SVU On Demand Webinar 110823: Venous Insufficiency and the Sonographers Role in its Diagnosis-11082023 OD Web

11082023 OD Web

Video Transcription

Good evening, everybody, and thank you all for joining tonight's webinar. My name is Dr. Anil Kumar. I am the co-chairperson of the SVU eLearning Education Committee.  Before we begin, here are a couple of notes from the SVU office to share, especially for the first-time attendees.  Everyone should see a question section along the side menu of your screen. It's near the bottom of the column just above the chat, so please type in any questions  that come to mind during the presentation. Once the presenter has concluded the presentation, we should have some time for discussion.  This webinar will be recorded and available on demand free to SVU members in seven to ten business days.  Within seven to ten business days, you will receive an email containing an evaluation that must be completed to obtain CME from tonight's webinar.  Tonight we are all honored to have Donna Kelly, a highly experienced and accomplished sonographer who will deliver an insightful presentation on chronic venous insufficiency  and the role of sonographer in diagnosing it. With a career dedicated to the field of vascular ultrasound imaging, Donna has amassed a wealth  of knowledge and expertise in the art and science of venous insufficiency and its diagnosis. Donna Kelly's commitment in this field for more than 20 years is truly remarkable.  She earned the credentials of RDMS, RVT, and RPHS. She has spent numerous years honing her skills at the Mass General Vein Care and Middlesex Surgical Associates.  Her dedication to providing accurate and essential diagnostic info about venous disease involving  the lower extremities, as well as palliative care, has had a profound impact on the lives of countless patients.  And that applies to most of the advanced sonographers who do this job. Personally, I have been in this field so I can understand.  This is a very, very advanced field and it is something that mostly and almost everything is driven by the sonographer in the field. So Donna also founded the SonoCoach.  It's a consulting company that provides sonographers with the skills needed to confidently perform  high quality, efficient ultrasound exams while creating an environment of respect and teamwork between the sonographer and the providers.  She's currently on the leadership team and ultrasound committee for AVLS, American Venous and Lymphatic Society.  And she has chaired the ultrasound programs in 2020 as well as in 2024 Congress. She has lectured locally in her hometown of Boston, Massachusetts, and at various national  meetings such as the Society of Vascular Ultrasound and AVLS. Donna is a subject matter expert on RPHS examination.  In addition, she has been a contractor for the ISE Vein Center Acquisition. She has been a lead author of several presentations.  We are all indeed fortunate to have Donna Kelly with us today. Please join me in welcoming Donna to the mic. Donna. Thank you very much. And thank you to SVU for inviting me.  And thank you for all the attendees for joining us. This presentation is chock full of information. And I added one thing to the title here, and I want to make sure that we get it.  So we're going to lower extremity venous insufficiency and the sonographer's role in diagnosing it. And we're going to do this practically speaking.  So as sonographers, what it all means to us and how we can, how all this information can help us do our job and do it well. So I have no financial disclosures.  I do have to have one non-financial disclosure, and it's because I show this book here. And the reason I show the book is because Gail Size was kind enough to let me use all  of the graphics from this book in this presentation. So I just want to make sure that I give her credit where credit is due. So thank you, Gail. So let's get rolling.  Our goals for tonight are to gain an understanding of chronic venous disorders.  Excuse me. I'm a true believer that you need to totally understand what a chronic venous disorder  is and what chronic venous insufficiency is in order to perform a successful ultrasound for this.  It is not a simple task, so we need to understand the disease itself before we can attempt to do a good ultrasound of it.  So tonight, hopefully, we're going to review the clinical features, the anatomy, the physiology,  some of the hemodynamics, ultrasound's role in diagnosing it, and then some of the basic protocols that we can follow in order to perform these studies.  So let's just quickly define venous insufficiency. So venous insufficiency is a failure for the veins to return the blood to the central venous system.  And that can happen for two different reasons, failure of the valves or secondary failure of the valves due to an outflow obstruction.  So let's just talk about each of those quickly first. So let's talk about valve failure. So we know that the valves are supposed to be one way, and they're only supposed to allow  the blood to go up the lower extremity towards the central venous system, right? So what can happen is we can have incompetent venous valves, or some people actually have  a lack of venous valves. It's not very common, but it happens. And it's typically a genetic thing.  So it's where the walls of the veins have a propensity to overstretch, and the valves can't function like they're supposed to.  And this is just a nice image of a popliteal vein valve, and you can see it nicely closed, you know, the valve clasped shut here.  But if we have these valves that aren't functioning properly, we can end up with venous insufficiency.  And then another thing that can happen to these veins is if we end up with chronic changes after a thrombosis. And this can happen in the superficial or deep system.  And we end up with this stuff down here that we can see in this vein that it almost looks like cobwebbing.  We talk about those as chronic changes, so it's not considered chronic DVT. They're chronic changes or chronic phlebitis. It's chronic changes within a vein.  And it looks like a little bit of a cobweb, but you can fully compress it, but it can damage the valves and not allow them to function properly.  And then we'll talk a little bit about the obstruction part of this. So what can happen is we can have an obstruction up in our iliac veins that's not allowing  the blood to get out of the lower extremity, and it's overfilling the veins, and it's not allowing the valves to function properly. And it's due to this outflow obstruction.  And what we're going to talk about today is not necessarily how to assess these iliac veins directly, but how during our lower extremity ultrasound can we assess these iliac veins  indirectly. So I always like to start with a quick clinical exam for the sonographer, because it's literally  going to help you determine the direction that your ultrasound is going to take. So we really do need to make sure that we're assessing these patients before we even start  our ultrasound. As we know, most of the studies that we do in our vascular labs aren't cookie-cutter exams.  There's not a protocol that has, you know, 10 images and we only need 10 images. You know, we have these protocols and they offer us guidelines that includes the required  minimums for all the studies we perform. And these guidelines and these protocols are created based on, you know, typically three things. One, an accrediting body.  