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Duplex assessment of venous hemodynamics 3 oct 13th, 2011, morning 20mn2

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Venous insufficency may be acurately assesed by DUS

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  • J'ai été un des premier à avoir été opéré par Claude. Depuis des années je marche très bien! Bravo à Claude et bonne continuation dans ses recherches.Dominique Degli Esposti
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Duplex assessment of venous hemodynamics 3 oct 13th, 2011, morning 20mn2

  1. 1. Duplex Assessment of Venous Hemodynamics Claude FRANCESCHI, Roberto DELFRATE Paris France, Cremona Italy
  2. 2. Hemodynamics knowledge is the backbone of nowadays performance in Diagnosis and Treatment of Arterial and Cardiac disease Hemodynamics ignorance is the reason for the still raw diagnosis and treatment of the Venous Disease despite the advanced technologies that cannot compensate theoretical lacks
  3. 3. Venous Hemodynamics knowledge demands a peculiar intellectual effort because: Not teached in most universities Weakly promoted ( known?) by the majority of Phlebology Opinion Leaders and Scientific Societies More complex than arterial
  4. 4. Duplex assessment of venous hemodynamics is the key point for a better diagnosis and appropriate treatment strategy IF lighted by rational and coherent theoretical models
  5. 5. Duplex aims at assessing the hemodynamic changes of the venous system According to the various hemodynamic configurations
  6. 6. Pressure and Flow Overloading is responsible for TMP EXCESS TMP Excess is Responsible for -Veins Dilatation ( Varicose) -Drainage impairment ( trophic changes : edema, hypodermitis, ulcer…)
  7. 7. Pressure and Flow Overloading is due to Venous Block responsible for -Permanent Venous Pressure Excess -Compensatory collaterals (Open Shunts) Valve Incompetence responsible for -Deep Reflux ( various grades) -Superficial Reflux - -Closed Circuits ( Closed Shunts) - -Deviated Flows ( Open deviated Shunts)
  8. 8. DUPLEX is able to assess all these complex configurations made of blocks and shunts IF performed according to appropriate data assessments So providing accurate diagnosis and consequently appropriate treatment
  9. 9. Hemodynamic Manoeuvres Are Mandatory to elicit the hemodynamic impairments
  10. 10. Hemodynamic Manoeuvres Upright Position Valsalva: Thoraco-abdominal Pump Stress Test Squizing, Paranà , Wundsdorf: Valvo-muscular Pump Stress Test Supine Position Venous Pressure: Hemodynamic obstacles assessment
  11. 11. Hemodynamic Manoeuvres Upright Position Valsalva: Thoraco-abdominal Pump Stress Test Squizing, Paranà , Wundsdorf: Valvo-muscular Pump Stress Test Supine Position Venous Pressure: Hemodynamic obstacles assessment
  12. 12. Valsalva Manoeuvre: May be performed easily and properly blowing into a blocked straw
  13. 13. Valsalva Manoeuvre: Increases the Toraco-abdominal venous pressure and reverses downwards the pressure gradient but not the flow when blocked by the valves closure
  14. 14. Valsalva Manoeuvre: Valsalva is negative when the valves are Competent Flow is blocked by blowing ( systole) and appears at release (diastole) At rest Systole = blowing Relax Diastole
