure so we can optimize resolution because we might be looking for branches or different segments that may not be apparent if we have too much depth on our image. And we wanna adjust our focal zones to the area that we're examining. So here's just an example of a normal venous insufficiency exam. We see the augmentation here and this little blip in the incorrect direction is just an indication of the valve closing. So this is perfectly normal. This is another example of a normal exam. So here on the baseline, we see the augmentation and shortly after, we see this indication of the valve closure. By color Doppler, this would represent an abnormal study. We don't know which direction either of these are going because we don't have our color bar up there but nevertheless, we know if blood is going in two directions for a significant amount of time that this represents reflux. Here's a very nice image of an augmentation with an abnormal response. We see the augmentation here and on release, we see the flow going in the wrong direction. And we look at this over time. So each of these notches represents a second and we measure the seconds based on this horizontal axis. In another abnormal study, we see the, although this is aliasing, this is not going above the baseline, it's just that the settings are so low that it aliased right around this spectrum and we see the augmentation here, we see the reflux here and if we were to measure this, this would be greater than two seconds of reflux in this particular image. This is with a Valsalva maneuver so it's not gonna be the same as with a distal augmentation because with the augmentation, the blood moves forward and it shouldn't go backwards. With a Valsalva, when the patient bears down, we immediately see flow going in the incorrect direction and on this, it represents at least one, two, a little more than two seconds of reflux. Another example, a nice ultrasound image, distal thigh. We're doing an augmentation here so we push flow in the correct direction and then this represents all the reflux and again, we're looking at time, one, two plus seconds so we know that's markedly abnormal. Another ultrasound image, this is a great saphenous below the knee. We've got augmentation here and this is all the reflux and in this situation, we have one, two, three, at least four seconds of reflux here. Now, we'll discuss duplex ultrasound and the diagnosis of incompetent perforators. The majority of incompetent perforators can be identified with duplex ultrasound. Incompetent perforators will have reverse flow or bidirectional flow. Incompetent perforators can be identified with a reverse flow or a bidirectional flow. Incompetent perforators can be identified with either reverse flow or bidirectional flow with a reverse component of greater than a half a second after release of augmentation. That's what is considered clinically significant. A good way to find incompetent perforators with the patient standing up with their legs dangling off the table is to palpate along and close to a superficial vein and that can help identify them. Incompetent perforators are often associated with defects in the fascia. What I showed you on that one diagram, it's called the blowout. Because the superficial vein is so enlarged, you can actually palpate that. In addition, while size is a consideration in incompetent perforators, it's not really the way to make a diagnosis. It has been reported in the literature that a diameter of greater than 3.5 millimeters is associated with reflux in more than 90% of the cases. Perforator diameter usually is measured wall-to-wall at the level of the fascia. And the use of color is helpful to determine if the vessel is a vein or an artery. You frequently will have a perforating artery side-by-side with the perforating vein. And also, dual perforators are found in about 70% of the cases, although one may be incompetent or show reflux where the other could be perfectly normal. And that's one of the reasons that we really recommend that we do measurements to know where this perforator is located before it's treated. Because if there is a dual perforator, that would be the one that could become incompetent after a procedure and you would think maybe that your treatment was not successful. Perforator reflux can be seen with color doppler, but pulse doppler is required to provide quantitative measurements of reversal of flow. Optimize doppler settings for the venous exam. You're usually doing the initial exam in cross-section, but once a perforator is identified, you want to obtain a longitudinal image and you want to use color and pulse doppler to assess competence by performing distal augmentation. Here we're showing an image of proximal thigh perforator. In this image we see it's labeled the Hunterian, but it's a femoral canal perforator and it's going from the great saphenous through the fascia, going down towards the deep system. And here it's being demonstrated in color and the way that we have our color bar set up here, red would be the correct direction going from superficial to deep. Another example, here's the great saphenous. This is the perforator going to the deep system and this is measuring the reflux with doppler and we're seeing several seconds of reflux. And you can even see that