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PPG-CDUS
in venous reflux disease
Alexandru Andritoiu, Cristian Silosi
Centrul de Medicina vasculara RM
Craiova
Chronic Venous Disease
• CVD is a common problem with a significant impact on both afflicted
individuals and the healthcare system.
• Normal venous function requires the axial veins with a series of
venous valves, perforating veins to allow communication of the
superficial to the deep venous system, and the venous muscle pumps.
• Dysfunction of any of the normal structures may lead to venous
hypertension and development of CVI.
• Spectrum of manifestations of CVI:
Varicose veins
Venous insufficiency (venous ulcer)
Hemodynamics
Effective venous return requires the interaction of:
• central pump
• pressure gradient
• peripheral venous pump
• competent venous valves
• venous capacitance
• Ambulatory venous hypertension
• Venous reflux
Ambulatory venous pressure
Determinants:
venous reflux
obstruction
calf muscle pump function
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
Correlations
• ? symptoms-venous reflux
• ? symptoms-severity of venous reflux
• ? symptoms-CEAP cls
• ? venous reflux grading-CEAP cls
How to objectify the venous reflux?
• Ascending venography
• Plethysmography
• Doppler US
The Plethysmography
• APG (air plethysmography)
• VOP (venous occlusion plethysmography)
• SGP (strain-gauge plethysmography)
• IPG (impedance plethysmography)
• PPG (photo-plethysmography)
• LRR (light reflection rheography)
Air plethysmography (APG)
• Air plethysmography is a non-invasive test that can quantify venous
reflux and obstruction by measuring volume changes in the leg
• Its findings correlate with clinical and hemodynamic measures
• It can quantitatively assess several components of venous
hemodynamics: valvular reflux, calf muscle pump function, and
venous obstruction
• Is time-consuming
• Lack of standardization
• In present, used in rare situations
APG-an old method
APG -parameters
• EF ejection fraction
(correlated with muscle pump function)
• EV ejection volume
• RV residual volume
• RVF residual volume fraction
(correlated with ambulatory venous pressure)
• VFI venous filling index
(correlated with venous reflux)
• VFT venous filling time
• VV venous volume
APG-CVI Class correlation
VFI measured by APG is an excellent predictor of venous reflux,
provides an estimate of the clinical severity of disease
Pts with venous ulcer have:
• higher VFI
• lower EF
• higher RVF
(Katz ML 1991)
Rooke TW et al. - Mayo clinic
• (1) A shortened post-exercise refilling time
accurately identified limbs with venous
incompetence.
• (2) The clinical severity of venous incompetence
was inversely related to the refilling time.
• (3) Exercise induced changes in lower extremity
volume correlated well with simultaneously
determined changes in venous pressure.
• (4) Valvular incompetence could be localized to the
deep or superficial veins based upon the
improvement in refilling times seen following
placement of elastic tourniquets around the lower
limb.
• (5) The type of exercise performed (knee bends
while the patient was standing versus ankle
reflexes while sitting) had little effect on results.
• Exercise venous plethysmography is a useful
noninvasive tool for assessing lower limb venous
incompetence.
PPG-Method
PPG-parameter
• VRT: venous refilling time
• normal value: >20-25 s
• severe reflux: < 10 s
VRT significance/interpretation
VRT-correlated with ambulatory venous pressure
Nicolaides AN 1987
Venous disease severity -VRT
Darvall K.A.L. et al. Eur J Vasc Endovasc Surg (2010) 40, 267e272
PPG in Deep Venous Insufficiency
• PPG can be used to distinguish between deep and superficial vein
incompetence by using a tourniquet applied above the knee at a
pressure of approximately 50mmHg, which is sufficient to restrict
flow in the superficial venous system
• PPG do not make the distinction between deep venous incompetence
and perforators incompetence
Pearce W 1983, Sakurai T 1997, Brenda M 2004
PPG in DVT
• PPG has proved effective in the screening for the presence of a DVT
• The negative predictive value has been reported as high as 100%
therefore, producing a high sensitivity
• However, the specificity is lower as a number of false positives have
been reported
• CDUS is superior to PPG in DVT diagnosis
Tan YK 1999, Patel DD 2002
Hypotonic phebopathy
CEAP Os-Cls
• Varicose veins symptoms
• No varicose veins
• Prevalence 15%; 2x F>M
• CDUS: normal veins, no reflux
• PPG: VRT <20 s
• Laser-Doppler
• the symptoms in HP [C0S] could be sustained by the increase of the venous
wall compliance
• The reduction of PPG refilling time without valve dysfunction could be
explained as a faster refilling caused by a decrease of filling resistance
sustained by the reduction of the venous and venular tone
Andreozzi GM 2006
Doppler US Method
• Venous anatomy (axial/superficial)
• Thrombus (occlusion)
• Venous reflux (valves incompetence)
• Perforators (incompetence)
• Venous-venous shunts (open vs closed)
Doppler-venous reflux
Maneuvers:
• Valsalva
• Squeeze
• Dorsal flexions
• Parana
Competent vs Incompetent veins
A) Competent B) Incompetent
Duplex sampling sites
• 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
Reflux pathway
Doppler reflux waves parameters
Variability of reflux waves
590 legs -326F-CEAP 2 Cls.