  15. 15. Valsalva Manoeuvre: Valsalva is Positive when valves are Incompetent Valve Reverse Flow appears when blowing ( systole) and at release (diastole) At rest Systole = blowing Relax Diastole
  16. 16. Exception!!!!! Contrary to the majority of the veins, AT DESCENDING TRIBUTARIES OF THE SAPHENA ARCH Positive Valsalva flow fed by pelvic leaks doesn’t reverse direction o P c P p P s g P ig P i P i P o P c P p P gs P g s P At rest Systole = blowing Relax Diastole
  17. 17. Hemodynamic Manoeuvres Upright Position Valsalva: Thoraco-abdominal Pump Stress Test Squizing, Paranà , Wundsdorf: Valvo-muscular Pump Stress Test Supine Position Venous Pressure: Hemodynamic obstacles assessment
  18. 18. Purpose: Assessing VALVE COMPETENCE VALVE INCOMPETENCE Grades: -Total, Partial, Segmental Haemodynamic effect: - -Closed Shunts (closed circuit ) -Open Deviated Shunt ( open circuit ) VENOUS BLOCKS AND BY-PASSING VEINS -Open Vicarious Shunt ( open circuit )
  19. 19. Purpose: Assessing VALVE COMPETENCE VALVE INCOMPETENCE Grades: -Total, Partial, Segmental, Closed Shunt Haemodynamic effect: -Open Deviated Shunt ( open circuit ) -Closed Shunts (closed circuit ) VENOUS BLOCKS AND BY-PASSING VEINS -Open Vicarious Shunt ( open circuit )
  20. 20. Paranà: Physiologic Active Systole of the VMP and plantar pump BY Proprioceptive reflex contraction triggerd by a light push-pull at the waist
  21. 21. Paranà: Physiologic Active Systole of the VMP and plantar pump BY Proprioceptive reflex contraction triggerd by a light push-pull at the waist
  22. 22. Paranà: Physiologic Active Systole of the VMP and plantar pump BY Proprioceptive reflex contraction triggerd by a light push-pull at the waist
  23. 23. Paranà: Physiologic Active Systole of the VMP and plantar pump BY Proprioceptive reflex contraction triggerd by a light push-pull at the waist
  24. 24. Purpose: Assessing VALVE COMPETENCE VALVE INCOMPETENCE Grades: -Total, Partial, Segmental Haemodynamic effect: -Closed Shunts (closed circuit ) - Open Deviated Shunt ( open circuit ) VENOUS BLOCKS AND BY-PASSING VEINS -Open Vicarious Shunt ( open circuit )
  25. 25. Ilio-femoro-popliteal TOTAL incompetence At rest Popliteal Vein Diastolic Reflux coequal to Systolic S coequal D
  26. 26. SEGMENTAL Popliteal incompetence Above Femoral Valve Closure At rest Decreases the Reflux Diastole S D Diastolic Reflux Peak lower than Systolic
  27. 27. PARTIAL Popliteal incompetence At rest Small valve leak S D Low and Lasting Diastolic Reflux
  28. 28. Purpose: Assessing VALVE COMPETENCE VALVE INCOMPETENCE Grades: -Total, Partial, Segmental Haemodynamic effect: - -Closed Shunts (closed circuit ) -Open Deviated Shunt ( open circuit ) VENOUS BLOCKS AND BY-PASSING VEINS -Open Vicarious Shunt ( open circuit )
  29. 29. Deep CLOSED SHUNT Diastolic Reflux overloaded by a competent collateral vein flow At rest Femoral Example Femoral Example Diastolic Reflux Peak and volume Higher than Systolic
  30. 30. Superficial CLOSED SHUNT Superficial Diastolic Reflux overloaded by a deep vein flow At rest Great Saphena Example Great Saphena Example Diastolic Reflux Peak and volume Higher than Systolic S D
  31. 31. Superficial CLOSED SHUNT Superficial Diastolic Reflux overloaded by a deep vein flow At rest Great Saphena Example Great Saphena Example SHUNT 1 Diastolic Reflux Peak and volume Higher than Systolic S D Positive (+) Valsalva