this is abnormal from the image because flow coming towards the transducer is red and this is red so we know it's going from deep to superficial. In the medial calf, you want to begin right below the knee on the medial aspect of the calf and you want to be in transverse and just your transverse coming right along the medial side of the tibia. You want to scan down the entire calf to the medial malleolus and then you want to move your transducer one scan head length towards midline and repeat the evaluation from the knee to the malleolus. So you're continually assessing all around the calf one transducer with each movement, going more medial and posterior. And this is the most important area that you're going to be looking at is the medial calf because that is the point at which most people would have incompetent perforators and where venous ulcers do occur. So here's just an example of a clip. We see reflux so if we just look at our image here and we see our color bar, we see that the flow is going when it's in the correct direction, it's in red and when it's refluxing, it's in blue. So we see the bidirectional flow by color Doppler but it will also be important to measure this in time. Here's another example of an incompetent perforator. So here we have a perforator with augmentation and this picture is going from superficial to deep in red and then we see reflux that's reflected in the blue. So it's showing abnormal flow by color Doppler. Again, you would need to measure in time. And here's another example in the distal calf. We're showing with augmentation that we have over greater than two seconds worth of reflux in this perforator. So here we have our augmentation flow going in the correct direction and then we show this reflux and we have at least two seconds, two plus seconds of reflux noted here on the spectrum. Now, it's always a problem because many of these patients will present with a venous ulcer. So there's various techniques that you can use to try to, and it's incredibly important to image over these ulcers because that's frequently where these incompetent perforators will be. So one of the suggestions would be to put a Tegaderm dressing over the area and then you can just scan right over the top of that ulcer or in some laboratories, they would use a sterile sleeve over the transducer and then sterile gel. But you should never avoid imaging in these areas because that is probably the place where treatment would be most helpful for these patients. In the posterior calf, you can begin scanning at the popliteal fossa and locate the small saphenous vein and follow the small saphenous vein in a transverse view and evaluate for perforators coming off medial and lateral from the small saphenous and they would connect into the gastrocnemius veins or the soleal veins. So let's move on to the next part of the procedure. Duplex scanning for endovenous ablation of the great saphenous. So there's certain things that we need to do to prepare for these procedures. And mapping and marking are one of the keys to a successful treatment. The reason we perform it is because we want to look at maximum diameter. We wanna look at the depth of the vein from the skin surface and that's important in order to avoid skin burns. We wanna look at significant branches because we may need to treat more than once at a certain level if there are very big collaterals or branches. We need to look at areas of tortuosity because when they're advancing the catheter, it may be difficult and you need to be prepared for any torturous vessels. Aneurysmal segments can also be very important because again, if the vessel is extremely enlarged in one area, it's not that it can't be treated, but we need to do additional tumescent anesthesia or extrinsic compression, some technique in order to bring that vein closer to the catheter or the laser. And we want to note duplicate saphenous systems because we don't want the physician to make a mistake and treat a vein that isn't incompetent if there's two great saphenous veins in the same area. So patient positioning, we want to make sure that the patient is supine, the knee is slightly rotated out, and they're in reverse Trendelenburg. Using a straw method, what you can do is as you image down the great saphenous vein, you can use a straw, which you can see these little indentations, just to mark the length of the vessel. And then after you wipe off the gel, you can follow your straw marks and mark with the ink or whatever method you want to mark the leg. In addition, you might want to mark the skin for areas of tortuosity, aneurysmal segments, large branches. You can mark those right on the skin. This is just showing you a picture where the vessel is being measured for maximum diameter. And also, this shows quite a large vessel that's 0.91 centimeters. The other thing this picture is showing you is the depth from the skin. We see over here that this is 1 centimeter from the skin. Well, in general, when a vein is being treated, we want to make sure that that vein is deeper than 1 centimeter. We don't want that vein to be too close to the skin surface. So in addition to just the diameter, we're also noting the depth from the skin surface. Pre-op mapping and marking, the superficial veins, we mentioned that they need to be