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- 1. Stefano Ermini MD Firenze Considerations about the valve competence tests
- 2. To be US detected, there must be an increase in speed of the venous flow To increase the venous flow speed we must create a pressure gradient. Pressure Gradient = Force directed from high to low pressure. The change in pressure measured across a given distance is called a "pressure gradient".
- 3. Considerations about applying a pressure gradient to the venous system A flow originates in a competent system only if the pressure gradient has the same valve direction If there is no valve competence, the flow has the same direction as the pressure gradient. When the patient is standing , a force is also represented by the hydrostatic pressure
- 4. A pressure Gradient may be Propulsive and/or Aspirative B A B A Propulsive Aspirative Force of the gradient Muscle Pump Systole (contraction) Muscle Pump Dyastole (relaxation) or Manual Compression/release Force of the gradient Increasing Decreasing B A Force of the gradient Valsalva Manouvre Increasing
- 5. Pressure Flow Pressure Flow - + + - X X Relaxed breathing in a standing position Valsalva Manouvre : 1)Forced Inspiration 2)Blocked expiration 1) Applyng force like that of a bowel movement 2) Blowing into a closed straw ( Franceschi)
- 6. Resting Valsalva ( Clamp effect) The residual Venous Pressure creates an increase in pressure and venous diameter Valsalva Manouvre in a Normal Subject
- 7. Valsalva Manouvre in SFJ incompetence Situation A ( Without Femoro-Iliac valve) Situation B ( With Femoro-Iliac valve)
- 8. Manual Calf Compression ( Squeezing) - Systolic Phase LSV Incompetence Compression Area of Blood Mobilization
- 9. Manual Calf Compression ( Squeezing) - Dyastolic Phase LSV Incompetence RelaxationEmptied Zone
- 10. Active Muscle pump activity - Systolic Phase LSV Incompetence Area of Blood Mobilization
- 11. Active Muscle pump activity - Dyastolic Phase LSV Incompetence Emptied Zone
- 12. Point A Point B Gradient Line Squeezing Test : The Gradient only involves superficial veins Gradient Line
- 13. Point A Point B Dynamic Tests : The Gradient involves superficial veins, perforators and deep veins Gradient Line Time duration of centrifugal flow = Time of gradient exaustion
- 14. Dynamic tests are still not accepted by the international community The most well-known dynamic test is the Paranà Manouvre, described by Claude Franceschi in 1998. To check its validity, I have compared this manouvre with the squeezing test in the following patient series/situations : A. Popliteal vein in healthy subject - 20 patients B. Incompetent SFJ , with incompetent terminal v., in varicose veins - 13 patients C. Incompetent saphenous axis 15 cm below the groin in cases with an incompetent terminal valve - 13 patients D. Re-entry perforators in varicose veins subjects - 11 patients
- 15. Both the Paranà Manouvre and the Squeezing Test are not mechanical tests but their results depend on a series of variables: For the Squeezing Test: Manual compression strength Muscle contraction / relaxation level while the patient is standing Leg volume For the Paranà Manouvre Pushing force Muscle contraction / relaxation level while the patient is standing A support point for the patient
- 16. PullPush A B
- 17. The force applied, produces a flow movement , that in an arc of time reaches the maximum speed that decreases later. The increase of speed in an arc of time is called “ acceleration” .