  32. 32. Superficial CLOSED SHUNT Superficial Diastolic Reflux overloaded by a deep vein flow Other Closed Shunts have the same hemodynamic features but are different according to the deep leak point that feed them their and the re-entry point that drain them and the involved network
  33. 33. i P i P o P c P p P s g P ig P o P c P p P gs P g s P Sapheno-femoral Junction Sapheno-popliteal Junction Pelvis leak points Various Perforators Networks: N1, N2, N3, N4
  34. 34. Purpose: Assessing VALVE COMPETENCE VALVE INCOMPETENCE Grades: -Total, Partial, Segmental Haemodynamic effect: - -Closed Shunts (closed circuit ) -Open Deviated Shunt ( open circuit ) VENOUS BLOCKS AND BY-PASSING VEINS -Open Vicarious Shunt ( open circuit )
  35. 35. Superficial OPEN DEVIATED SHUNT Superficial Diastolic Reflux overloaded by a deep other vein flow superficial collateral veins flow At rest Great Saphena Example Great Saphena Tributary Example Diastolic Reflux Peak and volume Higher than Systolic S D Negative (-) Valsalva
  36. 36. Purpose: Assessing VALVE COMPETENCE VALVE INCOMPETENCE Grades: -Total, Partial, Segmental Haemodynamic effect: - -Closed Shunts (closed circuit ) -Open Deviated Shunt ( open circuit ) VENOUS BLOCKS AND BY-PASSING VEINS -Open Vicarious Shunt ( open circuit )
  37. 37. Superficial OPEN VICARIOUS SHUNT Superficial Systolic Diastolic flow Reflux overloaded overloaded by by deep a deep vein flow Great Saphena Example At rest Great Saphena By-Passing a popliteal Rest, Systolic Peak and Diastolic antegrade flow S block Example venous flow D
  38. 38. o P c P p P s g P ig P i P i P o P c P p P gs P g s P Networks and their Connections are checked up : Flow direction and modulation - -at rest - under hemodynamic stress manoeuvres Selected according to the peculiar status of each patient In order to depict a taylored topo-hemodynamic feature
  39. 39. Hemodynamic Manoeuvres Upright Position Valsalva: Thoraco-abdominal Pump Stress Test Squizing, Paranà , Wundsdorf: Valvo-muscular Pump Stress Test Supine Position Venous Pressure: Hemodynamic obstacles assessment
  40. 40. Venous Pressure Measurement: Veins Patency Test Supine Position Normal ≤ 25 mm Hg Cuff inflation/deflation Posterior Tibial Vein flow
  41. 41. For a comprehensive information
  42. 42. Duplex assessment of venous hemodynamics Lower limbs Venous network Dynamic Stress Manoeuvres Hemodynamic Obstacles and Open Vicarious Shunts Hemodynamic Valve Incompetence and Closed/Open Derivate Shunts Protocole Assessment Hemodynamic Mapping
  43. 43. Duplex assessment of venous hemodynamics Lower limbs Venous Networks (N) Dynamic Stress Manoeuvres Hemodynamic Obstacles and Open Vicarious Shunts Hemodynamic Valve Incompetence and Closed/Open Derivate Shunts Protocole Assessment Hemodynamic Mapping
  44. 44. Venous Networks ( N ) 1988 Skin Sub- Cut. Tissue Duplicated Apon. fascia Sub-Apon. Compart.
  45. 45. Venous Networks ( N ) 1988 N3 sub-cut. veins N2 intra-fasc. veins N1 deep veins
  46. 46. Venous Networks ( N ) 1988 Hierarchical draining N3 N2 N1
  47. 47. Venous Networks ( N ) 1988 Draining Veins N1 N2 N3 Deep veins TRUNKS Ant.Saph. Great saph. GiacominiV. Small saph. Saph. and Extra Saph. tributaries
  48. 48. Venous Networks ( N ) 1988 Draining Veins N4 N2 ► N2 Connecting Veins
