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Mapeamento de varizes

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Mapeamento de varizes

  1. 1. AVALIAÇÃO DA INSUFICIÊNCIA VENOSAAVALIAÇÃO DA INSUFICIÊNCIA VENOSA DOS MEMBROS INFERIORESDOS MEMBROS INFERIORES PELO DUPLEX COLORIDOPELO DUPLEX COLORIDO
  2. 2. OBJETIVO DO EXAME • Verificar se há incompetência das croças das safenas e seus diâmetros • Avaliar a extensão do refluxo nas safenas e os diâmetros dos segmentos insuficientes • Verificar se há perfurantes insuficientes, seu número e sua localização • Avaliar outras veias relevantes que apresentem refluxo • Verificar a fonte que preenche as varizes superficiais • Atentar para veias hipoplásicas, atrésicas, ausentes ou que tenham sido removidas • Avaliar o estado do sistema venoso profundo quanto a insuficiência valvular e sinais de TVP prévia Eur J Vasc Endovasc Surg 2006;31:83-92
  3. 3. ANATOMIA DO SISTEMA VENOSO Divisão das veias do membro inferior – Sistema venoso profundo – Sistema venoso superficial – Sistema de veias perfurantes J Vasc Surg 2002;36(2):416-22
  4. 4. ANATOMIA DO SISTEMA VENOSO
  5. 5. ANATOMIA DO SISTEMA VENOSO – Sistema venoso profundo  Veias da coxa:  Femoral comum, femoral (superficial), femoral profunda  Veia poplítea  Veias da perna:  Fibulares, tibiais posteriores e anteriores  Gastrocnemias e soleares J Vasc Surg 2005;41(4):719-24 J Vasc Surg 2002;36(2):416-22
  6. 6. ANATOMIA DO SISTEMA VENOSO – Sistema venoso superficial  Veia safena magna  Veia safena parva  Veias safenas acessórias na coxa e perna  Veias tributárias da junção safeno-femoral  Veia de Giacomini e extensão cranial da veia safena parva  Sistema venoso lateral  Rede venosa do pé Eur J Vasc Endovasc Surg 2006;31(1):83-92 J Vasc Surg 2005;41(4):719-24 J Vasc Surg 2002;36(2):416-22
  7. 7. ANATOMIA DO SISTEMA VENOSO – Sistema de veias perfurantes  Veias perfurantes da perna  Veias perfurantes da coxa  Veias perfurantes do joelho  Veias perfurantes glúteas  Veias perfurantes do tornozelo  Veias perfurantes do pé J Vasc Surg 2005;41(4):719-24 J Vasc Surg 2002;36(2):416-22 Nectoux Filho, JL. Ultra-sonografia vascular. Revinter, Rio de Janeiro, 2000
  8. 8. ANATOMIA DO SISTEMA VENOSO
  9. 9. ANATOMIA DO SISTEMA VENOSO
  10. 10. ANATOMIA DO SISTEMA VENOSO – Nomenclatura tradicional  Perfurantes de Cockett Comunicação entre a safena magna e as veias tibiais posteriores Localizadas na face medial da perna Distância da superfície plantar: Cockett I: 7 +/- 1 cm Cockett II: 13,5 +/- 1cm Cocket III: 18,5 +/- 1 cm
  11. 11. ANATOMIA DO SISTEMA VENOSO – Nomenclatura tradicional  Perfurantes de Sherman Localizada na face medial da perna cerca de 24 cm acima da superfície plantar
  12. 12. ANATOMIA DO SISTEMA VENOSO – Nomenclatura tradicional  Perfurantes de Boyd Localizada na face medial da perna cerca de 10 cm abaixo do joelho
  13. 13. ANATOMIA DO SISTEMA VENOSO – Nomenclatura tradicional  Perfurantes de Hunter Localizada na face medial do terço distal da coxa Comunica a safena magna e a veia femoral