greater than 1 centimeter from the skin surface. Otherwise, less than that, we have an increased chance for skin burns. We also want to make sure that if that depth is not adequate, that the physician knows so that they can add additional tumescent infiltrate within the fascia. Large collaterals need to be noted. Here we have an ultrasound image of a large collateral. We know this is a collateral as opposed to a perforator because it's going superficial towards the skin. But at the point where this vessel would be treated, we may need to treat this vessel twice because of this large collateral. And it would help the vessel to collapse better. The walls collapse better. And we wouldn't have this additional flow from the collateral coming in and decreasing the temperature during treatment. And here's just an example of a worksheet that we use. And this is a very simple worksheet that just you click off if something is present or absent. In many labs, they prefer to write down the diameters of the vessels, write down the time, whether there's reflux of 1 second, 2 second, 3 second. This particular worksheet just indicates if it's greater than what's considered clinically significant. So this is a very simplified worksheet. But you can design your own. And this is very helpful to have when you're doing the mappings so that you can go back. You know exactly where you imaged. You know exactly the size of the vessel. And a physician can look at it. And it's really their roadmap to pre-op treatment. Here's just the back of the leg where you would indicate the size of the small saphenous vein and whether or not there's a vein of jocomene, a thigh extension vein. And it's pretty much you can do your measurements down here. And again, it's more just clicking yes or no and getting a very basic venous history. So in conclusion, duplex ultrasound is critical in identifying patients with deep and superficial venous insufficiency. Prior to treatment, ultrasound is used to map the vein to be treated and also to identify areas of concern for the physician, such as large branches, aneurysmal segments, areas of tortuosity. Also during treatment, ultrasound is important for identifying an access site, catheter placement, and administration of tumescent anesthesia. And following the procedure, ultrasound is used to assess the treatment's success and to rule out a possible deep vein thrombosis. Hello. I'm Dr. Nick Morrison, co-founder and medical director of the Morrison Vein Institute in Scottsdale, Arizona. I am the current president of the American College of Phlebology. I want to take this opportunity to provide some historical background on surgical venous disease and briefly describe the role of venous venous in the treatment of venous venous and the treatment of venous venous thrombosis. I want to take this historical background on surgical venous disease and briefly describe modern treatment options for patients who are diagnosed with superficial venous insufficiency. I also will provide some insight into what specific inclusion criteria for patients who may be considered for treatment and emphasize the importance of clinical accuracy in the duplex scan. This is my obligatory disclosure slide. There are no stock or stock options in any of these companies. Physical examination of the patient with venous disease, while very helpful, cannot, with the accuracy necessary to create an intelligent treatment plan, predict the level and extent of deep and superficial venous disease, whether it be incompetence, obstruction, or other less common venous problems, such as venous malformations. It is the need for a comprehensive duplex examination of the deep and superficial venous systems. For example, it is not necessarily true that patients with less severe manifestations of venous disease, such as mild edema or uncomplicated varicose veins, have predominantly superficial venous disease, while those patients with more severe sequelae of venous disease, such as perimalleolar skin discoloration or ulcerations, suffer from primarily deep venous disease. Historically, surgical options for treating superficial venous disease were largely stripping, saphenous ligation, and avulsion phlebectomy through moderately large incisions, such as are pictured here. Modern, minimally invasive techniques, on the other hand, include endovenous thermal ablation, utilizing either radiofrequency or laser energy, endovenous chemical ablation, often using a foam detergent sclerosing agent, and ambulatory phlebectomy, sometimes referred to as microphlebectomy. Symptoms of venous insufficiency will include leg pain or aching, leg fatigue, itching, muscular cramps, especially nocturnal, leg heaviness, foot, ankle, or lower leg swelling, restless leg, easy bruising, and burning or sometimes numbness. Physical signs will include superficial varicosities, coronal phlebectatica, hyperpigmentation, eczema, peripheral edema, lipodermatic sclerosis, atrophy blanche, or venous ulcer, typically perimalleolar, pictorial examples of which will be presented shortly. As patients present to the phlebologist, it is important to be precise in our description of patients' clinical presentation. To facilitate this, the International Union of Phlebology developed the SEEP classification, which allows comparison