rolul US Doppler in depistarea refluxului venos in insuficienta venoasa

1. Refluxul venosRefluxul venos
Alexandru Andritoiu
Spitalul Militar Craiova

2. Anatomia venoasaAnatomia venoasa
o noua taxonomieo noua taxonomie
Mozes G, Gloviczki P. New discoveries in anatomy and new terminology of leg veins: clinical implications.
Vasc Endovasc Surg 2004; 38:367-74.121
Supra/infrainghinale
Supra/infrageniculare

3. Jonctiunea S-FJonctiunea S-F
• Vv pudendale
• V. epigastrica
inferioara
• V. iliaca circumflexa
• Vv. safene accesorii
Von Lantz T, Wachsmuth W. Praktische Anatomie, Springer, Berlin, 1959, I

4. Jonctiunea S-PJonctiunea S-P

5. Hemodinamica venoasaHemodinamica venoasa
• Aprox. 75% din sangele circulant este
distribuit prin sistemul venos
• Intelegerea mecanismelor prin care
sangele venos se intoarce spre inima
este cruciala in intelegerea fiziologiei
sistemului vascular venos

6. Fiziologia fluxului venosFiziologia fluxului venos
Intoarcenea venoasa este guvernata de
• Presiunea arteriala
• Pompa musculo-venoasa
• Gravitatia
• Pompa toraco-abdominala
• Valvele venoase (pompa valvo-
musculara)

7. Distributia anatomica a sistemului venosDistributia anatomica a sistemului venos
1. Tegument
2. Fascia superficiala
3. Fascia musculara
4. Compartimentul profund
5. Compartimentul v. safene (interfascial)
6. Compartimentul subcutanat (vv colaterale sau tributare)
R (N) 3- colaterale
R (N) 2- vv safene- Giacomini
R (N) 1- vv profunde

8. Directia fluxului normalDirectia fluxului normal
(curgere ierarhica)(curgere ierarhica)
R 3R 3 R 2R 2 R1R1
perforante
tributare
(comunicante)

9. Directia fluxului incompetentDirectia fluxului incompetent
R 3R 3 R 2R 2 R1R1
perforante
tributare
(comunicante)

10. Fluxul normal vs IncompetentFluxul normal vs Incompetent
Fluxul venos normal
Directie cefalica
Dinspre superficial spre profund
Fluxul venos incompetent
Directie retrograda
Dinspre profund spre superficial

11. Fiziologia IVCFiziologia IVC
• Afectarea pompei musculare
• Obstructie Venoasa
• Incompetenta valvulara
1. Incompetenta perforantelor
2. Incompetenta vv superficiale (safene)
3. Incompetenta vv profunde

12. John BERGAN, MD
The Vein Institute of La Jolla
Department of Surgery
UCSD School of Medicine La Jolla, CA, USA
MEDICOGRAPHIA, VOL 30, No. 2, 2008

13. Tipuri de valve venoaseTipuri de valve venoase
A). unicuspid B) bicuspid C) tricuspid D) quaricuspid

14. Classification of valvular lesions
• Functional valve lesions (type I)
• Traumatic organic valve lesions (type II)
• Inflammatory organic lesions (type III)
• Valvular vestiges (type IV)

15. Functionarea normalaFunctionarea normala
vs anormala a valvelor venoasevs anormala a valvelor venoase

16. Despre reflux…Despre reflux…
• Refluxul in vv superficiale (safene si
tributare)–cea mai frecventa anomalie
fiziologica la pacientii cu CVD.
• Flux retrograd
-axial/segmentar
-multilevel/multisystem
-spontan/provocat
-descendent/ascendent

17. Metode de diagnostic non-invaziv inMetode de diagnostic non-invaziv in
evaluare RVevaluare RV
1. Fotopletismografia
2. Pletismografia cu aer
3. Flebografia descendenta
4. Duplex scan
5. B-flow
6. CEUS (in studiu)
Saliba O et al. J Vasc Bras. 2007;6(3):266-75.
Testele sunt complementare

18. Teste de stress efectuateTeste de stress efectuate
ptr evidentierea RVptr evidentierea RV
• Manevra Valsalva (activeaza pompa toraco-
abdominal)-variante
• Augmentatia manuala distala
• Augmentatia distala cu pompa de presiune
automata (automatic pressure cuff)
• Activarea pompei musculare gambiere prin
flexie plantara
• Manevra Parana