  14. 14. ANATOMIA DO SISTEMA VENOSO – Nomenclatura tradicional  Perfurantes de Dodd Localizada na face medial do terço proximal da coxa Comunica a safena magna e a veia femoral
  15. 15. ANATOMIA DO SISTEMA VENOSO – Nomenclatura tradicional  Perfurantes de May Localizada na face posterior do terço médio da perna Comunica a safena parva e as veias profundas da perna
  16. 16. FISIOLOGIA DO SISTEMA VENOSO – “Vis a tergo” – bomba da panturrilha ou coração periférico – Válvulas venosas – Alterações pressóricas: intra-abdominal e intra-torácica – Tônus vascular J Vasc Interv Radiol 2003;14(10):1233-1241 Browse NL et al. Doenças venosas. 2a ed. DiLivros, Rio de Janeiro, 2001
  17. 17. Stritecky-Kähler T. Cirugía de las venas varicosas. Marban, Madrid, 1997 PATOFISIOLOGIA
  18. 18. EPIDEMIOLOGIA – ÚLCERA VARICOSA – ↑ 80% das úlceras de perna – Prevalência – 0,06% a 2% – 2,5 milhões de americanos – 500 mil c/ úlcera – Custo tratamento (EUA) - $ 1,9 a 2,5 bilhões J Am Acad Dermatol 2001;44(3):401-21 J Vasc Surg 1996;24(5):800-8
  19. 19. AVALIAÇÃO CLÍNICA Classificação da Doença Venosa Crônica Classificação CEAP – American Venous Forum (Hawai,1994) – Classificação Clínica (C0-6) – Classificação Etiológica (EC, EP, ES) – Classificação Anatômica (AS,D,P) – Classificação Patofisiológica (PR,O) J Vasc Surg 1995;21(4):635-45
  20. 20. AVALIAÇÃO CLÍNICA Classificação CEAP – Classificação Clínica (C0-6)  Classe 0: s/ sinais de doença venosa  Classe 1: telangectasias, veias reticulares  Classe 2: veias varicosas  Classe 3: edema s/ alteração da pele  Classe 4: alteração da pele  Classe 5: úlcera cicatrizada  Classe 6: úlcera ativa Observação: + A p/ assintomático; + S p/ sintomático J Vasc Surg 1995;21(4):635-45
  21. 21. AVALIAÇÃO CLÍNICA Classificação CEAP – Classificação Etiológica (EC,P,S)  Congênita  Primária  Secundária J Vasc Surg 1995;21(4):635-45
  22. 22. AVALIAÇÃO CLÍNICA Classificação CEAP – Classificação Anatômica (AS,D,P) S – SUPERFICIAL 1. TELANG./V.RETIC. 2. VSM SUPRA-GENIC. 3. VSM INFRA-GENIC. 4. VSP 5. VEIAS NÃO TRONC. D – PROFUNDO 6. VCI 7. V. ILÍACA COM. 8. V. ILÍACA INT. 9. V. ILÍACA EXT. 10.VV.PÉLVICAS 11.VFC 12.VFP 13.VF(SUP) 14.V.POP. 15.VV.TIB.FIB. 16.VV.MUSC. P – PERFURANTES 17.COXA 18.PERNA J Vasc Surg 1995;21(4):635-45
  23. 23. O EXAME COLOR DOPPLER Color Doppler – método de escolha (“Padrão ouro”) para o estudo da anatomia e fisiologia das veias por causa de sua acurácia, reprodutibilidade e natureza não invasiva World J Surg 2002;26(12):1507-11 J Am Acad Dermatol 2001;44(3):401-21 J Vasc Surg 1998;28(5):767-76
  24. 24. O EXAME COLOR DOPPLER Técnica de exame – Aparelho de ultra-sonografia  Color Duplex  Sonda linear de alta freqüência – 7,5-13 MHz (Obs: 3,5-5,0 MHz)  Ajuste para baixo fluxo Eur J Vasc Endovasc Surg 2006;31(1):83-92 SBAVC 2005
  25. 25. O EXAME COLOR DOPPLER Técnica de exame – Posicionamento “O teste de refluxo em pacientes na posição supina deve ser evitado, devendo ser realizado somente na posição ortostática” – Labropoulos et al 2003 J Vasc Surg 2003;38(4):793-98
