The document extensively discusses various imaging techniques for evaluating venous diseases, emphasizing non-invasive methods like ultrasound (US) which combine both anatomical and physiological information. It describes the applications and limitations of conventional venography, duplex Doppler, and color Doppler, particularly in diagnosing deep vein thrombosis (DVT) and related conditions. Additionally, it highlights the importance of proper examination techniques, sensitivity to specific anatomical structures, and the implications of findings in both lower and upper limb venous systems.

1. Presented by Dr Vrishit Saraswat
Guided by Prof. Dr Dharmraj Meena

2. 1 - Non invasive- Non imaging Physiologic Methods.
These rely basically on the physiology and
hemodynamics which indirectly detects the presence
of venous disease.
Ex- Plethysmography
Drawbacks- Low sensitivity, Low specificity, fail to
define the anatomy.

3. 2 – Invasive Imaging Methods
Conventional Venography- displays the anatomy and is
the historical standard of venous imaging , against
which other techniques are measured.
C/I – risk of contrast reaction and phlebitis, cant provide
physiologic information.

4. 3 – Noninvasive imaging Methods
B-mode US witgh duplex Doppler and color Doppler
provides both physiologic(venous hemodynamics) and
anatomical information (conventional venography.)
***PIOPED – Prospective Investigation of Pulmonary
Embolism Diagnosis –> combined CTv and US-CD of
lower limb venous system has high specificity and
sensitivity in prospective diagnosis in suspected pts.
Cont…

5. **So, sonography is the primary imaging technique
for lower extremity venous evaluation. MRI and
CT serve a secondary role. Conventional venography is
kept reserved for unusual problems.

6. 1. Grey scale Imaging – High frequency Transducers are
used for most of peripheral veins (9 MHz). for iliac
or inf venacava , transducer of 4-6 MHz are used.
Superficial veins such as saphenous vein, calf veins
need even higher frequency transducers ( 9-15 MHz).

7. 2. Doppler Sonography – quantitative (duplex spectral)
& qualitative (color Dopler) .
This combination of anatomic and physiologic
information makes US-CD such a powerful tool in
evaluation of vascular pathology.

9.  Superficial Venous Sys
1. Great Saphenous Vein- *** 1-3&3-5 mm
2. Short Saphenous Vein- *** 1-2&2-4 mm
**Both these vessels can become abnormally enlarged or
varicose when superficial venous incompetent.

10.  Deep Venous System-
Evaluation of lower limb venous system is typically
directed towards deep system.
*Above knee , all deep veins lie medial to their
respective arteries.
Common fv – profunda f – (superficial) femoral v.

11.  Below knee , pop. V. lies superficial to pop art.
 Ant tibial vein- ant to interosseous mem and found in
ant compt of calf , ant-medially to tibia.
 Tibioperoneal trunk  post tibial and paired peroneal
v.
 Peroneal v- post-medial to fibula
 Post tv – posterior to tibia

12.  Visualization of post tibial v is difficult in superior
portion, however in lower portion, the vein can be
traced retrogradly posterior to medial malleolus
 Gastrocnemial and soleal v don’t hv accompanying
arteries, hence difficult to evaluate. They are high risk
site for acute DVT in post-op pts.

13.  Clinical examniation and diagnosis of DVT is quite
diificult bcoz , signs and symptoms like – pain
erythema and swelling are very non specific.
 The presence of “palpable cord” is most commonly d/t
superficial thrombophlebitis, which is NOT usually
associated with DVT.
 Most pts with acute DVT are asymptomatic , so an
accurate non invasive method is the best choice for
diagnosis.

14.  Pt in supine postion
 Hip – AB-ER
 9MHz linear probe
 In transverse plane with mild compression(pressure
depends on the depth and s/c tissue) , every 2-3 cm
 Till , when femoral v enters adductor canal.
 Great saphenous vein and profunda femoris v. can also
be examined in this fashion.

17.  For popliteal v exam, prone position with slight knee
flexion.
 Valsalva Maneuver – indirect way to examine pelvic
veins.
Intra abdo.pressure increase compression of
abdominal and pelvic veins  no flow in CFV.
Absense of loss of this pattern can confirm the complete
obstruction of external/common iliac vein.

18. Drawback- false neg examination can occur , if significant
collateral develop or thrombus is non occlusive.
If pelvic veins are poorly seen on CD, contrast enhanced CT
should be performed in suspicious cases.
 On Color doppler , normal vein should fill the lumen
completely, with little or no aliasing outside the vessel wall.
 Sometimes in calf veins, flow is seen less than actual, becoz
of surrounding muscles. Here venous flow is increased by
compressing the calf muscles, to see complete filling .

22.  Before, lower leg was not evaluated , bcoz of its rare
involvement in DVT , and is time consuming.
Althought post tibial and peroneal veins can cause
DVT, but thromus from them don’t cause significant
pulmonary embolism
 Now it is mandatory to scan the posterior segment of
leg for complete evaluation.
 ***If post tibial and peroneal v is normal, no need to
scan ant tibial, as isolated thrombus of ant tibial v is
very rare.

23.  Most of examiners don’t scan Gastro-sol vein in
general routine , however centres performing anti-
coagulation for DVT , do scan these small veins as
routine.
 Still for symptomatic pts (with risk of dislodging)
short examination is needed. Here we just need to
examine femoral and pop.vein. It will be the rare
cinerio when isolated calf vein thrombsis will cause
grave symptoms & isolated iliac vein thrombosis is also
rare.

