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Who Needs More Testing Beyond Venous Duplex?
The document discusses the need for additional testing beyond venous duplex ultrasound in diagnosing venous issues, particularly in cases of chronic venous insufficiency (CVI) and related symptoms. It highlights limitations of duplex imaging and presents clinical scenarios where further testing, such as CT venogram or plethysmography, is warranted based on patient conditions and treatment history. The document emphasizes the correlation between reflux severity and symptoms, and when more invasive interventions may be considered.
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Who Needs More Testing Beyond Venous Duplex?
- 1. Who needs moretesting beyond venous duplex? IVC 2014 Miami Beach FL William Marston MD Professor and Chief, Division of Vascular Surgery University of N. Carolina Hospitals
- 2. Disclosures • Scientific Consultant –Veniti – Volcano – Organogenesis • Clinical Trial Investigator – Smith and Nephew/Healthpoint
- 3. Deriving maximum information fromduplex ultrasound • Venous duplex report – No acute DVT – Reflux in GSV – No deep reflux
- 4. Duplex information • Pathwayof venous abnormality to symptoms – VV, edema, ulceration • Reflux to symptom site • Size of refluxing veins to symptom site • Obstruction proximal to symptom site
- 5. Informative venous duplexreport • Abnormal pathways – SSV to pop and/or vein of Giacomini – Duplicate GSV – Hypoplastic femoral system – Pelvic or other collaterals to labia • Sites of reflux and size of refluxing segments – Deep, superficial, perforator • Obstruction in all segments including iliac and IVC
- 6. Duplex limitations -anatomic • Operator dependent – Nicos vs the rest of the world
- 7. Duplex limitations -physiologic • Duplex can provide: – Direction of flow – Velocity of flow – Caliber of conduit – Cannot directly infer venous hypertension or other measure of severity of venous insufficiency
- 8. Clinical situations requiring additionaltesting • 38 YO former collegiate volleyball player • h/o meniscus repair on left • Right leg pain, aching with activity - no edema or skin changes • Most severe in knee area • GSV reflux at knee 4-5 mm diameter
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- 10. Venous Filling Index(VFI, normal < 2 cc/sec), the value determined by 90% of VV divided the time required to reach 90% of VV
- 11. Additional Testing • 47YO female with h/o leg pain, aching after walking • Mild/moderate edema late in day • s/p GSV ablation, 5 sessions of scleroRx • Continued leg aching w minimal improvement
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- 13. Additional testing: Deepand superf disease post-proc • 52 YO male w Class 4 CVI left leg • Deep and superficial reflux on exam • No evidence of venous obstruction • Reflux times – CFV 2.1 secs – FV 0.4 secs – Pop 3.3 secs – GSV at SFJ 4.5 secs – GSV at knee 6.2 secs – SSV 0.2 secs
- 14. S/p GSV ablation •How much will symptoms improve with superficial correction alone? • Does patient still need to use compression? • Repeat duplex to see if deep reflux corrects • VFI improvement to normal range suggests correction of primary cause of CVI
- 15. Additional testing: pelvic symptoms,groin VV • Labial VV • Pelvic congestion symptoms • Nutcracker syndrome
- 16. VLU and h/oDVT • 63 YO female w right leg ulcer and h/o DVT 7 years ago • Compression and topical therapies with some improvement for 3 months, but still large persistent wound
- 17. Venous duplex findings •GSV reflux throughout with vein size 7-10 mm • CFV waveform with reduced phasicity • Reflux in SFV and pop v with changes c/w old DVT (partially compressible)
- 18. CT/MR venogram • Determinepresence and severity of ilio-caval outflow obstruction – Could you stent at same setting as GSV ablation? – Further evaluate severity of pop and fem v obstruction • Femoral venoplasty?
- 19. Or go straightto venous intervention - IVUS
- 20. When are furtherdiagnostic tests necessary? • Not often for infrainguinal questions – If symptoms don’t match duplex findings – If patients don’t improve after appropriate intervention • Venous outflow obstruction • Abd/Pelvic symptoms or source • At the time of therapeutic venous intervention 600-0003.42/001 20