19. Pozitia pacientului ptrPozitia pacientului ptr
evaluarea RVevaluarea RV
• Verticala (standing)
• Reverse-Trendelemburg (RT)
• Decubit dorsal (No!-doar ptr diagn. trombozei)

20. Pozitia pacientului in timpul examinariiPozitia pacientului in timpul examinarii
sistemului venos superficialsistemului venos superficial
(A) Examinarea VSM (B) Examinarea VSm

21. Augmentation/Compresie distalaAugmentation/Compresie distala
Neil M. Khilnani, Robert J. Min. Seminars in Interv Radiology, 2005;(22):3

22. VenaPulse Hands-Free Augmentation Device

23. Cuff measurements were more accurate in diagnosing
deep venous reflux than manual measurements, and
more reproducible

25. Vena competenta vs incompetentaVena competenta vs incompetenta
A) v. competenta B) V. incompetenta

26. Duplex sampling sitesDuplex sampling sites
• The patient below
demonstrates primary
varicose veins in the
GSV territory with
several tributaries.
• Arrows indicate the
few locations which
need to be tested.
Necas M. AJUM 2010; 13 (4): 37–45

27. Diagrama refluxuluiDiagrama refluxului
Mapping venos superficial

28. J Vasc Surg 2005;41:645-51

29. RV in VSm (pattern-uri)RV in VSm (pattern-uri)
Engelhorn C et al. J Vasc Surg 2005;41:645-51

30. RV in VSmRV in VSm

31. Forma anvelopei RVForma anvelopei RV

33. Gradele duratei RV siGradele duratei RV si
Peak Reverse Flow VelocityPeak Reverse Flow Velocity
Danielson G et al. J Vasc Surg 2003;38:1336-41
Peak reverse flow velocity seems to reflect venous malfunction more appropriately

34. 590 mm. infer.590 mm. infer.
326F-CEAP 2326F-CEAP 2
Reflux detectat in 80%
• 17% reflux in VSM si VSm,
• 60% reflux numai in VSM,
• 3% reflux numai in VSm,
Prevalenta totala:
- 77% in VSM
- 20% in VSm
Engelhorn C et al. J Vasc Surg 2005;41:645-51

35. Unde incepe RV? (escape points)Unde incepe RV? (escape points)
• RV poate apare in oricare dintre vv superficiale sau
profunde la pacienti asimptomatici sau cu varice
proieminente
• infra-supragenicular
• RV local sau multifocal
• RV axial sau segmentar
Labropoulos N et al. J Vasc Surg 1997;26:736-42.)

36. Sursele refluxuluiSursele refluxului
Diametrul v safene scde distal de o tribura incompetenta
(urmareste prezenta v. safene in compartiment)

37. Axial ultrasound image of great saphenous vein (Axial ultrasound image of great saphenous vein (asterisk)asterisk) inin
saphenous compartment and adjacent tributary (saphenous compartment and adjacent tributary (arrowheadarrowhead))
superficial to saphenous compartmentsuperficial to saphenous compartment
KhilnaniN M. AJR 2014; 202:633–642

38. Variabilitatea undelor de refluxVariabilitatea undelor de reflux

39. Progresia refluxuluiProgresia refluxului

40. Efectul temporal asupraEfectul temporal asupra
refluxuluirefluxului
• Tarrant G, Clark, J et al. Differences in Venous Function of the
Lower Limb by Time of Day: A Comparison of Chronic Venous
Insufficiency Between and Afternoon and Morning Appointment by
Duplex Ultrasound. J.Vasc. Ultrasound 2008;32(4):187-192.
• Zamboni, P, Cisno, C et al. Reflux Elimination without and Ablation
of Disconnection of the Saphenous Vein. A Haemodynamic Model for
Venous Surgery: Eur J Vasc Endovasc Surg 2001; 21: 261-369
• Meissner,M, Moneta, G,et al. The hemodynamics and diagnosis of
venous Disease. J Vasc Surg 2007; 46:4S-24S
INVEST STUDY: Reports should include time of day,
patient position and reflux provoking maneuver used

41. J Vasc Surg 2012;55:437-45
• Standardization of duplex ultrasound detection of venous
reflux can improve reliability.
• Reports should be standardized to include information on
the time of the test, the position of the patient, and
the provoking maneuver used.
• The repeated scans can be performed in the same settings,
improving reliability.
• Adopting a uniform criterion of 0.5 second for pathologic
reflux can significantly improve the reliability of reflux
measurement and interpretation.