So whether it's an IAC accreditation or an ACR accreditation, you know, what do they require for you to be accredited?  And then what do your local insurance carriers make you share with them in order to get coverage for these patients? And then what does your provider need?  What story do they need you to tell them so that they can correctly choose a procedure that they can use to help these patients if that's the route they're going to go?  So with venous insufficiency studies in particular, the required minimums are more often than not not enough.  So the big question becomes, well, how do we decide which patients need more than the required minimums? We can't go through these studies and expect to only take 25 images.  It's going to, you know, it's going to change from patient to patient depending on their disease. So let's talk a little bit about what do we mean by more?  What do I mean when I say we need more than the required minimums? What we want to remember is that our deep system needs to be a part of this and it should  be part of your protocol. I think most accreditation should require it. But I always like to hammer home that we're not just looking at the superficial system.  We need to truly assess the deep system for these patients and we need to do that looking for insufficiency as well as chronic changes and we even look for patency.  We also want to make sure that we have in the back of our mind this proximal obstruction that I had talked about.  And then we also want to think about pelvic source varicose veins and I know probably half of the audience has now officially groaned.  That being said, you don't necessarily have to know how to look at the pelvic veins and spend time looking for these varicose veins in the pelvis.  You just need to understand that it's a possibility that they're affecting the lower extremities and we're going to learn how to recognize that.  And then if need be, these patients can be sent off to somewhere that does assess for this stuff. So what are some of the things that we can do to help before we even start?  Know what we need in addition to the required minimums? Well, we need a good clinical assessment. We can start with a verbal history. It's very simple. I start with two questions.  Typically you have to kind of suss information out of the patients. They don't quite know what their answers are. So you have to kind of prod a little bit.  But when I have a patient that comes for a venous study, whether it be an insufficiency or a patency study, my first two questions are, have you ever had a blood clot?  This question will tell you an awful lot of what direction your test is going to head. If they've had one, then you need to figure out if it's deep or superficial.  Was it close to the skin? Could you feel it? Or was it under the skin? Did they put you on blood thinners? If they say yes, well, are you still on blood thinners?  And they say yes, well, okay, did they figure out that you had some kind of clotting disorder? If that's the case, then we can kind of say, okay, we know why they got the clot.  But if we have patients who've had multiple episodes of DBTs, particularly in the same leg, we need to start thinking about, well, why does this happen to this patient?  What's going on? Could there be a proximal obstruction that's not allowing the blood to escape properly? And this is what's causing these DBTs.  So that's one of our history questions. And then the other big question, particularly with venous insufficiency studies, is have they ever had a vein procedure?  So if they have, and they had success, and they felt relief from their vein procedure, but then their veins returned, and now they're coming to you for reoccurrence of varicose  veins, we need to start thinking about, well, why did this happen? Did we not get to the source of the problem?  Could it simply be another axial vein that we didn't treat, and now that one's not functioning properly?  It could be that. But it also could be a different source, like the pelvis or the iliac veins.  The more procedures with the more reoccurrence, the higher our suspicion is that it's not one of what I call the usual suspects, and we're going to talk about all those.  And then I always like to mention venous claudication, because not a lot of people know about it.  And you don't run into it a lot, but every now and then you'll have a patient who'll describe it, and you'll know exactly what it is.  And basically what it is, the patients describe it as this bursting sensation that happens when they are increasing with intensity with exercise.  So upon exertion, they get this constrictive feeling in their calf or thigh, and it feels like their leg is going to burst.  And the only way to make this go away is for them to actually lie down and put their leg up to enhance venous drainage.  And that's the big difference between arterial and venous claudication. With arteries, we know that at rest, you'll start to feel better.  But these patients need a little bit of help to get that blood to drain out of the leg, and they'd use gravity to do that. And then we need to talk about our visual exam.  But before we do that, I want to do a little bit about terminology, because I'm going to use some of these terms as I talk about the visual exam.  So one of the words that I want to clarify, and somebody actually asked me specifically to do this, is what's an axial vein?  So the axial veins, and they're otherwise known as truncal veins, are the veins that live within the saphenous fascia. So we have our superficial compartment here.  This is our deep compartment down here. Within our superficial compartment, we have our saphenous fascia. And we all know about the saphenous eye, right?  So here's our saphenous fascia, and here's this vein living within it. Now looking at this image, there's no way to know which saphenous vein this is, because  we know that there are a bunch of them, right? But we know that it's a saphenous vein because it's within the fascia.  So the axial veins or the truncal veins, they live within that fascia. Another term, so these are the ones that I call the usual suspects. These are our saphenous veins.  And I'm just going to point out a couple things about the terminology, okay? Because this can get a little confusing as well.  So we have our great saphenous vein, and we all know what that is, right? So we have our big long vein here. And then we have the anterior accessory saphenous vein.  Now if you look here, it's listed as anterior accessory saphenous. You look over here in our graphic, and it's called the anterior accessory great saphenous vein.  It's the great debate, honestly. The real terminology for it right now is anterior accessory saphenous.  People have added the term great to it because there was some issues with insurance. And it seemed to help the insurance companies understand that this is an axial vein.  So that's why we've added, you know, the great was added to it. But truly right now, the term is anterior accessory saphenous.  And then if you look below that, posterior accessory saphenous. I will tell you that there is a new paper coming out, and it's going to change again.  But for now, we're going with AASV or anterior accessory saphenous. And I'm going to apologize if I throw in the great in there because that's what I've been  calling it for many years. So that being said, the other thing that's important to point out is the word accessory.  We find that people get confused by that word accessory, and they tend to confuse it with tributaries.  