  49. 49. Venous Networks ( N ) N2 ►N1 collectors Sapheno-Femoral Junction Sapheno-Popliteal Junction
  50. 50. Venous Networks ( N ) N2 ►N1 main perforators LEGS
  51. 51. Venous Networks ( N ) N3 ►N1 some perforators LEGS
  52. 52. Venous Networks ( N ) N3 ►N1 perforators Pelvis 6 perforators Perineal V P Point Rd Ligt V I Point Clit. V C Point Obt. V O Point I Glut.V IG Point S Glut. V SG Point o P c P p P s g P ig P i P i P o P c P p P gs P g s P Franceschi C, Bahnini A. (2005) Treatment of lower extremity venous insufficiency due to pelvic leaks points in women; Ann vasc Surg; 19; 284-88
  53. 53. Networks and their Connections are checked up : Flow direction and modulation - at rest - under hemodynamic stress manoeuvres Selected according to the peculiar status of each patient In order to depict a taylored topo-hemodynamic feature
  54. 54. Duplex assessment of venous hemodynamics Lower limbs Venous Networks (N) Dynamic Stress Manoeuvres Hemodynamic Obstacles and Open Vicarious Shunts Hemodynamic Valve Incompetence and Closed/Open Derivate Shunts Protocole Assessment Hemodynamic Mapping
  55. 55. Hemodynamic Manoeuvres Upright Position Valsalva: Thoraco-abdominal Pump Stress Test Squizing, Paranà , Wundsdorf: Valvo-muscular Pump Stress Test Supine Position Venous Pressure: Hemodynamic obstacles
  56. 56. Hemodynamic Manoeuvres Upright Position Valsalva: Thoraco-abdominal Pump Stress Test Squizing, Paranà , Wundsdorf: Valvo-muscular Pump Stress Test Supine Position Venous Pressure: Veins Patency Test
  57. 57. Valsalva Manoeuvre: Systolic Block of Thoraco-abdominal Pump increases the Toraco-abdominal venous pressure
  58. 58. Valsalva Manoeuvre: Systolic Block of Thoraco-abdominal Pump increases the Toraco-abdominal venous pressure So reversing downwards the pressure gradient without flow reversal thanks to the peripheral valves closure
  59. 59. Valsalva Manoeuvre: Toraco-abdominal Pump Systolic Block increases the Toraco-abdominal venous pressure So reversing downwards the pressure gradient it produces a reversal reflux flow when the peripheral valves are incompetent
  60. 60. Valsalva Manoeuvre: How to achieve Valsalva Manoeuvre easily and effectively : Blowing into a KNOTTED STRAW Blow!
  61. 61. Valsalva Manoeuvre: Negative Valsalva = Competent Valve VALVE COMPETENCE = NO SYSTOLIC REFLUX
  62. 62. Valsalva Manoeuvre: Negative Valsalva = Competent Valve VALVE COMPETENCE = NO SYSTOLIC REFLUX At rest, Permenant and Slow Upwards flow due to Residual Pressure At rest
  63. 63. Valsalva Manoeuvre: Negative Valsalva = Competent Valve VALVE COMPETENCE = NO SYSTOLIC REFLUX then the flow is blocked by the Valsalva At rest systole Systole = blowing
  64. 64. Valsalva Manoeuvre: Negative Valsalva = Competent Valve then the flow is blocked by the Valsalva At rest systole Systole = blowing
  65. 65. Valsalva Manoeuvre: Negative Valsalva = Competent Valve VALVE COMPETENCE = NO SYSTOLIC REFLUX Then at release, le blood flows upwards again thanks to the thoraco-abdominal At rest pump diastole Systole = blowing Relax Diastole
  66. 66. Valsalva Manoeuvre: Positive Valsalva = Incompetent Valve VALVE INCOMPETENCE = ONLY VALSLVA SYSTOLIC REFLUX
  67. 67. Valsalva Manoeuvre: Positive Valsalva = Incompetent Valve VALVE INCOMPETENCE = ONLY SYSTOLIC REFLUX Normal at rest At rest