42. RV primar superficial asociat cu trunchiRV primar superficial asociat cu trunchi
safen competentsafen competent
Labropulous N. Eur J Vasc Endovasc Surg 1999 (18): 201–206

43. Originea refluxului inaltOriginea refluxului inalt
• JSF
• Tributare ale JSF
• VSAA
• Originea pelvina
• Vv varicoase supra-pubiene
• Ileo-femurale

44. RV Profund vs SuperficialRV Profund vs Superficial
A) Single system/multilevel reflux (only superficial)
B) Multisystem/multilevel reflux (deep and superficial)
Neglen P.et al. J Vasc Surg 2004;40:303-310

45. Semnificatia RV profundSemnificatia RV profund
• Localizarea si gradul RV sunte elemente
cruciale in stabilirea managementului clinic al
pts. cu CVI.
• Refluxul in sistemul venos profund joaca un
rol major in progresia IVC spre ulcer venos.
• Refluxul venos in sistemul profund se
asociaza stadiilor avansate CEAP si Sdr post-
trombotic.
Welch H et al. J Vase Surg 1996;24:755-62

46. Refluxul profund (axial)Refluxul profund (axial)
un important contributor la aparitiaun important contributor la aparitia
tulburarilot trofice cutanate (ulcer) in IVCtulburarilot trofice cutanate (ulcer) in IVC
• Continuous axial deep venous reflux is a major
contributor to increased prevalence of skin changes
or ulcer in patients with chronic venous disease
compared with segmental deep venous reflux above
or below the knee only.
• The total peak reverse flow velocity score is
significantly higher in patients with skin changes or
ulcer.
Danielson G et al. J Vasc Surg 2003;38:1336-41

47. RV in venele perforanteRV in venele perforante
• Refluxul in VvP apare numai in prezenta unor vv
superficiale incomptenete care actioneaza ca un
capacitor pentru refluxul provenit din perforante.
• VV P incompetemnte au calibru marit peste 3,5 mm
ca o consecinta a cresterii presiunii venoase
hidrostatice.
• Fluxul este bidirectional
• Prevalenta VvP insuficiente creste odata cu agravarea
clinica a CVD (CEAP 4-6)-2/3 pts
Labropoulos N et al. J Vasc Surg 2006;43:558-62

48. Locatia VV perforanteLocatia VV perforante

49. V. perforanta cu refluxV. perforanta cu reflux
Chander RK, Monahan TS. Journal of Vascular Diagnostics 2

50. Progresia RVProgresia RV
• Aprox. 1/3 dintre pts cu RV au o evolutie
progresiva a CVD–evaluare dupa 6 Mo.
• Pts. supusi unui tratament venos trebuie
reevaluati prin CDUS exam.
Labropoulos N et al. J Vasc Surg 2005;41: 291-5

51. Cauzele de recurenta a
varicelor
Refluxul in vv pelviene (ovariene, iliace interne)
• 25-30% dintre femeile care au nascut
• frecv. neinvestigat inainte de interventie (CDUS TV)
Tratament suboptimal
• Reflux in JSF, Vv. Perforante, vv tributare, vv. accesorii
• Neovascularizatie in aria tratata
• Refluxul venos rezidual dupa ablatia v. safene nu se
asociaza cu riscul de recurenta a ulcerului venos
Whiteley A et al. J Vasc Surg: Venous and Lum Dis 2014;2:411-5.
Kulkarni S et al. Eur J Endovasc Surg 2007;34,107-111
Stonebridge et al. Br J Surg 1995

52. RV si relatia cu ulcerul venosRV si relatia cu ulcerul venos
• Ulcerul venos se asociaza mai frecvent cu
• refluxul in vv infrageniculare decat
suprageniculare
• refluxul multisistemic/multilevel
• refluxul in sistemul profund si vv
perforante (sdr post-trombotic)
• v. perforanta dilatata si incompetenta
adiacenta ulcerului

54. Vascular Health and Risk Management 2012:8 59–64

55. Venous segmental disease score
(Based on venous segmental involvement with reflux)
Rutherford RB, Padberg FT Jr, Comerota AJ, Kistner RL, Meissner MH, Moneta GL.
Venous severity scoring: an adjunct to venous outcome assessment. J Vasc Surg 2000;31:1307-12.