So I want to make sure we understand the difference between a tributary and an accessory vein. So if you look at it, it goes anterior accessory saphenous.  It's always accessory saphenous. Well, if it's a saphenous, that means it's in the saphenous fascia. It is a truncal vein. Tributaries are not. So just keep that in mind.  Accessory goes with saphenous, and that means it's an axial vein. So let's talk a little bit about tributaries.  So our saphenous veins, our axial veins live within this fascia, right? And then the tributaries exist outside of the fascia and anterior to it.  That being said, they cross through the fascia to join the axial veins sometimes. Now we all have tributaries, whether our valves function properly or not, we have tributaries.  They're normal veins. They're a normal part of our venous system. But what makes them part of our venous insufficiency testing is that when a tributary becomes incompetent,  it becomes distended, lengthened, and tortuous due to venous hypertension. And that is what is also known as a varicose vein. So those words are interchangeable.  So we all have tributaries, whether we have venous disease or not. They become a problem when they become incompetent tributaries. And again, they're also known as varicose veins.  So now we can start with our visual assessment. We have to, have to, have to look at these patients before we start their study.  You do not want to walk in and have them already lying on a bed in the dark. We need to look at the front of their leg, the medial, the lateral, and the posterior aspects.  We want to identify the clusters of varicose veins because really our job is to figure out which axial vein do these varicose veins attach to. So which ones do they drain into?  And does that saphenous vein work properly or not? That's really what our job is. And we want to make sure we identify these because we really want to make sure that we  follow them back to their source. That being said, as we go through this presentation, we'll find that not all of them drain to,  not all of them confluence with axial veins, but we'll get into that in a little bit. So we have to have our visual assessment and we can look for patterns of reflux, right?  So we can look at these veins and sometimes we look at them and say, oh, I think it's going to be this. I think it's going to be that.  So let's start with these two pictures here on the left. These are kind of run-of-the-mill patterns of reflux where we see some varicoses along the medial thigh or in the calf.  If we look at the posterior calf, we might see some. And these are typically what I would, what I would expect when I look at these, I'd think,  I'm going to find some great saphenous anterior accessory saphenous posterior, you know, one of the usual suspects. I'm going to find that those can be traced back to those.  And then we assess those veins. However, there are other patterns of reflux that we can see. And this is where our clinical exam is really going to lead us into what we're thinking  as we're moving into doing our study. Look at these veins here, these veins, you know, up in this inguinal crease here or a  vein that presents like this on the posterior lateral thigh that we can actually visually see head up towards the buttocks. These are indicative of a pelvic source varicose veins.  So they're veins that aren't associated with any of our saphenous veins. They're veins that are sourced from the pelvis and they're associated with varicosities of  the internal iliac vein branches. So we're not going to get too much into that because that's more about pelvic disease,  but I just wanted to get a sense of, you know, if we're following these to these points where they connect to the pelvis, this is what it looks like within the pelvis.  And we're going to get to that a little later on in the talk. So once we've done our visual exam, we kind of have a sense of where these, where these  patterns of varicose veins are and where we're going to start, you know, following them. But one of the good ways to kind of really think about the depth that our insufficiency  study is going to take is by looking at the seep scale. So seep scale is a way that we grade the severity of venous disease, and it goes on a scale from C0 all the way up to C6.  So C0 are the, the run of the patients who come in on Friday afternoon at three o'clock and they have absolutely no varicose veins, but somebody ordered a bilateral varicose  vein study for them. And you're like, what is happening? But when you start talking to this patient, you know, that they have tired, achy, heavy legs.  So they don't have any visible signs, but they have the symptoms. Then we have our C1 patients and they have these little telangiectasias and reticular veins.  And then we have our C2 patients. And these are the first timers for varicose veins. They haven't had varicose vein surgery in the past.  They're coming to us for the first time to have their varicose veins and their axial veins assessed.  When we see these patients, we can make a pretty good assumption that one of our usual suspects are gonna be involved, right? And we're also gonna be looking at our deep system  and we're gonna go through all of that, but we can kind of associate these with some of this typical superficial reflux. But that being said, as we start to move up our CEEP scale,  we're gonna bump into the C2R patients. So these are recurrent varicose veins. These are those patients I mentioned that have already had procedures and now they're back with veins.  So we need to think about this in a couple of ways. Well, we need to think, okay, we're gonna go in and we're gonna do our assessment, our protocol,  and we're gonna look at the axial veins. And this very well could just be that they've only had their great saphenous treated in the past and now their anterior accessory saphenous  is not functioning properly and it's causing these varicose veins. Or it could actually be that we follow them all the way up to a point where they connect with the pelvis.  So we're gonna have to start thinking C2R, they're reoccurring, well, why are they getting reoccurring varicose veins?  Are we getting to the source? Moving on, up in our scale, we can get to our C3 patients. Our C3 patients are our swelling patients.  And we need to think, okay, our superficial system, yes. Our deep system, did they have a history of DVT? I wonder what's gonna happen when I check their deep system for reflux.  And then if they have the unilateral swelling, that's fairly significant. We need to consider that there's some kind of possible proximal obstruction.  We have our C4s. These are all the skin changes that happen. This is really advanced disease stages. And we can follow all of these different types. They're all have different,  you know, they're 4A, B, C. And then we get to our C5, which is a healed venous ulcer. And our C6, which active venous ulcers and recurrent venous ulcers.  When we start seeing these patients, we need to really start thinking what's happening with this. Are there clinical signs and symptoms  more severe than what we're finding on our ultrasound? Could a anterior accessory saphenous reflux cause, you know, that kind of disease process?  We need to think what's our deep system doing? Is there something happening more proximally causing this venous hypertension? And of course, when we start talking  about active venous ulcers, we need to make sure we're looking in that ulcer bed for pathological perforators. And this just shows a perforator here.  