1. Pulsatile venous flow in the legs can occur in certain abnormal conditions such as heart disease, severe chronic venous insufficiency, and arteriovenous fistulas. 2. The document describes a case of a 57-year-old man with severe left leg chronic venous insufficiency and refractory leg edema and thrombophlebitis who was found to have a congenital femoral arteriovenous fistula causing high venous pressures. 3. Pulsatile venous flow was detected throughout the deep and superficial venous systems of the left leg in this case and was attributed to the presence of the arteriovenous fistula as the underlying cause of the patient's chronic venous ins

1. Pulsatile Venous Flow
in Legs
Alexandru Andritoiu, Cristian Silosi, Maria Mitrica
Spitalul Clinic Militar
Centrul de Medicina vasculara
CRAIOVA

2. Normal venous flow
Characteristics:
• Phasicity –flow changes with respiration
• Spontaneity-spontaneous flow without augmentation
• Compression –transverse plane
• Augmentation/Valsalva response
• Independent from heart pulsations

3. Proximal-Distal Venous Flow
• CFV S Fem V
• Pop V Posterior
tibial v.

4. Augmentation
Posterior tibial vein

5. Hemodinamics
• Mult mai complexa decat hemodinamica arteriala
• Multiple influente hemodinamice
-presiunea dinamica
-presiunea hidrostatica

6. Pulsatile Venous Flow
• A hemodynamic curiosity?
• An abnormal condition?
• Sincron cu pulsatiile inimii
• In deep venous system
• In superficial venous system

7. Pulsatile flow in healthy people

8. Pulsatile venous flow in abnormal conditions
• Heart disease (RHF)-higher pressure in RA >7 mmHg
• Severe CVI (CEAP4-6)
• A-V fistula

9. Pulsatile venous flow in R-HF
• Edeme bilaterale
• Sufluri cardiace
• Istoric de boala cardiaca
-maladii congenitale
-valvulopatii (Tc)
Eco Doppler cord:
-regurgitare Tc severa (gr3-4)
-VD si AD dilatate
-VCI/-Vv. hepatice dilatate

11. B. Toma, 75 ani, CHF-cls. 3

12. Pulsatile venous flow in CVI
• Venous hypertension (CEAP4-6)
• After GSV ablation, pulsatile flow in deep venous system remain the
same!
Of the 101 limbs, 47 (46.5%) had evidence of pulsatile flow in the lower-
extremity venous system preoperatively. Paired observations using the
Wilcoxon method showed no difference in the venous pulsatility post
ablation regardless of the presence of deep venous reflux

13. Pulsatile flow in A-V fistula
• Fistula A-V
• Localization:
-in legs: Fem>Pop>tibial vv
• Congenital
• Post-traumatic fistula
• Post-interventional procedures
• Dialysis (arm)

14. A-V fistula as a vascular access
for hemodialysis
• Surgically created connection
Stepansky F et al. Radiographics 2008;28:e28-e28

15. Clinical case:
B. Dumitru, 57yr
• CVI 4CEAP-left leg
• varicose veins
• multiple episodes of thrombophlebitis
• refractory to medical treatment
(OAC, sulodexid, VAD, stocking)
• many times admitted to hospital (3-4 x/yr)
• Ankylosing spondylitis

16. Venous CDUS exam.
• Pulsatile flow in deep and superficial venous system
• No heart disease
normal ECG/echocardiography
• subcutaneous venous edema-left leg

17. GSV with pulsatile flow

18. Varicose veins with pulsatile flow

19. Perforator vein with pulsatile flow

20. Fem. A-V fistula

21. CT-angio
• Femoral A-V fistula
• Congenital?

22. Evolution/Prognosis
• very high venous pressure! How thrombophlebitis can occur?
• secondary cause for varicose veins
• danger for a refractory (hemorrhagic) ulcer?
• endovascular ablation of left GSV? No!!!
• no therapeutic solution for AVF (high surgical risk)

23. Conclusions
• Fluxul venos pulsatil poate fi intalnit la nivelul membrelor inferioare
• Asociat edemului bilateral-cauza cardiaca (cresterea PAD>7 mmHg)
• Asociat edemului unilateral-cauta o posibila fistula A-V
• Boala venoasa poate coexista frecvent cu suferinta cardiaca
• Boala venoasa poate fi consecinta unei fistule A-V
• Fluxul venos pulsatil la nivelul mm. inferioare poate fi de cauza
complexa-multifactoriala