  68. 68. Valsalva Manoeuvre: Positive Valsalva = Incompetent Valve VALVE INCOMPETENCE = ONLY SYSTOLIC REFLUX Systolic reflux At rest Systole = blowing
  69. 69. Valsalva Manoeuvre: Positive Valsalva = Incompetent Valve VALVE INCOMPETENCE = ONLY SYSTOLIC REFLUX Normal at Diastole At rest Systole = blowing Relax Diastole
  70. 70. Valsalva Manoeuvre: Positive Valsalva = Incompetent Valve VALVE INCOMPETENCE = ONLY SYSTOLIC REFLUX Normal at Diasole At rest Systole = blowing Relax Diastole
  71. 71. Valsalva Manoeuvre: Contrary to the majority of the veins, DESCENDING TRIBUTARIES OF THE SAPHENE ARCHS flow downwards and its refluxes are not reverse flows SO Valsalva is Positive when it produces a no reverse systolic downwards flow The reflux is fed by one of the pelvic leak points o P c P p P s g P ig P i P i P o P c P p P gs P g s P
  72. 72. At rest Valsalva Manoeuvre: Contrary to the majority of the veins, DESCENDING TRIBUTARIES OF THE SAPHENE ARCHS flow downwards and are not reverse flows nor reflux when at rest
  73. 73. Contrary to the majority of the veins, DESCENDING TRIBUTARIES OF THE and are not reverse flows nor reflux at rest . The absence of reflux is attested by absence of flow during the Systole At rest Valsalva Manoeuvre: SAPHENE ARCHS flow downwards Systole = blowing
  74. 74. Contrary to the majority of the veins, DESCENDING TRIBUTARIES OF THE and are not reverse flows nor reflux when at rest and during the diastole At rest Valsalva Manoeuvre: SAPHENE ARCHS flow downwards Systole = blowing Relax Diastole
  75. 75. Valsalva Manoeuvre: DESCENDING TRIBUTARIES OF THE SAPHENE ARCHS PositiveValsalva = Systolic Downwards flow WITHOUT REVERSE FLOW REFLUX FROM INCOMPETENT PELVIC PERFORATORS
  76. 76. At rest Valsalva Manoeuvre: DESCENDING TRIBUTARIES OF THE SAPHENE ARCHS PositiveValsalva = Systolic Downwards flow WITHOUT REVERSE FLOW
  77. 77. DESCENDING TRIBUTARIES OF THE PositiveValsalva = Systolic Downwards flow WITHOUT REVERSE FLOW At rest Valsalva Manoeuvre: SAPHENE ARCHS Systolic REFLUX = blowing REFLUX FROM INCOMPETENT PELVIC PERFORATORS
  78. 78. At rest Valsalva Manoeuvre: DESCENDING TRIBUTARIES OF THE SAPHENE ARCHS PositiveValsalva = Systolic Downwards flow WITHOUT REVERSE FLOW Relax Diastole Systolic REFLUX = blowing
  79. 79. Valsalva Manoeuvre: Positive Valsalva = Incompetent Valve At rest Systole = blowing Relax Diastole
  80. 80. Hemodynamic Manoeuvres Upright Position Valsalva: Thoraco-abdominal Pump Stress Test Squizing, Paranà , Wundsdorf: Valvo-muscular Pump Stress Test Supine Position Venous Pressure: Veins Patency Test
  81. 81. Squizing, Paranà , Wundsdorf: Valvo-muscular Pump Stress Test Purpose: Elicit VALVE COMPETENCE VALVE INCOMPETENCE Features: -Total, Partial, Segmental, Closed Shunt Haemodynamic effect: -Open Deviated Shunt ( open circuit ) -Closed Shunts (closed circuit ) VENOUS BLOCKS AND BY-PASSING VEINS -Open Vicarious Shunt ( open circuit )
  82. 82. Squizing, Paranà , Wundsdorf: Valvo-muscular Pump Stress Test Purpose: Elicit VALVE COMPETENCE VALVE INCOMPETENCE Features: -Total, Partial, Segmental, Closed Shunt Haemodynamic effect: -Open Deviated Shunt ( open circuit ) -Closed Shunts (closed circuit ) VENOUS BLOCKS AND BY-PASSING VEINS -Open Vicarious Shunt ( open circuit )