We don't spend a ton of time looking at perforators anymore. We used to spend a lot of time on perforators. And really the consensus is that they're not typically treating them.  For a while, it was just in the C6 patients, but now they're even thinking about them in those C4 where there's those skin changes. So when you see that advanced disease,  you need to start thinking about your perforators as well. All right, so now let's get to what you're really here for. Venous insufficiency ultrasound. How do we do it?  So our testing protocol needs to include an assessment of the deep and the superficial systems. And for both of those, we need to look for patency. So is there clots?  Is there chronic changes within them? And we need to check for insufficiency. Is there reflux in these systems? We're gonna start with the patient  in a supine or semi-fowler position. Now, moving forward, I'm gonna tell you that I stand my patients for the reflux portion of the study, but I start with them.  And even if you actually use a steep reverse Trendelenburg,  not here to debate that, because obviously that's a big debate that happens all the time.  What we need to be very sure of and clear is that when we're checking for reflux, the patients cannot be in a supine position. The valves are meant to function  with the hydrostatic column of blood.  And in order for them to actually function properly, we need to have that. So supine, you will get false positives all the time with the supine position.  That being said, we do wanna check for patency  in the supine position or semi-fowler, and that just means raise the head of the bed up a little bit so they're not totally flat. And we need to do it with them in this position  for a couple of reasons. Our first images need to be,  or not necessarily first images, but what needs to be included are pulse wave Doppler waveforms of the common femoral veins. And we're doing this to assess for the iliac veins.  So I had mentioned indirect testing of the iliacs. Well, this is super important. And I think it's one of the biggest things that people skip over.  And I really urge you to take the time to do it and just do it correctly. So, but we need the patient lying flat like that because if we try to assess for this,  for these respiratory variation, these changes in the waveforms that we're gonna be talking about with them in the standing position, you won't find the changes  because of the hydrostatic column of blood flow. So let's look at these waveforms. We need to look at both common femoral veins. We need to do it with the patient lying down at rest  with their arms by their side or on their chest. And they just need to be breathing. You don't wanna ask them to valsalva. You don't wanna augment.  We're just looking for reaction to breathing, okay? And we're gonna do that by placing our Doppler in the common femoral veins. And we're just gonna listen.  And what we're gonna look for are respiratory changes. So this is variation with respiration. We see a change in the velocity. We see a cessation of flow.  We see it come back after the patient's inhaled and exhaled and they're very similar from right to left. So I would say that this patient's waveforms are phasic and symmetrical.  So now we jump down to here. And old school, one could argue that if we were to put our probe on that left common femoral vein, we wouldn't necessarily need the contralateral side  to tell us that there's something wrong here, right? We have absolutely no respiratory variation. There is no changes within this waveform. So what that's telling us  is that there's something happening more proximally that's not allowing the walls of the iliac vein to react to the changes in pressure in the belly,  which is what changes the blood flow. So it's not allowing it to react. So we're just getting this continuous flow. So yes, one could argue that we could diagnose  an iliac obstruction based on just that one waveform there. However, let's talk about this patient. This patient actually came to our office.  They had a very swollen left leg. They went somewhere for a DVT study that came back negative. Their doctor sent them to our vascular surgery practice.  So when we looked at the ultrasound, we said, well, what are the common femoral vein waveforms look like? And they only had the left.  So we looked at it and looked pretty similar to this, but then we brought them into our vascular lab and we got these two waveforms. So if we were to stop  with that left common femoral vein waveform, we could definitely say that it's phasic, right? So we have this respiratory variation. We have cessation of flow,  but we did the right side and look how different they are. Something is happening that's not allowing this left side to react the same. So it's not an absence of reaction.  It's just a difference in reaction. And that's gonna prompt us to think about those iliac veins. Now, some people actually use ultrasound to assess them  and we're doing that more and more these days, but it is not without its challenges. So oftentimes they'll be sent off for other testing,  like a CT or an MR or something along those lines. So we need to make sure that we're always assessing both to make sure that they are phasic and symmetrical.  So let's talk about patient position for Patency. You can have them lying down, leg can be externally rotated. You can assess the whole system for compressibility.  You wanna make sure you're doing this supine too, because if you try to compress veins, if you had this patient in a standing position  and you're trying to compress their femoral vein, it's going to, number one, be very painful for the patient. It's also not good ergonomically for you.  And then the other part of this is that femoral veins should, and popliteal veins, should compress fairly easily, right? But if there's venous hypertension  because of proximal obstruction, you'll actually notice that the femoral vein is not, the veins are not compressing as easily. And that should clue you into the fact  that something might be happening more proximally as well. Now you see those other two images there. These are just alternate positions for assessing the calf veins.  I remember as many moons ago when I was learning how to do these studies, I really struggled with the calf veins. And one of the things they taught me  was to just pump the bed up nice and high and then have the patient dangle over and you can even rest them on your leg. And then you have full access to these veins  and they get much bigger because now they have that hydrostatic pressure and they get filled up. They're probably double the size. On top of that, you have full access  to the posterior, the lateral, and that whole medial piece of it. And you can actually, while you're there, look for any large tributaries coming off the saphenous.  So you can kind of do a little mapping from the knee down of your superficial system while you have them in this position. So that's just another alternate position for that.  So patency, again, supine position, transverse with and without compression  at a minimum common femoral, femoral, and popliteal. Some people include the gastrocs, the PDs, the perineals. You should include your superficial veins as well,  at least make sure they're fully compressible. Once we know that our superficial and deep systems are patent, then we can go ahead and move on to assessing for reflux.  