of patient groups in different clinical studies. We will primarily concern ourselves with the C portion of this classification scheme, the clinical classification. Clinical classification of patients is divided into six groups, C1 through C6. SEEP 1 patients are patients with spider veins or telangiectasias, and those with coronal phlebectatica or blue crown, which is nearly pathognomonic of venous disease. SEEP 2 class patients have varicose veins, although they are not often as severe as depicted here. SEEP class 3 patients have edema, as is nicely depicted here. This is perhaps the best method to identify something less than gross edema by turning the patient away from the examiner and comparing the ankles from behind. You can see on the left the swelling when compared to the right ankle. SEEP class 4 patients are divided into 4A and 4B. 4A patients have skin pigmentation, an eczema, while 4B patients have more severe skin changes, such as lipodermatosclerosis and atrophy blanche. SEEP class 5 patients are those with healed ulcers, such as depicted here. And SEEP class 6 patients have open active ulcers, typically in the perimalleolar area. Now, with respect to surgery for venous insufficiency, traditional high ligation and groin-to-ankle stripping under general anesthesia has been largely replaced here in the US with newer methods because of prolonged painful recovery and late recurrence rates, which are disappointing. However, I am not at all sure that even our newer methods will be associated with a low or nonexistent recurrence of venous disease. Likewise, high ligation alone has been abandoned because of high recurrence rates. Primarily because of technical difficulties, recurrence rates following small saphenous stripping are even more dismal, with a greater risk of complications than with great saphenous stripping. In vaginal and pericardial cancer, the recurrence rate of venous insufficiency is much higher than that of pericardial cancer. Invagination, or pin stripping, under ultrasound-guided local anesthesia is a modification of traditional stripping that results in less tissue damage and enjoys popularity in Europe and elsewhere. This is a procedure that is inexpensive to deliver, produces consistently good results, and cannot be dismissed out of hand as simply old-fashioned. These represent the objectives of our modern treatment methods, and like in most other surgical disciplines, minimally invasive therapy has become prominent for quicker recovery and better cosmesis, especially for what is usually a relatively benign disease. The patient is marked in the standing position so that all of the bulging varicosities better treated with ambulatory phlebectomy are identified, but also so that only those varicosities that are better removed than injected are removed. A small, two-millimeter skin incision is made after a sterile prep and infiltration with local anesthetic. The vein is identified in the subdermal tissue and extracted through the incision as depicted here. These are typical vein segments removed through the micro-incisions, and this is that same patient one week post-op with pretty typical results. The advantages of ambulatory phlebectomy include better cosmesis and faster recovery, while disadvantages include a learning curve and the problem with parasesia or dysasesia. The three currently available methods of endovenous ablation are radiofrequency, laser, and chemical ablation. Correction of reflux and removal of truncal veins or saphenous veins from the venous circulation are the intended results of ablation. Endovenous ablation procedures are indicated for the treatment of incompetent great, small, and accessory saphenous veins, the vein of Giacomini, cranial extensions, and persistently incompetent perforator veins. RF and laser destroy the vein wall with electromagnetic energy, while chemical destruction is accomplished by means of a detergent sclerosing agent typically foamed. These are the manufacturers of thermal ablation equipment. Prior to thermal ablation of the great saphenous vein, it is important to identify the saphenofemoral junction and the location of the superficial epigastric vein so that treatment can be started inferior to this vein. In treatment of the small saphenous vein, the tip is placed well proximal to the saphenopapoteal junction to avoid nerve damage. As far as endovenous chemical ablation, the indications in postoperative treatment are the same as for thermal ablation, but no anesthesia, generators, or fibers are needed. Chemical ablation requires advanced skill level. It's an excellent contrast medium for ultrasound, with early results perhaps not as good as surgery or thermal ablation, although re-treatment is much easier with chemical than with thermal ablation. Adjunctive treatment is mandatory for complete control of reflux points and must include thermal or chemical ablation of accessory saphenous or major tributaries, persistently incompetent perforators, and incompletely ablated veins. So in conclusion, all of these treatment methods for superficial venous disease are generally safe, although complications are generally less frequently seen with the endovenous methods than with surgical methods. One of the most important aspects of the evaluation of a patient with chronic