  83. 83. Squizing, Paranà , Wundsdorf: Valvo-muscular Pump VMP Stress Test Squizing: Not physiologic Passive Systole of the VMP + N2 and N3 emptying
  84. 84. Squizing, Paranà , Wundsdorf: Valvo-muscular Pump VMP Stress Test Paranà: Physiologic Active Systole of the VMP and plantar pump BY Proprioceptive reflex contraction triggerd by a light push-pull at the waist
  85. 85. Squizing, Paranà , Wundsdorf: Valvo-muscular Pump VMP Stress Test
  86. 86. Squizing, Paranà , Wundsdorf: Valvo-muscular Pump VMP Stress Test
  87. 87. Squizing, Paranà , Wundsdorf: Valvo-muscular Pump VMP Stress Test
  88. 88. Squizing, Paranà , Wundsdorf: Valvo-muscular Pump VMP Stress Test
  89. 89. Squizing, Paranà , Wundsdorf: Valvo-muscular Pump VMP Stress Test
  90. 90. Squizing, Paranà , Wundsdorf: Valvo-muscular Pump VMP Stress Test At rest, very low upwards flow At rest
  91. 91. Squizing, Paranà , Wundsdorf: Valvo-muscular Pump VMP Stress Test Pull 2 cms back but quickly In order to trigger a Systole by Proprioceptive reflex contraction of the calf At rest
  92. 92. Squizing, Paranà , Wundsdorf: Valvo-muscular Pump VMP Stress Test Then Push ahead 2 cms but quickly In order to relax the Proprioceptive reflex contraction of the calf (Diastole) At rest
  93. 93. Squizing, Paranà , Wundsdorf: Valvo-muscular Pump Stress Test Purpose: Elicit VALVE COMPETENCE VALVE INCOMPETENCE Features: -Total, Partial, Segmental, Closed Shunt Haemodynamic effect: -Open Deviated Shunt ( open circuit ) -Closed Shunts (closed circuit ) VENOUS BLOCKS AND BY-PASSING VEINS -Open Vicarious Shunt ( open circuit )
  94. 94. At rest Squizing, Paranà , Wundsdorf: Valvo-muscular Pump VMP Stress Test Ilio-femoro-popliteal TOTAL incompetence Popliteal Vein At rest
  95. 95. Squizing, Paranà , Wundsdorf: Valvo-muscular Pump VMP Stress Test Ilio-femoro-popliteal TOTAL incompetence Systole At rest Popliteal Vein
  96. 96. At rest Squizing, Paranà , Wundsdorf: Valvo-muscular Pump VMP Stress Test Ilio-femoro-popliteal TOTAL incompetence Popliteal Vein Diastole S coequal D
  97. 97. At rest Squizing, Paranà , Wundsdorf: Valvo-muscular Pump VMP Stress Test SEGMENTAL Popliteal Incompetence Popliteal Vein At rest
  98. 98. Squizing, Paranà , Wundsdorf: Valvo-muscular Pump VMP Stress Test SEGMENTAL Popliteal Incompetence Systole At rest Popliteal Vein
  99. 99. At rest Squizing, Paranà , Wundsdorf: Valvo-muscular Pump VMP Stress Test SEGMENTAL Popliteal Incompetence Popliteal Vein Diastole S D peak D < S peak Femoral Valve Closure Decreases the Reflux
  100. 100. At rest Squizing, Paranà , Wundsdorf: Valvo-muscular Pump VMP Stress Test PARTIAL Popliteal Incompetence Popliteal Vein At rest
  101. 101. Squizing, Paranà , Wundsdorf: Valvo-muscular Pump VMP Stress Test PARTIAL Popliteal Incompetence Systole At rest Popliteal Vein
  102. 102. Squizing, Paranà , Wundsdorf: Valvo-muscular Pump VMP Stress Test At rest PARTIAL Popliteal Incompetence Popliteal Vein Diastole S D D peak < S peak D time > S time
  103. 103. At rest Squizing, Paranà , Wundsdorf: Valvo-muscular Pump VMP Stress Test Deep Closed Shunt Example Incompetent Fem-Popliteal V + Competent Collat.V ( may be Deep Fem.) Popliteal Vein Diastole D peak > S peak
  104. 104. At rest Squizing, Paranà , Wundsdorf: Valvo-muscular Pump VMP Stress Test Ilio-femoro-popliteal TOTAL incompetence Great Saphenous vein At rest