So this is just a quick video showing how I assess for reflux. And really, the takeaway is typically we wanna use a distal augmentation of some sort.  And there's lots of tools in the toolbox that we can do that with, whether it's a cuff augmentation system, like I use manual augmentation, having the patient do some maneuvers.  So there's lots of different ways. I prefer the cuff only because, number one, it's completely repeatable every time. Ergonomically, it makes my life much easier  and we get a really nice augment when we use it. So just a quick display of this. The patient's in the standing position. My probe is on their great saphenous vein.  We have our cuff augment. Look at that nice augment. And then we have cuff reliefs and all of that reflux. This is what reflux should look like. You should never have to guess  whether you're measuring noise versus actual reflux. It should look like this. And if you're not getting a good enough cuff augmentation,  you are going to struggle with that every time. So it makes it much clearer if you were to think about using one of these cuff inflation systems.  So we wanna make sure that we show the augment. We wanna show our antegrade flow below the baseline. And then here we have our cuff release and then we have this retrograde flow  within our saphenous vein. We measure it with calipers, make sure that we show how long that reflux is lasting in the superficial system. It needs to be greater than half a second  or greater than 500 milliseconds to be considered reflux, greater than one in the deep system, one second in the deep system. So this is what negative for reflux looks like.  We have a really nice calf augmentation. We had a cuff release and then we have our valve snapping shut right there. It's obvious that there's no reflux. There's no noise.  Using that cuff really makes a nice difference. This is clearly negative for reflux. So let's talk a little bit about this. Somebody asked me to actually share this.  So what is this waveform? So what is happening here where we augment  and then all of a sudden we get continuous antegrade flow. So blow below the baseline. Well, what I wanna say to you is please do not invert this and make it reflux.  This is blood flow that is going up the leg, just like when you augmented. It went up and then you released and it kept going up. Well, why is that happening?  And these are just some nice images that Sarah Shonsberg shared with me here, just demonstrating the same situation. Augment, cuff release, and then just continuous antegrade flow.  Well, what's happening? So let's just jump over to this graphic because we can't see all the veins at once. But if we were able to, and we're looking at with our ultrasound,  we augment and we see antegrade blood flow up our great, up our anterior accessory and up our posterior accessory saphenous veins here, right?  So then upon release, what can happen is if we're looking at our great saphenous vein, we might see that we have all this retrograde flow,  just like we saw in that demonstration, right? But if we were to move our probe over here and we're looking at our posterior accessory saphenous vein,  let's say, and we do our augment and we see the blood go up just like it's supposed to, and then our cuff releases, but then all of a sudden we still get this antegrade flow.  Well, what's happening and what you can't actually see is happening is that another vein that's associated with this vein, which in this case, it's the great saphenous,  actually has retrograde flow in it. And it's basically, and this is not a physics technical term at all, but it's siphoning or suctioning the blood flow up this posterior accessory.  And then it ends up going down the great with along with the other blood flow that was in the great saphenous. So please just keep in mind, you don't just invert your waveform  and all of a sudden it's incompetent. That is not the case. This is all about the hemodynamics that are happening.  All right, so reflux in the deep system, we're gonna check the common femoral, the femoral and the popliteal vein. I just wanna talk about the common femoral for a second.  So this is a graphic of the sapheno-femoral junction and all this dark is actually part of the junction. So notice that that includes part of the common femoral.  So this whole thing is considered sapheno-femoral junction. So we need to remember that when we're assessing for reflux within the common femoral, we do not wanna be in this piece  that's considered the sapheno-femoral junction because if you have reflux within your great saphenous as it starts to join the common femoral,  you're going to actually pick it up here in this section and you might end up diagnosing somebody with deep venous insufficiency and all you're really getting is reflux  from that sapheno-femoral junction and once this vein is fixed, that's going to disappear. So you wanna either go above or below these valves here  to assess for the common femoral insufficiency.  So then we start talking about our superficial system and we're gonna assess all of these veins just like we did using that cuff augment  or whatever it is that you use to make your augment. Okay, so we're gonna do our junction and then we're gonna do our great saphenous, our anterior accessory, posterior accessory,  small saphenous if it has a thigh extension, a vein of jacamine, all those good things but we're gonna start looking at all of our axial veins.  So let's start by talking about the sapheno-femoral junction. So we're gonna head back to our graphic here. In order to elicit reflux from the sapheno-femoral junction,  we can use a distal augmentation  and it works really nicely. But what I do wanna caution and one of the things that I've talked to many providers about because they're finding that, you know,  the sapheno-femoral junction should be refluxing based on the other findings in the lower extremity but the techs aren't able to demonstrate it.  And one of the things that I often remind them to do is if it's not refluxing with distal augmentation, the one place that I use Valsalva is at the sapheno-femoral junction.  If you suspect that there's sapheno-femoral junction reflux and you wanna go ahead back and again, pull that out of your toolbox and have the patient perform a Valsalva,  then you can go ahead and do that. And that might demonstrate the reflux you're missing. Now again, we talked about the sapheno-femoral junction and its anatomy, right?  So look how long the sapheno-femoral junction is. Most people, not most people, but people sometimes think that this is the junction right here. Well, that's just the confluence  of the great saphenous with the common femoral vein. The sapheno-femoral junction is actually a few centimeters long and involves a few valves.  So you can not have reflux here, but have reflux here, and that is still considered sapheno-femoral junction reflux. So we need to remember that  because unfortunately, as we all know, insurance tends to dictate whether a procedure could be performed if there's sapheno-femoral junction reflux in these veins.  So we need to understand what the junction is  and where and how we can test it properly. So just keep all that in mind as you're testing this.  So one of the things that people ask about is, well, how do you measure the sapheno-femoral junction? And some people get the true Mickey Mouse and measure it just,  so let's pretend this is actually the junction here. They would measure it here to here. Other people know that this is a good two centimeters, three centimeters long.  