Doppler venous reflux
• 17% V. reflux in LSV and SSV
• 60% reflux only in LSV
• 3% reflux only in SSV
Total prevalence of venous reflux:
77% in LSV
20% in SSV
Engelhorn C et al. 2005
The Protocol
PPG and ABI-Doppler
Indications for surgery
• Aesthetic reasons?
• Pathological reasons?
• 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.
Monitoring the treatment
 Graduated compression stocking
 Venoactive drugs
 Guided Foam sclerotherapy
 Surgery (thermal ablation)
Ovens LV 2000, Benigni JP 2003, Darvall KAL 2010, Saliba O Jr 2014
In 42 of the 48 limbs examined,
the postoperative VRT was >20 seconds
PPG and CDUS
Normal PPG tracking
R-LSV incompetence
Before Tnqt
After Tnqt
Diastolic reflux
Bilateral LSV Insufficiency
Bilateral LSV with deep vein incompetency
LSV incompetence with varicose veins and
perforator incompetence
PPG
Bilateral reflux, more severe in the R-Leg with
perforator incompetence
PTS –R Leg
PPG limits
• inconsistent data in DVT
• VRT: accurate indicator of severity only for diastolic reflux (not for
systolic reflux)
• differentiation between deep vein and calf perforator incompetence
is not possible with PPG
• Is not reliable in:
obese patients
edema
Conclusions
Venous reflux- the main determinant factor for chronic venous disease
• PPG
-easy and cheep
-VRT: accurate indicator of severe reflux
-for CEAP Cls. 1-3
-screening for DVT (normal PPG-No DVT!)
• CDUS
-used for patients before surgery or CEAP 4-6
-more expensive
-long time training
-time-consuming
-accurate in DVT
• PPG and CDUS
-more accurate diagnostic for CVI (before surgery)

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PPG and CDUS in venous reflux disease

  • 1. PPG-CDUS in venous reflux disease Alexandru Andritoiu, Cristian Silosi Centrul de Medicina vasculara RM Craiova
  • 2. Chronic Venous Disease • CVD is a common problem with a significant impact on both afflicted individuals and the healthcare system. • Normal venous function requires the axial veins with a series of venous valves, perforating veins to allow communication of the superficial to the deep venous system, and the venous muscle pumps. • Dysfunction of any of the normal structures may lead to venous hypertension and development of CVI. • Spectrum of manifestations of CVI: Varicose veins Venous insufficiency (venous ulcer)
  • 3.
  • 4. Hemodynamics Effective venous return requires the interaction of: • central pump • pressure gradient • peripheral venous pump • competent venous valves • venous capacitance • Ambulatory venous hypertension • Venous reflux
  • 5. Ambulatory venous pressure Determinants: venous reflux obstruction calf muscle pump function
  • 6. 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
  • 7. Correlations • ? symptoms-venous reflux • ? symptoms-severity of venous reflux • ? symptoms-CEAP cls • ? venous reflux grading-CEAP cls
  • 8. How to objectify the venous reflux? • Ascending venography • Plethysmography • Doppler US
  • 9. The Plethysmography • APG (air plethysmography) • VOP (venous occlusion plethysmography) • SGP (strain-gauge plethysmography) • IPG (impedance plethysmography) • PPG (photo-plethysmography) • LRR (light reflection rheography)
  • 10. Air plethysmography (APG) • Air plethysmography is a non-invasive test that can quantify venous reflux and obstruction by measuring volume changes in the leg • Its findings correlate with clinical and hemodynamic measures • It can quantitatively assess several components of venous hemodynamics: valvular reflux, calf muscle pump function, and venous obstruction • Is time-consuming • Lack of standardization • In present, used in rare situations
  • 12. APG -parameters • EF ejection fraction (correlated with muscle pump function) • EV ejection volume • RV residual volume • RVF residual volume fraction (correlated with ambulatory venous pressure) • VFI venous filling index (correlated with venous reflux) • VFT venous filling time • VV venous volume
  • 13. APG-CVI Class correlation VFI measured by APG is an excellent predictor of venous reflux, provides an estimate of the clinical severity of disease Pts with venous ulcer have: • higher VFI • lower EF • higher RVF (Katz ML 1991)
  • 14.
