By: Joseph Zygmunt, Jr., RVT, RPhS Visit VeinGlobal at http://www.veinglobal.com/ for more presentations and videos on this topic, or for more information on venous disease news, education and research.

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

2. DUPLEX FOR SUPERFICIAL
VENOUS DISEASE
Joseph A. Zygmunt, Jr., RVT, RPhS
IVC 2011

3. Clinical to Duplex Map

4. Key Technique References – Duplex
 Meissner M, et al: The Hemodynamics and diagnosis of venous disease. J
Vasc Surg 2007; 46:4S-24S.
 Coleridge-Smith P, et al Duplex 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;31:83-92
 Cavezzi, A et al: Duplex Investigation of the Veins in Chronic Venous Disease
of the Lower Limbs-UIP Consensus Document. Part II Anatomy. Eur J Vasc
Endovasc Surg 2006; 31:288-299
 Labropoulos, N, et al: Definition of venous reflux in lower extremity veins. J
Vasc Surg 2003; 38:793-8
 Labropoulos, N, et al: Study of venous reflux progression. J Vasc Surg 2005;
41:291-5
 Foldes, M et al: Standing Versus Supine Positioning in Venous Reflux
Evaluation:Journal of Vasc Tech 1991;15(6):321-24. * 70%
 Zygmunt, J : What’s New in Duplex Scanning of the Venous System.
Perspectives in Vasc Surg and Endovasc Therapy 21(2):2009 94-104

5. Superficial vein reflux is the most
common abnormality in patients
with chronic venous disease (CVD).
Reflux in the saphenous veins and their
tributaries has the highest prevalence.
Labropoulos et al. Am J Surg 1995;169:572-4
Labropoulos et al. J Vasc Surg 1996;23:504-10

6. Prevalence of saphenous and non-
saphenous tributary reflux
n %
GSV 111* 65
SSV 33 19
GSV+SSV 12 7
Non-saphenous veins 15 9
Total 171 100
*p<0.0001 for all comparisons

7. Reflux Vein Mapping
RPhS – Registered Phlebology Sonographer
(recognized**) www.cci-online.org

8. Reflux Values - Pathologic
Labropoulos, N et al. Definition of Venous Reflux,
J Vasc Surg 2003;38:793-8
Cut Off Values for reflux
Fem – pop >1000ms
Calf +DFV > 500ms
Superficial > 500ms
*Perforators > 350ms
*size >3.5mm
reflux : measured during muscular diastole

9. GSV is medial and
slightly posterior to
the deep system
Sheath Landmark “key”
Where is the GSV located on the leg?

10. SVU LE Venous Insufficiency
Guideline #3 a…. – veins to check for reflux
 CFV
 SFJ and the GSV @ multiple (5) sites
 FV
 Pop V –above and below SPJ **
 SSV (2)
 Perfs as needed
 Examine prox, mid and distal vein segment and at major
tributaries or perforators
-To ensure sufficient data is provided to the physician to direct patient
Management and render a final diagnosis
-focused physical exam – observation of signs, symptoms etc…

11. Diameter of a saphenous vein
may decrease distal to a
major incompetent tributary
Sourcing Reflux : Clues

12. Scan in Transverse – The Alignment Sign
AAGSVGSV
FA
FV
Geometric Relationships & Patterns

13. GSV Variations – Sheath and Tributaries
Ricci and Georgiev - Journal of Vascular Technology
“h” vein
Anterior Saph
Multi-level investigation

14. Mapping of a GSV Tributary
leaving the sheath
GSV
Trib
GSV in “eye”
US image
to diagram
Diameter of a saphenous
vein may decrease
distal to a major
incompetent tributary

15. Location of Probe and Augmentation Site
Van Bemmelen et al JVS 1989
Evaluated technique and position:
Valsalva, prox compression, release of distal
compression
Manual compression of the supine limb proximal to the
transducer site did not result in closure of the valve
but rather in reflux during the entire compression
followed by cessation of flow
The deflation of a cuff distal to the transducer is the
most reliable maneuver to obtain sustained
closure of the valve with physiologic transvalvular
pressure gradients.
The correct and consistent translation of reflux into
valve incompetence is a prerequisite for the
understanding of patho-physiologic characteristics of
veins

16.  Foldes, M et al: Standing Versus Supine Positioning in Venous
Reflux Evaluation:Jour of Vasc Tech 1991;15(6):321-24. * 70%
 Neuhardt, D et al – Differences in Saphenous Vein Reflux
Detection According to Patient Positioning – Abstract UIP Monaco
2009 26-49%

17. Temporal Effects on reflux
how to interpret the data?
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. The Journal for Vascular
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

18. Shape of the reflux curve….
0.5 sec = pathologic
VCTs poor correlation to CEAP
Varicose Reservoir Capacitance
Rodriguez JVS 1996 –
VCTs do not accurately
reflect the magnitude of
refluxed volume
Iafarati JVS 1994 -
Reflux time does not
discriminate severity [C0-
C6]
Vasdekis 1989 –
Peak flow volume – non
discriminatory
Large refluxing vein empties into small capacitor
– peak velocity is high and duration short
Small refluxing vein empties into a large
capacitor – velocity is low and duration long

19. Keys to Proper Documentation
ICAVL, ACR and SVU standards:
 Transverse with and without
compressions (patency)
 long Axis Image
 Spectral Doppler tracing
required
 60 degree angle
 Color – optional
 standing position for reflux
determinations
 Separate US report
 Archived Images
~2.5 seconds of reflux

20. Color Information Display
What does that FLASH of color
REALLY mean?

21. Compartments – change in compartment
 3 Compartments
 N3
 N2
 N1
EXIT
RE ENTRY

22. Images and drawings courtesy of
Olivier Pichot, MD
Competent SFJ w/
Incompetent sub-termainal
Valve and distal reflux
Anterior Saph (AAGSV) Incompetence
with distal GSV reflux
**transverse view for orientation

23. Summary:Does your test match the clinical picture?
 Information will impact
treatment options
 Failure to identify and treat all
sources of reflux is likely to
result in early recurrence
 Exam is very operator and
technique dependent
 Reflux is not STATIC1
1Labropoulos, N, et al: Study of venous reflux
progression. J Vasc Surg 2005; 41:291-5

24. CONCLUSIONS
Color duplex ultrasound should be performed
to understand the pathology and plan
treatment for CVI patients.
This will tailor the treatment to the patients’
needs and misdirected treatment can be
prevented.
Be Curious - look for the source - does it
match the clinical picture
Joseph.Zygmunt@covidien.com

25. SFJ Anatomy – what do we know?
 Saphenous Arch
 Region includes superior
 branches, SFJ including
the TV and Pre-TV
 Terminal Valve *femoral side of TV
 Pre Terminal Valve
 *competence of saph arch
 Femoral Vein Valves
 Suprasaphenic valve (SSV)
 Infrasaphenic valve (ISV)
ISV