So you can get a true cross-section and you can measure it slightly lower than that so that you feel like you're measuring it correctly  because that's how we typically measure veins, right? I will say to you that as far as IAC goes, they don't tell you how you need to do it,  but what you need to do is do it consistently throughout all your studies. So you need to choose one of these methods and then actually do it that way.  So that's just a little tip on that because I know it tends to stress people out on how do you measure this?  All right, so let's talk about the axial veins. We're going to talk a little bit about what's going on right here because this tends to confuse people. There's a lot happening  in our superficial axial system here. So we have our great saphenous, we have our anterior accessory saphenous, and then we have this guy that a lot of people don't think about,  the posterior accessory saphenous. So we need to remember that that's there and we need to be able to look at it. So this video is going to play twice.  One's a little quick and then one's a little slow but it's basically going to show you all three of those vessels as they come off. So as we're scanning from the junctions,  that was our junction. We have our GSV here, we have our anterior accessory there. And then as we come down, we start to see that little guy there  and it's going to go a little slower for us here so that we can actually see it all. So great anterior accessory. And then as we kind of come a little more medially,  posterior accessory. And if we look here, we can see this image. And what I want to show you is that all of these veins are within the saphenous fascia.  This is what makes them saphenous veins. This is what makes them axial veins. This is what makes these accessory saphenouses actual saphenouses because they live in this fascia.  Now, don't forget the anterior accessory is much shorter than the great, more often than not, not always. So you will follow it along and then all of a sudden it will appear  to come out of the fascia. And that's how we want to talk about it. But we have to remember once it's out of the fascia, it is no longer a saphenous, it's a tributary.  So we're going to go ahead and we're going to look at this picture here. And we see this patient comes into us and we see all these varicose veins. So what we need to know is that,  yes, we know that there's reflux because it's the only way we get varicose veins, right? We need to figure out which one of these axial veins these varicosities are associated with,  if they actually are, and does that axial vein function properly or not?  They can be associated, all of them could be associated with one, or they could be associated with many. So we need to make sure we check them all.  And then we can always often have these random ones that aren't associated with any of the axial veins. So we're gonna check all of those veins for reflux,  just like we did, we showed earlier, and we're also gonna obtain diameters of all of those veins. And I know in my practice,  I don't obtain the diameters unless there's actual reflux. So if the veins are functioning fine, I do not do the diameters. It's just for efficiency sake only,  and where I am, it's not required. So, but be cautious and follow your own protocol. We wanna measure the veins in a cross section. We want to measure them, typically,  we look in the IAC standards, and it just says wall to wall. And it doesn't specifically say, I don't think, whether it's inner wall to inner wall or outer wall to outer wall,  I think it's defined for the arteries. That being said, whichever it is you do, you need to do it consistently, and you need to do it well.  You wanna make sure that you're on the wall, you're not way outside of the wall, because they're very cautious looking for that, because you don't want to appear  to be inflating the size of your veins. So you're gonna follow your protocol, and you're gonna measure it in all the different spots. You're also gonna do your reflux  in all the different spots that your protocol calls for. And you're gonna do that in all of the veins, your great saphenous, your anterior accessory saphenous,  your posterior accessory saphenous, and just do it very methodically. I start at the groin, and I work my way down to the proximal calf of the GSV,  and I check it in the places that my protocol call for, which would be the junction, proximal GSV, mid-thigh GSV, knee GSV, and proximal calf GSV. If it's refluxing, I go back up,  and I do my diameters in those same exact spots. Then I move on to my anterior accessory, do the same, and then the posterior accessory.  Then what we're gonna do is once we decide they're refluxing and we wanna figure out if there are varicosities associated with them,  we follow them along in a transverse, and we look for any tributaries crossing that fascia to join the saphenous. And lo and behold, there's a big one there.  So if this was truly the patient, we would see a varicosity, a cluster of varicose veins at that knee. So we found the source of those varicose veins.  And we're gonna repeat that exact same thing for all the veins. So for our great, for our anterior, for our posterior, then we're gonna turn our patient around,  and we're gonna do the same thing for the small, okay? So we don't wanna ignore the small.  And the different distributions for the small saphenous could be, it could literally just be the small saphenous alone with incompetent tributaries that are associated with it,  or it could be the small saphenous' posterior thigh extension with varicosities that are associated with that. And then we also have the other veins such as the vein of Giacomini.  So for me, patient standing, I get this, I have them up on a little bit of a platform just to keep my shoulder in line so I don't drop my shoulder, or for ergonomics.  And I use the same cup augmentation to the small saphenous and up into the back of the thigh.  So for this patient, we've finished our axial insufficiency study, and we know we have these varicose veins. But if we must find that the great saphenous vein  was incompetent, and we just assumed that all these varicose veins were associated with it, and that's all we treated, this patient would not have successful treatment. Why?  Because their anterior accessory saphenous was the source of these varicose veins here. So even if we treated this and then did some treatment to this,  they would more than likely have a reoccurrence because we did not get to the source of the problem. So we need to find the source of the varicosities,  whether it be one of these axial veins or some other veins that we're gonna talk about next.  So we're gonna move on now to the veins that are not the usual suspects, non-saphenous lower extremity varicose veins. Well, what causes these varicose veins?  What would make them be there that if they're not associated with the saphenous veins? So there are varicose veins that can be associated with perforating veins.  So we know our perforators connect our superficial to our deep, and very simply said, it's much more detailed than this, but the blood flows from the superficial to the deep  and they have one-way valves, just like our other veins. Although there can be bi-directional flow within these veins that can be normal. But we're not gonna get into that.  