  • 15. Rooke TW et al. - Mayo clinic • (1) A shortened post-exercise refilling time accurately identified limbs with venous incompetence. • (2) The clinical severity of venous incompetence was inversely related to the refilling time. • (3) Exercise induced changes in lower extremity volume correlated well with simultaneously determined changes in venous pressure. • (4) Valvular incompetence could be localized to the deep or superficial veins based upon the improvement in refilling times seen following placement of elastic tourniquets around the lower limb. • (5) The type of exercise performed (knee bends while the patient was standing versus ankle reflexes while sitting) had little effect on results. • Exercise venous plethysmography is a useful noninvasive tool for assessing lower limb venous incompetence.
  • 17. PPG-parameter • VRT: venous refilling time • normal value: >20-25 s • severe reflux: < 10 s
  • 18. VRT significance/interpretation VRT-correlated with ambulatory venous pressure Nicolaides AN 1987
  • 19. Venous disease severity -VRT Darvall K.A.L. et al. Eur J Vasc Endovasc Surg (2010) 40, 267e272
  • 20. PPG in Deep Venous Insufficiency • PPG can be used to distinguish between deep and superficial vein incompetence by using a tourniquet applied above the knee at a pressure of approximately 50mmHg, which is sufficient to restrict flow in the superficial venous system • PPG do not make the distinction between deep venous incompetence and perforators incompetence Pearce W 1983, Sakurai T 1997, Brenda M 2004
  • 21. PPG in DVT • PPG has proved effective in the screening for the presence of a DVT • The negative predictive value has been reported as high as 100% therefore, producing a high sensitivity • However, the specificity is lower as a number of false positives have been reported • CDUS is superior to PPG in DVT diagnosis Tan YK 1999, Patel DD 2002
  • 22. Hypotonic phebopathy CEAP Os-Cls • Varicose veins symptoms • No varicose veins • Prevalence 15%; 2x F>M • CDUS: normal veins, no reflux • PPG: VRT <20 s • Laser-Doppler • the symptoms in HP [C0S] could be sustained by the increase of the venous wall compliance • The reduction of PPG refilling time without valve dysfunction could be explained as a faster refilling caused by a decrease of filling resistance sustained by the reduction of the venous and venular tone Andreozzi GM 2006
  • 23. Doppler US Method • Venous anatomy (axial/superficial) • Thrombus (occlusion) • Venous reflux (valves incompetence) • Perforators (incompetence) • Venous-venous shunts (open vs closed)
  • 24. Doppler-venous reflux Maneuvers: • Valsalva • Squeeze • Dorsal flexions • Parana
  • 25.
  • 26. Competent vs Incompetent veins A) Competent B) Incompetent
  • 27. Duplex sampling sites • 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
  • 29.
  • 30. Doppler reflux waves parameters
  • 32. 590 legs -326F-CEAP 2 Cls. Doppler venous reflux • 17% V. reflux in LSV and SSV • 60% reflux only in LSV • 3% reflux only in SSV Total prevalence of venous reflux: 77% in LSV 20% in SSV Engelhorn C et al. 2005
  • 35. Indications for surgery • Aesthetic reasons? • Pathological reasons?
  • 36. • 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.
  • 37. Monitoring the treatment  Graduated compression stocking  Venoactive drugs  Guided Foam sclerotherapy  Surgery (thermal ablation) Ovens LV 2000, Benigni JP 2003, Darvall KAL 2010, Saliba O Jr 2014 In 42 of the 48 limbs examined, the postoperative VRT was >20 seconds
  • 40. R-LSV incompetence Before Tnqt After Tnqt Diastolic reflux
  • 42. Bilateral LSV with deep vein incompetency
  • 43. LSV incompetence with varicose veins and perforator incompetence
  • 44. PPG Bilateral reflux, more severe in the R-Leg with perforator incompetence
  • 46. PPG limits • inconsistent data in DVT • VRT: accurate indicator of severity only for diastolic reflux (not for systolic reflux) • differentiation between deep vein and calf perforator incompetence is not possible with PPG • Is not reliable in: obese patients edema
  • 47. Conclusions Venous reflux- the main determinant factor for chronic venous disease • PPG -easy and cheep -VRT: accurate indicator of severe reflux -for CEAP Cls. 1-3 -screening for DVT (normal PPG-No DVT!) • CDUS -used for patients before surgery or CEAP 4-6 -more expensive -long time training -time-consuming -accurate in DVT • PPG and CDUS -more accurate diagnostic for CVI (before surgery)