venous disease is the physical examination, and that examination starts with inspection. Inspection can start even watching the patient walking down the hallway, because one of the things you need to know is how well is their calf pump mechanism working. The calf pump mechanism, as you know, is the squeezing of the calf muscles, propelling blood towards the heart. If that calf pump is not working very well or the patient is shuffling and not using it very well, that can be one reason that a patient has venous disease or the signs of venous disease in addition to their intrinsic venous disease. So you can watch the patient walk just a short distance and evaluate that calf pump mechanism. So we have Joe, and I'm gonna watch him walk from the podium over here to the stand and move on over. That's great. He just demonstrated to us that he has, his calf pump is totally intact. So he's using it very well. So we know for sure that's not part of his disease process, that this is intrinsic venous disease. Now, inspection, as I said, is one of the first things that you do when you do a physical evaluation. And the first thing that I noticed with Joe's legs as he stands here in this direction is that he has varicosities up in the groin. He has some varicosities in this area and down in the calf. What I also noticed is he has a scar here. I don't know how well it shows up, but this is a scar that is reminiscent of a scar that we used to use for ambulatory phlebectomy in the old days when we used to do that. The ambulatory phlebectomy scar can give you a hint of what's happened with that patient in the past, whether they've had surgery, venous surgery in the past, whether they've had a stripping. If they think they've had a stripping and actually the only incisions that you see are in the legs you know that they actually had an ambulatory phlebectomy and that great saphenous vein may still be intact. I also wanna palpate those varicosities. And the reason is the light in the studio like this is very optimal. In your office it might not be so good. So I'm looking and then I palpate. And again, the reason I'm palpating these veins, I wanna know whether these veins will be better handled by injection or by removal. So microphlebectomy or ambulatory phlebectomy, much more modern with small incision. So I'm palpating and these are very palpable. So these are veins coming down distal thigh around the medial aspect of the knee and into the medial aspect of the calf. These are varicosities that I'm going to want to remove as opposed to inject. And then I'm gonna ask Joe to turn his ankle out. What comes to, again, you can see the varicosities a bit better. But what you can really see is the area in the medial malleolus. So that is classic corona phlebectasia, blue crown. It's a series of small blue veins. This is pathognomonic of chronic venous insufficiency. So patient walks into the office, you look at the ankles, you know for sure that that patient has chronic venous insufficiency and you just have to identify where it's coming from and the extent of it. So this discoloration is also a sign of chronic venous insufficiency. Now I'll have him turn a little bit more, Joe. Good, that's great. I want to examine the outer aspect of the leg. Again, palpation and inspection looking for veins that would be better handled with phlebectomy as opposed to injection. And I don't see much on that side. He does have some varicosities down in this area but those will resolve with the other treatment. Now Joe, I'm gonna ask you to turn facing away from me and put your feet together. That's great. Now, this is the best way to test for edema. So if a patient has fairly subtle edema, you'll be able to look at the Achilles tendons and that's the place that you'll see the edema. Many times it's gross so you don't even have to guess at it but in patients where it's not so gross, where it's subtle, this is the nicest way to look for edema. And again, I'm looking in the posterior aspect of the thigh. Let me raise that up, Joe, good. Varicosities that start up in the thigh and extend down around the lateral aspect of the knee into the posterior calf. Now, because they're here, you might expect maybe these are coming from the small saphenous vein. But in fact, it's more likely that they're coming from either a thigh perforator or a higher buttock perforator or perhaps even coming around from the lateral aspect of the groin all the way around into the calf. So duplex is going to help sort that out for us. But again, I'm palpating these veins I want to remove as opposed to inject. And that's about it as far as the examination. But the very last thing I'm going to do is once I finish this part, the last thing that I want to check is for arterial disease. I want to know for sure that I'm only dealing with a patient who has venous disease and not a combination of venous and arterial disease. So I'm going to examine him lying down. I'm going to examine the dorsalis pedis, the posterior tibial, the popliteal, and the femoral arteries, all to be sure that there are good vigorous pulses there and that I'm not missing arterial disease in combination with venous disease. ♪♪ Hello, my name is Diana Newhart, and I am president of CompuDiagnostics, a multi-specialty ultrasound imaging center in