  105. 105. Squizing, Paranà , Wundsdorf: Valvo-muscular Pump VMP Stress Test Ilio-femoro-popliteal TOTAL incompetence Systole At rest Popliteal Vein
  106. 106. At rest Squizing, Paranà , Wundsdorf: Valvo-muscular Pump VMP Stress Test Ilio-femoro-popliteal TOTAL incompetence Popliteal Vein Diastole S coequal D
  107. 107. Hemodynamic Manoeuvres Upright Position Valsalva: Thoraco-abdominal Pump Stress Test Squizing, Paranà , Wundsdorf: Valvo-muscular Pump Stress Test Supine Position Venous Pressure: Veins Patency Test
  108. 108. Venous Pressure Measurement: Veins Patency Test Supine Position Normal ≤ 25 mm Hg Cuff inflation/deflation Posterior Tibial Vein flow
  109. 109. Duplex assessment of venous hemodynamics Lower limbs Venous Networks (N) Dynamic Stress Manoeuvres Hemodynamic Obstacles and Open Vicarious Shunts Hemodynamic Valve Incompetence and Closed/Open Derivate Shunts Protocole Assessment Hemodynamic Mapping
  110. 110. Hemodynamic Obstacles The hemodynamic significance of a block in terms of drainage quality is inversely proportional to the collateral compensatory veins developing
  111. 111. N1 N2 N3 N4L N4T Collectors: N2 -N1: SFJ, SPJ N3 -N1: Perineal V P Point Rd Ligt V I Point Clit. V C Point Obt. V O Point I Glut.V IG Point S Glut. V SG Point Internetworks connections Perforators: N2 -N1: saphenous truncks→deep Veins N3 -N1:Saphenous tributaries and others→deep Veins Connectors: N2 –N2: saphenous truncks N3 -N1:Saphenous tributaries and others
  112. 112. N1 N2 N3 N4L N4T Collectors: N2 -N1: SFJ, SPJ N3 -N1: Perineal V P Point Rd Ligt V I Point Clit. V C Point Obt. V O Point I Glut.V IG Point S Glut. V SG Point Internetworks connections Perforators: N2 -N1: saphenous truncks→deep Veins N3 -N1:Saphenous tributaries and others→deep Veins Connectors: N2 –N2: saphenous truncks N3 -N1:Saphenous tributaries and others
  113. 113. Draining network from skin to suprafascial veins (Network 3) then intrafascial veins (Network 2) then deep subfascial veins (Network 1) Common Femoral Vein Great Saphenous Arch Anterior Saphena Deep Femoral Vein Great Saphenous Trunk Superficial Femoral Vein Giacomini Vein Small Sahenous Arch Popliteal Vein Small Sahenous Trunk N2 N3 N4L N4T 1988 N1
  114. 114. Dynamic manoeuvres Valsalva manoeuvres Active calf pump test Passive calf pump test Networks N1,N2,N3,N4 Obstacle assessments Dynamic Obstacle assessments Demodulatlion collateral by-pass doppler ankle pressure Anatomic Obstacle assessments Color Compression
  115. 115. Assessment protocole Mapping Strategies Tactics Valve competence assessment Valve incompetence assessment : value SHUNTS: venous segment overloaded by extra volume/pressure fed by Escape points and redirected into Re-entry points : Sapheno-femoral junction Sapheno-Popliteal junction Pelvic leak points Perforators Open vicarious shunts Open derivating shunts Closed shunts superficial : type 1 to 6 deep Mixt shunts
  116. 116. N1 N2 N3 N4L N4T Collectors: N2 -N1: SFJ, SPJ N3 -N1: Perineal V P Point Rd Ligt V I Point Clit. V C Point Obt. V O Point I Glut.V IG Point S Glut. V SG Point Internetworks connections Perforators: N2 -N1: saphenous truncks→deep Veins N3 -N1:Saphenous tributaries and others→deep Veins Connectors: N2 –N2: saphenous truncks N3 -N1:Saphenous tributaries and others

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