By: William Marston, MD 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. Who needs more testing 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
from duplex ultrasound
• Venous duplex report
– No acute DVT
– Reflux in GSV
– No deep reflux

4. Duplex information
• Pathway of 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 duplex report
• 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
additional testing
• 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

9. Plethysmography

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
• 47 YO 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

12. CT venogram and APG

13. Additional testing: Deep and
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/o DVT
• 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
• Determine presence 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 straight to venous
intervention - IVUS

20. When are further diagnostic 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
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