Arizona. And I've been asked to demonstrate the technical aspect of the superficial venous insufficiency examination. A critical portion of the exam is the examination of the deep venous system first. This, for the purpose of time, we are just going to be demonstrating the superficial system. But I'd ask you to refer to the DVD series by SVU on the proper examination techniques of the superficial system and the deep system. So I'm going to select the proper instrumentation, a duplex ultrasound machine, and the proper transducer. Since we're going to be focusing on structures that are above five centimeters, we're going to choose a transducer that's high frequency and designed to look at those types of structures. For this case, we're using a 15 megahertz transducer, and we're going to begin. Because we do have duplex instrumentation, we're going to be using grayscale and color flow. And we're going to focus first on the anatomical presentation of the venous structures. We're going to start at a very important landmark. We're going to begin at the sapheno-femoral junction. So we're in transverse, and as we slide proximal up to the inguinal crease, we see an important landmark here, the sapheno-femoral junction, GSV, common femoral, common femoral artery. So as we slide just slightly distal, and we'll come into a longitudinal view, you can see here, sapheno-femoral junction, common femoral, terminal valve, and superficial epigastric vein. So this is an important landmark and also an important view that we would begin in most of our examinations. The terminal valve here of venous structures contain valves, bicuspid valves, that help regulate flow back to the heart. We'll move back into a transverse view so we can just talk a little bit about some anatomical landmarks for you to help identify the GSV. The GSV is here, and the anterior accessory saphenous, a tributary of the great saphenous, is here. We know that because this is the common femoral vein, and the anterior accessory vein lines up with the deep system. And the GSV moves away medial. GSV, anterior accessory. And notice a very important characteristic of this saphenous vein is that it's located within this fascial layer. The anterior accessory is also in the saphenous plane, in the saphenous sheath, but usually only for a short time, where the GSV typically will remain in this fascial layer. There are so many variations of the saphenous vein, but an important landmark is this saphenous layer that you see here, the superficial fascia. And I'm scanning distal, just so you can get a viewpoint of the transverse view. We see that the venous system is a low-pressure system. And I have my patient standing here, and so we can see that he's starting to get that slowing of flow in the center. I'm going to point out some other important structures, and one being a perforating vein here. And perforating veins perforate the deep fascia, and they are very important for venous drainage because blood flows from here down into the deep. So beginning at the skin layer, through the fascia, and then through the deep fascia. So as we begin to examine the superficial veins, remember this drainage pathway, as that is an important philosophy when we're trying to diagnose whether or not flow is normal or abnormal. So we're going to begin up here at the junction. And I'm just going to put a little more gel on the patient so we can get a nice contact. Now, we have Joe standing, and that's because gravity plays such a huge role in the examination of the venous system. When we're lying, the pressure in our veins are lower. But when we're standing, with the gravitational force, they're higher. We want to try to mimic, in our standardized technique, the process of gravity. So standing is a good way to accomplish this. It also promotes standardization of the study. But if you can't replicate this, then you might want to use a tilt table. And if you must perform the exam lying down, regardless of what technique you use, please place that in your dictation so when we're trying to standardize and compare our results, we want to list what technique we're using. OK, so what we've demonstrated thus far are some transverse images of the ultrasound landmarks, including the fascia layer, and the sapheno-femoral junction. So now what we're going to be doing is looking with some color flow to detect any flow abnormalities within the saphenous vein. The saphenous vein, as you're performing this exam, we'll be looking at many segments of the vein. And just for purposes of discussion, in our lab, we have segmented the saphenous vein into seven sections, one being the terminal valve, two being pre-terminal, and three about mid-thigh, and four above the knee. That way, when we're scanning down and we would text or annotate where we are, we would know that, by the process of that picture, where we are exactly. So we're going to start right here at the terminal valve. And we're going to use different techniques in which to elicit reflux. The first technique is going to be using Valsalva. Joe, deep lung breath. Hold it in and bear down. And breathe. OK. So now we'll try a different technique. And I'm going to be using the rapid cuff inflation device, rapid inflation and deflation. So both of those techniques did not elicit any reflux. So