56. • Varicose Vein AblativeProcedures:
Thermal ablation, stripping, ligation and excision of the great saphenous vein and small saphenous veins are
considered reconstructive and medically necessary when ALL of the following criteria are present (1, 2, 3 and 4):
1. Junctional Reflux
a. Ablative therapy for the great or small saphenous veins will be considered reconstructive and therefore medically necessary only if
junctional reflux is demonstrated in these veins;
b. Ablative therapy for accessory veins will be considered reconstructive and medically necessary only if anatomically related
persistent junctional reflux is demonstrated after the great or small saphenous veins have been removed or ablated.
2. Member must have one of the following functional impairments:
a. Skin ulceration; or
b. Documented episode(s) of frank bleeding of the varicose vein due to erosion of/or trauma to the skin; or
c. Documented superficial thrombophlebitis or documented venous stasis dermatitis; or
d. Moderate to severe pain causing functional/physical impairment.
Venous Size:
The great saphenous vein must be 5.5 mm or greater when measured at the proximal thigh immediately below the saphenofemoral
junction via duplex ultrasonography
b. The small saphenous vein or accessory veins must measure 5 mm or greater in diameter immediately below the appropriate
junction.
4. Duration of reflux, in the standing or reverse Trendelenburg position that meets the following parameters:
a. Greater than or equal to 500 milliseconds (ms) for the great saphenous, small saphenous or principle tributaries
b. Perforating veins > 350 ms
c. Some duplex ultrasound readings will describe this as moderate to severe reflux which will be acceptable.

57. Duplex US in ghidajul ablatiei termice aDuplex US in ghidajul ablatiei termice a
Vv Safene (RFA/EVLA)Vv Safene (RFA/EVLA)
• CDUS-identificarea accesului
venos la cel mai decliv nivel de
reflux evidentiat in trunchiul
safen incompetent.
• Cel mai frecvent, RV al VSM
apare in regiunea subinghinala si
coboara spre gamba unde fuge
spre o tributara din care
rezulta segmentul varicos. In
acest caz, accesul venos este
stabilit la locul abusarii
tributarei.

58. Echipa Sp. Clinic Militar Craiova
Dr Silosi Cristian
Dr Alexandru Andritoiu
Ablatia prin RF a vv safene

59. The Hemodynamic MappingThe Hemodynamic Mapping
CHIVA method- identification of Shunts in order to plan their disconnection

60. Shunturile veno-venoaseShunturile veno-venoase
Circuite venoase anormale intre diferitele compartimente
• profund-superfical
• safene –tributare
• Shunt inchis
• Shunt deschis
• Shunt vicarios
• Shunt sistolic/diastolic/sistolo-diastolic
• Puncte de scapare
• Puncte de reintrare (P)

61. Shunt tip 1 (30%)Shunt tip 1 (30%)
• RV incepe la JSF avand
reintrare printr-o v.
perforanta care leaga
teritoriul safen de sistemul
profund.
• O v. tributara cu reflux
poate fi adesea descoperita
• v. perforanta este situata
distal de originea tributarei.
• Caracteristic, diametrul v.
safene scade sub originea
tributarei incompetente in
timp ce refluxul persista
pana la locul de reintrare.

62. Shunt tip 3 (60%)Shunt tip 3 (60%)
• RV incepe la JSF si
progreseaza spre o v.
tributara avand punctul
de reintrare in sistemul
venos profund via v.
perforanta in vena
tributara.
• In acest caz, lipseste
refluxul distal de v.
tributara incompetenta.
90% dintre pts prezinta tipul 1 si 3 de shunt veno-venos

63. DiferentiereaDiferentierea
Shunt-ului tip 1 vs 3Shunt-ului tip 1 vs 3

64. ConcluziiConcluzii
Duplex scan venos:
• evaluare anatomica
• evaluare hemodinamica
• mapping venos superficial si profund
• RV o componenta cruciala in stabilirea
managementului terapeutic al pts. cu
CVD
• RV multilevel/multisystem asociat std.
4-6 CEAP