- 18. Paranà and Squeezing test in a healthy Popliteal Vein Area= (Speed xTime A /2) + (Speed x Time B/2) Acceleration = Max Speed/Time A Max Speed Time A Time B Time A Time B Max Speed
- 19. Squeezing and Paranà in an incompetent Saphenous Trunk Speed A Time B Time A Speed B Area A = ( Speed A x Time A )/2 Area B =( Speed B x Time B)/2 Time A Time B Max Speed A Max Speed B
- 20. To determine if the average variation is similar in the squeezing test and the Paranà manouvre group we have calculated the acceleration and its “Standard Deviation”. Standard Deviation shows how much variation from the average exists. A. The Paranà manouvre and Squeezing test have some variables that change the final result B. The energy applied to the venous system gives origin to a flow acceleration that is detected by the US. We have said that: The higher the standard deviation, the lower the test accuracy
- 21. Examinations done Vein examined Number of cases Total measurements done Popliteal vein in healty subjects 20 patients 120 measurements Incompetent SFJ 13 patients 156 measurements Incompetent LSV axis 13 patients 156 measurements Re-entry perforators 11 patients 143 measurements TOTAL 57 patients 575 measurements One of the Excel spread sheet
- 22. Mean ( μ ) Coefficient of variation C V Standard Deviation ( 𝞂 ) Squeezing Acceleration Paranà Acceleration Healthy Popliteal Vein
- 23. Average Squeezing Average Paranà 𝞂 Squeezing 𝞂 Paranà Healthy Poplitea 0,19 0,13 0,06 0,07 Incompetent SFJ 0,06 0,11 0,02 0,14 Incompetent GSV 0,06 0,04 0,04 0,02 Re-Entry Perforator 0,07 0,03 0,04 0,01 In the Paranà group standard deviation is similar or lower than in the squeezing group. This means that the Paranà manouvre is more accurate than the squeezing test. Standard deviation (𝞂 )
- 24. Popliteal Vein in Healthy subjects ( 20 cases) Squeezing Paranà Tempo A (ms) 379 593 Tempo B 349 546 Max Speed cm/sec 68 72 Area 25033 41657 Area : In 3 cases the squeezing test moves 10% more than the Paranà In 17 cases the squeezing test moves 40% less than the Paranà Area measurement
- 25. Incompetent Saphenous Axis Squeezing Paranà Time A 501 571 Speed A 45 26 Area A 12683 9695 Time B 4332 7881 Speed B 35 40 Area B 66533 144392 SystolicEventsDiastolicEvents The centrifugal relaxation ( diastolic) flow is more than double in the Paranà compared to the squeezing test
- 26. Incompetent SFJ Squeezing Paranà Time A 751 1078 Speed A 45 34 Area A 16100 18502 Time B 2269 5808 Speed B 43 71 Area B 48597 185478 SystolicEventsDiastolicEvents The centrifugal relaxation ( diastolic) flow is more than triple in the Paranà compared to the squeezing test
- 27. Re-entry perforator Squeezing Paranà Time A 468 764 Speed A 28,35 26,08 Area A 6605 10722 Time B 1488 4861 Speed B 22,76 45,96 Area B 19057 92476 SystolicEventsDiastolicEvents The centrifugal relaxation ( diastolic) flow is more than four times greater in the Paranà.
- 28. Conclusions Standard deviation acceleration shows that the Parana manouvre is more accurate than the squeezing test. In healthy subjects the Paranà manouvre moves 40% more blood than in the squeezing test. In incompetent systems, the diastolic phase of the Paranà manouvre’s flow lasts 3 times longer than the squeezing test. The Parana manouvre is more accurate and more effective than the squeezing test.
- 29. Thanks for your attention Stefano Ermini MD
- 30. PullPush A B
- 31. Paranà Test versus Toe Standing Test in the Popliteal Vein in Healthy subjects ( 20 cases) Toe standing Paranà Tempo A (ms) 343 561 Tempo B 332 549 Max Speed cm/sec 109 70 Area 36155 39172 Accelerazione 0,34 0,13
- 32. Valsalva Manouvre in deep vein incompetence Situation A ( Without VV Shunt) Situation B ( With VV Shunt)
- 33. Corso di Flebologia Emodinamica e Linfologia Con sessioni teorico-pratiche Università di Camerino direttore e vicedirettore : Amenta-Bernardini docenti: Bernardini-Cappelli-Ermini- Castagnoli-Moretti
- 34. Push Support point for the patient

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