as we begin the segmental evaluation of the saphenous, we come now, this is the pre-terminal use of color. And we'll just use the cuff inflation device again, forward flow. And we're seeing here some flow eddies around the valve, in color, that we didn't pick up on Valsalva. Deep breath in, Joe. Hold it in, bear down. And breathe. It's a lot more significant with the cuff inflation device. There's certain things that do affect the sensitivity of our test. And one is the sensitivity of our color, which is set up perfectly. The other method, the other reasons that we can get false negative is that sometimes the diameter of the vein becomes larger with progression of reflux. And so having the flow move from one compartment to another may be compromised slightly by just the size of the vessel itself. Deep lung breath in, Joe. Hold it in and bear down. And breathe. Now we're going to demonstrate that again, only this time with the cuff inflation. Getting and seeing a little bit more sensitivity here. And adjusting my color gain slightly. So this is a nice demonstration of retrograde flow at the pre-terminal valve. And we're demonstrating here flow to the head and then retrograde flow. One, two, three, greater than four seconds. We've successfully documented the most proximal source of reflux. And the terminal valve is a little bit And the terminal valve is competent. The pre-terminal valve was incompetent. Now as we scan distally, we notice here a perforating vein coming from the saphenous, perforating the deep fascia to the deep system. Perforating veins are essential for venous drainage. But they can sometimes be the source of reflux. Going to try to demonstrate again. Setting my color box. And we're going to use the cuff inflation. Again, demonstrating reflux. Going to use the transverse view so that we can look at color through the perforating vein. Cuff inflation. We're not demonstrating flow out from the deep system to the superficial. So we were able to demonstrate saphenous reflux with a competent perforator. We're going to continue distally. An examination of the great saphenous vein and small saphenous vein in tributaries is the full-length examination. So a segmental evaluation of the saphenous. So we're here in transverse. And again, we see this really nice fascial layer. And as we move distal, we immediately notice that these tributary veins, which pierce the superficial fascia. That's an excellent view. And the GSV now becomes much smaller than these larger tributaries. And that is because the venous system is a reservoir. So most of the flow here and here. Seeing that this is a shunt out to the skin. We're going to demonstrate that with color. And I'm going to again use the rapid cuff inflation device. And a nice demonstration here of a competent saphenous and reflux here. So the tributary is draining. And this is normal. OK. So as we remember, there are two saphenous veins in the body. The great saphenous vein, which we have effectively examined segmentally from the groin to the ankle. And now we're going to be examining the small saphenous vein. The small saphenous vein located about the popliteal crease and distal. And sometimes it's difficult to find at the popliteal crease. It's much easier to come about mid-calf. And we can see by this picture, again, that beautiful fascial layer. And we're taking notice slightly of the size. Some patients, their small saphenous vein is very small. And we have double determining or distinguishing it. In Joe's case, he has a very nice small saphenous vein. And we see this large tributary that comes off medial. And as we move distal, small saphenous vein is well seen. And as we move up proximal, we identify and notice that, again, breaking that fascial deep layer, many veins coming into this and the inner saphenous and a large perforator here. And this inner saphenous, if we're moving medial, joins many of the great saphenous vein tributaries. So as we move back, small saphenous, and move proximal, these are gastroc. What we are looking for is the saphenopopliteal junction or saphenous entrance into the deep system. And Joe's anatomy is unique in that he doesn't have a true saphenopopliteal junction. So we'll continue proximal. Connection here to the deep. And then a continuation of the vein. I have already scanned Joe. So I know that this vein actually joins the saphenous vein up in the proximal thigh. So that is a vena giacomini. Many times, patients will have a thigh extension of the small saphenous, which terminates into a muscular branch or a muscular bed. In Joe's case, this is the vena giacomini. Coming back down, demonstrate a little bit of how that joins the deep system. Here. Saphenofemoral junction and thigh extension, in his case, the vena giacomini here. So similar to our evaluation of the GSV, we would do an examination of the small saphenous vein segmentally, usually at the junction, mid-calf, and distal. We're going to use a different maneuver in this case. And it's called a Pernot maneuver. And so what we use is Joe's isometric muscular movements. We can see with just him rocking, it's a little harder when you're holding the transducer. But it can help us demonstrate if the patient does have bidirectional flow in the vein. And Joe, we'll have you stop. So we would take spectral