Joseph Zygmunt, Jr. discusses the significance of duplex ultrasound as the standard for assessing deep venous disease, highlighting its role in evaluating the deep venous system and detecting conditions like DVT and insufficiency. He notes changes in treatment approaches, emphasizing the importance of early intervention to prevent complications such as post-thrombotic syndrome. The document also outlines diagnostic criteria, examination techniques, and key anatomical aspects relevant to deep venous assessments.

1. Disclosure
Joseph Zygmunt, Jr., RVT, RPhS
I disclose the following financial relationship(s):
•Employment: Covidien Inc.

2. Detecting Deep Venous Disease
with Duplex Ultrasound
Joseph Zygmunt, Jr. RVT, RPhS
IVC 2011

3. “Duplex Ultrasound has become the reference standard in
assessing the morphology and hemodynamics of the
lower limb veins”
 Coleridge-Smith et al. Duplex Ultrasound Investigation of the
Veins in Chronic Venous Disease of the Lower Limbs – UIP
Consensus Document. Part I Basic Principles. Eur J Vasc
Endovasc Surg 2006.
 Cavezzi et al. Duplex Ultrasound Investigation of the Veins in
Chronic Venous Disease of the Lower Limbs – UIP Consensus
Document. Part II Anatomy. Eur J Vasc Endovasc Surg, 2006
“Duplex Ultrasound is the most significant contribution
made to Phlebology in the last ten years”
~Dr. Hugo Partsch 2004
Deep Veins …….Some ask: Why Bother?

5. Deep Venous System
 Examination of the deep venous system is considered an
essential step in the evaluation of ANY phlebology patient
 Primary system for venous return to the heart
 Examination the superficial system only is inadequate
 Evaluate for DVT – ( acute, sub-acute and chronic)
 Evaluate for insufficiency (axial or segmental deep)
Change in Dogma -
 Deep disease is no longer the “kiss of death”
 Early intervention and clot load removal

6. IVUS
 Iliac vein obstruction ubiquitous and often silent
in general population
 C3-C6 patients with primary and postthrombotic
CVI - >90% with IVUS
 Early restoration of iliac vein patency in the
acute phase is becoming the norm to prevent
post thrombotic syndrome
Lurie et al, Invasive treatment of deep venous disease,
a UIP consensus; Int Angiol 2010; 29:199-204

7. Anatomy : Deep System
 Tibial
–Anterior
–Posterior
 Peroneal
 Gastrocnemius
 Popliteal

8. Anatomy : Deep System
 Popliteal
 Femoral Vein (of the thigh)
– NOT SFV
 Deep (profunda)Femoris
 Common Femoral Vein
 External Iliac
 Duplications in the FV and POP
can result in missed DVT

9. Patient Position
 Hip slightly rotated
 Supine (slight tilt on
table)
 Incorrect positioning
can lead to inaccurate
assessment
 Consider: ergonomics!

10. Deep System Diagnostic Criteria
Three complementary modes

11. Common Femoral Vein
Normal Findings – good compressibility
Split screen documentation

12. Femoral Vein
not superficial femoral vein

13. Popliteal Vein
Note: vessel orientation

14. Post. Tibial and
Peroneal Veins
Paired in calf
Anterior Tibial: omitted routinely

15. External Compression
performed every 1-2 cm
along entire length of vein
90º to vein
(anterior and posterior
approach)
Don’t bounce the probe –
Use a slow deliberate
compression technique
Confirmation with other
modalities

16. Multiple Views to fully understand the pathology

17. DVT RT CFV

18. Spectral Doppler
 Spectral Doppler
 Spontaneous flow
 Phasic flow with respiration (large veins)
cease with deep breath inspiration
 Flow also ceases with the Valsalva
maneuver
 Flow augmentation with distal compression
 Unidirectional flow (toward the heart)
 Non-pulsatile
 Importance of contralateral CFV analysis

19. Valsalva:
“ a well performed Valsalva maneuver detects significant reflux
in major veins until a competent valve is detected.….
Like descending venography, detection of reflux distal to
competent valves may not be detected with these
techniques”
Talbot, S Vascular Ultrasound Today 9(1): 1-28, 2004

20.  A continuous venous waveform is abnormal –
recommend study of proximal veins
Normal
phasic

21. Normal Color Doppler
Femoral Vein
thigh
Venous Confluence
Color images in long axis to document patency of vein

22. Color Doppler Abnormal
Incomplete filling – no color = no flow

23. Case Study: Partial Compression
What about the spectral doppler?
Whats
going
On?

24. Rt CFV Continuous Flow

25. Walking Doppler
Venous Stenosis

26. Contralateral Comparison
infra inguinal clues
Full Easy Compression Contralaterally

27. Report: What to document
Transverse Gray Scale Spectral Wave Forms
CFV, SFJ Right and Left CFV
Prox, Mid, and Distal FV
Pop V Pop V
Post Tib V
Peroneal V
additional images as needed
additional as per protocol additional as per protocol
*iliacs, GSV, SSV, prox Profunda, gastrocs, soleals, ant tibs,
Perfs
ICAVL Imaging Standards 2010
Protocol: DVT

28. Deep Reflux vs Siphon affect?
Is deep reflux segmental or axial?

29. Thank You For Your Attention
joseph.zygmunt@covidien.com