It's a little bit too much for this talk. That being said, we're gonna talk specifically about refluxing perforators that connect directly to a cluster of varicose veins.  And they call these exit veins. And you can actually follow the varicose veins right to these perforators. And this is what they'll look like.  So these patients have had their axial veins assessed and we found that these varicosities didn't necessarily associate with one of what we call the usual suspects.  So we just simply put our probe on them and quickly followed them back. You don't need to spend a ton of time on them because these tests can take long enough.  So you just need to do a quick scoot up and basically look for where it goes to. If they become very tiny and you can't follow them, then you call it. But more often than not,  you can follow them right up to a perforator. So in both of these cases, there were incompetent perforators there. Now, that being said,  depending on where you work, they may or may not treat that incompetent perforator, but they certainly now know the source of that varicose vein.  The other type of perforator that's associated with the varicose vein is what's called a re-entry perforator. And it's important to be able to know the difference  because what's happening is these re-entry perforators, when you look at them, they might appear to be dilated and they might actually have bi-directional flow in them  or some retrograde flow. But what's happening is, if you look here at this diagram, it's easy to show in a diagram versus an ultrasound image.  We have this retrograde flow going down our great saphenous and then it fills up one of the tributaries here. And then what we see here is it draining into a perforator.  So it's taking this blood flow and it's bringing it back into the system. And that's why it's called a re-entry perforator. So these can be dilated,  but they're dilated because of that venous hypertension from this pressure from above. If this pressure were eliminated, this perforator would probably go back to normal.  So what we need to recognize is that if there's an incompetent tributary above the perforator and draining into it, it's a re-entry perforator.  If the perforator is the source of a varicosity, then you would see the varicosity coming from it and then heading down the lower extremity  versus certainly wouldn't be associated in traveling up. So those are our varicosities that are associated with perforators. The other thing that we can have varicose veins from  is called neovascularization. Now neovascularization is only present when somebody has had a vein treatment. And it's because it's literally defined  as the recurrence through growth of new vessels after somebody's had a vein procedure. So it's a regeneration. And these veins never grow back functioning.  They never grow back easy to follow. And they don't grow back, I wouldn't say they're not easy to treat. We just have to have some different tools to treat them.  So this is what neovascularization looks like. If we start scanning at the sapnofemoral, oops, sorry. If we start scanning at the sapnofemoral junction  and we start to follow this vein down, look at this tortuous mess of vessels here within that saphenous fascia. And then all of a sudden, as we make our way down,  it comes out of the fascia and it gets close to the skin and becomes a varicosity. Well, some things that we need to be able to tell our providers are number one,  the source of this varicose vein is this neovascularization or you can describe it. And it's important to describe it as a tortuous vessel that courses within the fascia  for the most of the length of the thigh. In that way, your provider knows that they're not gonna be able to treat this with your thermal ablation techniques  because you cannot feed a catheter through that tortuous vein segment. So they're gonna have to start thinking about alternate forms of treatment  and there are plenty of choices like foam sclerotherapy or whatever it is they choose, but we need to make sure that we tell them and that way they know going in,  okay, this is how I'm gonna have to approach these veins. And then last but not least, we're gonna talk about pelvic origin varicose veins  and varicose veins of the lower extremities, okay? And these are the veins that I was talking about that are associated with varicose veins of the pelvis  that have to do with pelvic meanness disorders. And we're not gonna get into that, we just need to recognize that it is a possible source from up above.  If you look at this patient here, and this is kind of an important point to take away, if I'm assessing the great saphenous vein and I start at my sapheno-femoral junction  and it is negative for reflux, and then I move down and my proximal great is negative for reflux, and my next step would be to take my probe and to put it right at mid-thigh level.  Now this red indicates that there's reflux here. So I would go ahead and place my probe here and I would do my cuff inflation and all of a sudden I'm finding reflux.  Well, what I have to realize is that the blood flow in the saphenous vein is not gonna change below the junction, so whether it's working properly or not,  so refluxing or not refluxing, it's not going to change unless something's draining into it or out of it. So what I mean by that is if I found reflux here,  but I didn't see reflux here, I'm gonna in my mind know that something's happening between here and here that's making this become, making this incompetent and start to reflux.  So I'll put my probe in a transverse, I follow it proximally until I bump into lo and behold, an incompetent tributary that I had not noticed that courses along the medial thigh  and drains up into our perineum or our labia and that's indicative of a pelvic source varicose vein. The varicose vein is not have an origin of a saphenous vein  or the sapheno-femoral junction. And in fact, this varicosity is probably what's causing this great saphenous vein to become incompetent. So treating the saphenous  is not actually going to help this at all.  Next patient, we check all the axial veins and whether they're working properly or not, we noticed that this medial thigh incompetent tributary  does not course back to any of those axial veins. So we just quickly follow it to its source. It does not have to take a long time. We're just gonna zip right along with it.  And lo and behold, again, we're bumping into that perineum pelvic source. We turn our patient around and we assess their small saphenous and we see that there's reflux,  but we also see that there's this big varicosity up the posterior aspect of the thigh, right? So what we do know is that there's no way  this small saphenous is causing this varicose vein to be here. And more than likely, it's what's causing the small saphenous to be incompetent. If we were to go ahead  and follow this incompetent tributary approximately, we might follow it, whoops, I'm sorry. We might follow it up into the buttocks or we might follow it over  and it'll go medial up towards the perineum. Again, signs that there's a reason to look higher, to look up. So let's talk quickly about what pelvic escape points are,  because they're the connection between the pelvis and the lower extremity. And you don't even need to know these names, honestly. What you need to know is to recognize  that these veins are coming from the pelvis, but it's always nice to put a name with it. So these escape points are actually kind of holes within the fascia  that connect the pelvis to the lower extremity or the genitals or the buttocks, right? And they have names. There's the inguinal escape point, and that's up here.  