waveforms from the proximal, mid, and distal segment. In this case, I want to focus on an important finding. And that is the region of this inner saphenous vein with color. And place my cursor correctly. And Joe, have you rock back and forth. OK, that's excellent. So we can see with color and stop, there is retrograde flow in the saphenous, a segment of the saphenous vein. We're going to turn the color off and try to discover why that would be true. And there is the inner saphenous, and also a large perforator here. Now, as we examine distally, and just a small rocking, that paranormal maneuver, excellent. And stop. And no retrograde flow. So when patients have segmental portions of reflux, in our mind, we want to be able to see in our mind, we want to think, where does the reflux come from and start? Is it segmental from a valve? Or is it segmental from flow connections from other sources, such as this case, as large reservoirs of varices here that drain into a portion of the small saphenous vein. So the small saphenous vein may not be abnormal. It may have become a reservoir for large tributaries that then drain through the small saphenous vein. We've enlisted the help of another model to demonstrate a very key point regarding perforating veins. As you begin taking on this task of diagnosing superficial venous insufficiency, one of the problems is, and complex, of course, is perforating veins. So I'm going to demonstrate a perforating vein in the mid-thigh. And we'll talk about the points as we go along. I'm going to place the transducer here in the mid-thigh, demonstrating the saphenous above. And as we move distal, we see this vein perforate the deep fascia, coming in longitudinal. See a nice valve here, valve cusp here, saphenous. We're going to use color first. And remember that flow drains from superficial to deep using our cuff inflation. And we see absence of retrograde flow in this normal perforator. Yet when we read in the literature about perforating veins, one of the diagnostic criteria is size. In this case, this patient has a perforator that measures 3.8 millimeters, which is normal perforator, but in the literature may suggest that this is abnormal. So we can't use size as our determining factor in diagnosis alone. And we've elicited the help of one more model to demonstrate a very important point when we talk about venous reflux in the saphenous vein. We define reflux as retrograde flow. But I want to demonstrate a concept for us to consider when we start evaluating multiple veins and drainage points. The veins must drain from the skin through the saphenous and through perforating veins. I want to demonstrate one simple concept with the ultrasound machine. In a patient, when I scanned him, essentially he has a normal sized saphenous vein and a very prominent perforating vein here, which connects to the saphenous. So as we examine this patient in our typical fashion with the color, we see here that there are tributaries that drain directly into the saphenous vein. I will use my cuff inflation device. With sensitivity, we can see retrograde flow here coming from the tributaries and draining through the saphenous. But the saphenous vein may not be abnormal. So as we look at these veins, we want to consider drainage and how did flow get from the tributaries through the perforator. So as we undertake this exam, we want to consider perforating drainage may use the saphenous as a conduit. So we don't always want to consider this to be abnormal if drainage is coming from normal tributaries. So as we undertake the diagnostic accuracy of this test, we have to think about flow, where does it start, and how does it drain. So I appreciate all the attention that you've given and the opportunity to provide some diagnostic information. Some of the key points that maybe you cannot appreciate by the shortness of this video is how complex these exams can be and how time consuming. We've tried to undertake some of the high points so that we could facilitate more opportunity to discuss some important topics. Remember that when you examine the saphenous vein, you must examine the vein from the sapheno-femoral junction through the terminal valve, pre-terminal valve, and segmentally along the course of the vein. And also determine the escape points to which reflux begins and where does it re-enter into the deep system, looking for incompetent perforators, examining the small saphenous vein, and examining again for incompetent perforators. We were simply trying to demonstrate an overview of this. And in our office, with the aid of a step device such as this, we can really demonstrate some ways to make it easier. This is a very complex and long exam, somewhere between 45 to an hour and 15-minute examination. So it's something that you can't undertake lightly or quickly, but we hope that this information that we've showed you can be helpful as you begin to undertake this process. For more information, visit www.ncbi.nlm.nih.gov

duplex ultrasound

diagnosing venous insufficiency

SVU Professional Performance Guidelines

ultrasound in identifying patients

patient positioning

communication

thorough evaluation

deep venous systems

superficial venous systems

superficial venous insufficiency

saphenous vein

perforating veins

reflux techniques