24. 1. Grey Scale – drect visualization of thrombus with
lack of compressibilty. Some acute thrombus
might be anechoic.
 Therefore , lack of complete venous compression is
hallmark finding of DVT.
 Venous distention is seen in acute cases. As clot
becomes organized, the distention disappears.
Cont..

29.  Changes in calibre with respiration and valsalva
maneuver is lost in proximal segment of femoral vein.
But if thrombus is below bifurcation of common
femoral v, this sign is not helpful.
2. Color doppler- Persistent filling defect with thrombus
in colour column of vessel lumen or complete
absence of flow.

30.  Venography is the standard imaging method .
 Usg being non invasive and low comparatively low cost Is
the preferred d method.
 Acute thrombus appears hypoechoic or isoechoic to vessel
wall with often complete obstruction & distention of
lumen.
 As the clot ages, it under goes fibrosis with more
fibroelastic tissue in it, causing retraction of clot and
thickening of involved vessel wall.
 Becoz of clot retraction compression sonography alone
has lesser role in diagnosis of chronic thrombus.
Cont

31.  CD usually needed to differentiate between the two.
 US-CD findings suggesyive of Chronic DVT-
1. Irrsegular echogenic vein wall
2. Thickening of vein walls
3. Retracted thrombus( may be calcified)
4. Decrease diameter of vein lumen
5. Atretic venous segment
6. Well developed collaterals
7. Absence of distended vein containg hypoechoic
thrombus.

37.  Thrombus in Great or small saphenous vein.
 Clinical presentation is not same as DVT
 Treated symptomatically with heat and aspirin
 Exception – treated with anti-coagulants when
thrombus is present with in 2cm of deep venous
system,i.e, either SFJ or SPJ.

39.  Deep Venous Insuff.
Following retraction of
thrombus and vein wall ,
causing damage of valve
and increasing
hydrostatic pressure in
lower leg venous sys.
Leading to swollen leg,
woddy induration,
chronic venous ulcer and
pigmentation.
 Superf. Venous Insuff.
Either becoz of superficial
thrombophlebitis of long
standing deep venous
insuff.
Long standing Deep ven
insuff Leads to
incompetent perforating
veinsdistended
superficial subcut.veins
Much better prognosis.

40.  At SFJ , with valsalva manuvear.
 At popliteal Vein – with distal venous augmentation.
 Usually there is a short phase or no reversal flow on
Spectral doppler.
 But in case of insufficiency long reversal flow is noted.

43.  For subfacial endoscopic ligation of incompetent
perforators
 Majority of perforators are located below knee
 Insufficient perforators on USG appears as distended
veins passing from sub cut tissue through muscle
plane into deep muscles of calf.
 **Competent perforators are much smaller in calibre
and often impossible to visualize.

46.  Cephalic vein – lateral aspect of forearm
 Basilic Vein - medial aspect of forearm.
 Brachial veins- smaller deeper and run adjacent to
radial artery.
 Axillary Vein- superficial to Axillary artery
 Subclavian vein- superficial to Subclavian artery
 Medial end of subclavian vein recieves smaller ext
jugular and larger deep jugular vein

47.  Internal jugular runs in carotid sheath n runs lateral to
carotid artery.
 Left and right int jugular are often unequal in size.
 Brachiocephalic vein formed by subclavian and int
jugular vein. {left > right}
 Both brachiocephalic join to form sup vena cava.

49.  Cause of DVT in upper extremity- Central venous
catheterization, pacemaker lead, long standing venous
canulations, malignant obstruction.
 With all these causes , the incidence of thrombosis is
around 40%
 The sequele of these thrombosis is less severe than
lower extremity (pul. Emb- 10 to 12%)
 cont.

50.  So ; development of venous stasis, chronic swelling,
non healing venous ulcers – after DVT ; is very rare in
upper limb.
 All this is becoz of extensive collateral formations and
no exposure to high hydrostatic pressure ( as in case of
lower limb).
 US of upper limb venous sys also helps in venous
access for central venous cathetherization.

51.  Supine
 Shoulder-ABER
 6-9 MHz
 Int Jugular brachio-subC junction
 *greater pulsatility due to close proximity of heart.
**loss of this pulsatility may suggest more central
venous occlusion.
 Comparision of doppler wave form from contralateral
arm may also help in diagnosis of occlusion.

54.  When normal pt sniffs(valsalva), the int jugular and
sub clav vein will decrease in diameter, and spectral
will show an increase in blood velocity. Occluded veins
will loose this property.
 Becoz of thoracic cage and clavicle, visualization as
well as copression sono becomes impossible for
brachio- subclav veins.
 A coronal, supra-clav, inf angled approachis used for
medial sec of subclavian v.
 A coronal, infra-clav, sup angled approach is used for
lateral sec of subclavian v.

55.  CD becomes essential in subclav becoz, no possiblity
of compression.
 The examiner should also confirm the normal inf –
superficial relationship of vein with adjacent artery.
This will avoid the pitfall of confusing well developed
collateral vessels for patent subclavian vein in chronic
venous occlusion.
 Typically the examination is continued till the
bifurcation of axillary vein into two brachial veins (*
for DVT)

56.  Similar to the thrombosis of lower venous system.
 Also abnormal response on sniff/valsalva ,
absent/decreased cardiac pulsatility and abundant
collateral development becoz of long standing venous
occlusion.