  26. 26. O EXAME COLOR DOPPLER Técnica de exame – Avaliação do refluxo – Compressão manual – Avaliação da compressibilidade – Tromboflebite J Vasc Surg 1997;26(1):49-52
  27. 27. O EXAME COLOR DOPPLER Técnica de exame
  28. 28. O EXAME COLOR DOPPLER Técnica de exame – Dimensões das veias safenas* –Safena Interna na coxa Até 4,0 mm: Habitual 4,1 a 5,0 mm: Limítrofe >5,0 mm: Ectasiada * Apenas Referência
  29. 29. O EXAME COLOR DOPPLER Técnica de exame – Dimensões das veias safenas* –Safena Externa e Safena Interna na perna Até 3,0 mm: Habitual >3,0 mm: Ectasiada * Apenas Referência
  30. 30. O EXAME COLOR DOPPLER Técnica de exame – Dimensões das veias perfurantes – Ø > 3,5 mm – 90% de refluxo significativo – Sandri et al 1999 – Ø > 3,9 mm – 86% de refluxo significativo – Labropoulos et al 1999 J Vasc Surg 2001;33(4):773-82 J Vasc Surg 1999;30(5):867-75
  31. 31. O EXAME COLOR DOPPLER Técnica de exame – Refluxo valvular –↑ 1,0 s – refluxo significativo – Veias profundas –↑ 1,0 s – refluxo significativo – Veias superficiais –↑ 0,5 s – refluxo significativo – Veias perfurantes
  32. 32. Paciente em decúbito supino •Verificar se há TVP atual ou pregressa •Verificar a junção safeno-femoral – Pesquisar refluxo com Valsalva – Medir o diâmetro •Verificar se há refluxo nas veias femorais – Manobras de Valsalva O EXAME COLOR DOPPLER
  33. 33. Paciente em ortostase •Verificar refluxo em veias profundas – Femorais, poplítea, tibiais e fibular – Manobras de Valsalva – Compressão distal •Verificar novamente a junção safeno-femoral – Pesquisar refluxo com compressão distal •Verificar os trajetos das safenas interna e externa – Manobras de Valsalva – Compressão distal – Medir os diâmetros (terço proximal e distal da coxa, joelho, terço proximal e distal da perna) •Pesquisar perfurantes insuficientes O EXAME COLOR DOPPLER
  34. 34. O EXAME COLOR DOPPLER
  35. 35. ANATOMIA DO SISTEMA VENOSO
  36. 36. O EXAME COLOR DOPPLER
  37. 37. O EXAME COLOR DOPPLER
  38. 38. O EXAME COLOR DOPPLER
  39. 39. O EXAME COLOR DOPPLER
  40. 40. O EXAME COLOR DOPPLER
  41. 41. O EXAME COLOR DOPPLER
  42. 42. O EXAME COLOR DOPPLER
  43. 43. O EXAME COLOR DOPPLER
  44. 44. O EXAME COLOR DOPPLER
  45. 45. O EXAME COLOR DOPPLER
  46. 46. O EXAME COLOR DOPPLER Laudo Relatar os vasos ou trajetos vasculares analisados Descrever os trechos com refluxo significativo, seus pontos de origem e drenagem Relatar os diâmetros Descrever perfurantes insuficientes Localização, distância de pontos de referência e diâmetros. Descrever os vasos com refluxo significativo, sinais de TVP atual ou pregressa no sistema venoso profundo SBACV 2005
  47. 47. O EXAME COLOR DOPPLER Laudo Técnico Ultrasound Quaterly 2001;17(1):3-10
  48. 48. O EXAME COLOR DOPPLER Laudo Técnico Nectoux Filho, JL. Ultra-sonografia vascular. Revinter, Rio de Janeiro,
  49. 49. AGRADECIMENTOS • Dr. José Eduardo Mourão • Dr. David Shigueoka • Dra. Natália Elias • Dr. Sérgio Ajzen

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