And that's associated with the round ligament veins. And all of these veins that are associated with these escape points are branches of the internal iliac veins.  And we only see them when there's venous hypertension in the pelvis and they're making their way out. So then we have our obturator escape point, and that's the obturator vein.  And if we look here, we're gonna notice that the obturator oftentimes associates itself and drains into the deep system. So the femoral veins versus the sapheno-femoral junction  where we would notice the inguinal escape point  joining. And then we have our peroneal escape point, and that's the internal pendundal veins. And I think that's probably one of the most common, that and the inguinal escape points  are the ones that we see that present to us, for these typical pelvic venous patients. We have gluteal escape points, and there's two of those. We have a superior gluteal,  which is kind of in the meat of the buttocks or slightly lower, and then right at the crease of the buttocks. So let's just look real quick  at what the lower extremity ultrasound shows us to let us know that there's pelvic involvement. Our inguinal escape points,  if we were to put our probe on our sapheno-femoral junction, and we see some varicosities right around the sapheno-femoral junction,  we can just think, well, where are these coming from? Why are they here? If we angle our probe slightly superior immediately,  we're gonna head right up towards this inguinal escape point and we're gonna see a little cluster of varicose veins here, and those are associated with that inguinal escape point  and that round ligament vein. So this is what the patients typically present like with the inguinal escape points. They'll have these varices around the inguinal canal here  of the inguinal ligament, and as you angle up, you're gonna see this little cluster of varicose veins, and if you have the cuff on, you can augment, and more often than not,  you'll get a good augment like that, and then when the cuff releases, you'll get continuous flow, retrograde flow within those, and you'll just see, without the color on,  you'll just see this bed of tiny little veins, and that's indicative of pelvic involvement through the inguinal escape point. We have our perineal escape point,  and the way that we identify this is we use the Captain Morgan pose here where we get that foot up on the stepstool so that we have good access to the perineum,  and you need to do this with them standing. You can't find this. It's difficult to find with them lying down. We need hydrostatic pressure for sure.  So we just basically have our probe coursing along any vein on that medial thigh that we're trying to find the source,  and we notice we're not coming to the junction or to the saphenous. What we're doing is we're making our way to the perineum, and we'll finally land our probe  up in either side here on the perineum, and this is what the patients will present like. They have these varicosities really medially, or we'll see them on the posterior thigh,  but as we follow them, they'll come up and drain right up towards that perineum,  and once your probe is there, if you have the patient valsalva, you will basically see all these veins just light up like a bit of a Christmas tree,  and that's indicative of varices escaping from the pelvis through that perineal escape point.  Obturator escape point. This is an interesting one where our probe is at the sapnofemoral junction, but to identify these, if we're at our junction and we angle slightly inferior,  we'll see oftentimes we see, I used to think it was a perforator, but it's actually this connection with the pelvis, but you'll see some varicosities,  and they're oftentimes within the fascia, so they look like neovascularization, but there's not necessarily been a surgery, so it can't be neo,  and then what we see is when we look at this, this is the common femoral. We're gonna see our sapnofemoral junction and this obturator point, and you're gonna see some varices here,  and we have our nice cuff augment, and then so here's our augment,  and then we have our cuff release, and you're gonna notice there's no reflux within the junction, but look at the reflux within these varices that are associated with the O point,  and those drain directly into that common femoral, and then finally we're into our gluteals. We have our inferior gluteal. It's oftentimes associated  with varices of the sciatic nerve, so you can see it's hash marked here, and the reason it's hash marked is because we don't see it on the leg. It's under the skin.  It kind of reminds me of a saphenous fascia, but it's not, and I could get in trouble for saying that, but I'm gonna say it anyway. There's this sciatic nerve sheath  that the sciatic nerve travels in along the posterior thigh, and it can have varicose veins that are associated with it, and those patients actually get sciatic symptoms,  and oftentimes this inferior gluteal escape point, you'll follow these sciatic nerve varices, and they're tiny, and you can follow them up,  and they reflux when you inflate your cuff and release it, but they drain into that inferior gluteal escape point, so again, pelvic source,  and then finally our superior gluteal escape point, and these are the varicoses visually that you can see, and you follow them up the back of the thigh  or the lateral thigh up to the mid buttocks, and oftentimes they're associated with the small saphenous, and they're causing small saphenous insufficiency  just like on this patient here,  so in conclusion, our mission is to find the source of reflux, not to find reflux. We know there's reflux. The patients have varicose veins. They have signs of venous insufficiency,  but we need to figure out why. Where are they coming from? What is the source? Is it a proximal obstruction? Is there pelvic veins involved? Is there neovascularization?  Is there an incompetent perforator? We need to find the source.  We wanna always trace them back to their source. We wanna look beyond the usual suspects. Of course, we look at the usual suspects, but we also need to keep an open mind  that it's not always those. Pelvic varicose veins can be the source of lower extremity varicose veins, and no, you don't need to know how to assess the pelvic veins.  Not everybody treats the pelvic veins,  but we just need to be aware that it's a possible source.  Thank you very much. I'm happy to share my email and my phone number. I love to talk veins, so I am happy to answer any questions that anybody has separate after this show.  Please feel free to reach out with any questions you have, and thank you very much for your attention.  Thank you, Donna, for a wonderful presentation. I see a lot of questions. I have a few minutes left. So, and I will pick some of the questions.  So one of the straightforward questions that I noted was what is the cuff pressure when you augment using the blood pressure cuff? So that's a great question.  It has to be at least around 80. So when they created the diagnostic criteria for it, I believe it was Nikos Lavaropoulos has a paper,  and I believe they used 80 millimeters of mercury. I actually have mine up a little higher than that. I usually keep mine around 110, but 80 is actually what they used  to create the diagnostic criteria. So that should be.

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