Dr Ahmed Esawy

Tips Tricks

Peripheral Venous Duplex

Dr. Ahmed Esawy

MBBS M.Sc MD

Dr Ahmed Esawy

Varicose veins

DUPLEX US

Dr Ahmed Esawy

DEFINITION

• Varicose veins are veins that have become abnormally

enlarged and tortuous.

• The term “varicosities”, represent enlarged collaterals

(branches) of so-called saphenous venous system affected

by a disease called “superficial venous insufficiency of

lower extremities

• The term commonly refers to the veins on the leg

• although varicose veins can occur elsewhere i.e.

Abdominal Wall ,Anus , Vulva, Oesophagus.

• Varicose veins are bulging veins that are larger than spider

veins i.e. typically 3 mm or more in diameter.

Dr Ahmed Esawy

venous circulation uphill

Hemodynamics

• Gravity/hydrostatic pressureForce of gravity , pressure of body weight & task of carrying blood

from bottom of body up to heart make legs primary location for varicose veins.

• Intra-abdominal pressure

• External Venous compressionleft iliac vein compression by the right iliac artery, known as

May-Thurner syndrome (MTS).

compression of right iliac vein by the right iliac artery or

compression of the left iliac vein by the left iliac artery

Leg muscles pump the veins to return blood to the heart, against

the effects of gravity

Dr Ahmed Esawy

VARICOSE VEIN

primary varicose (superficial

system abnormally dilated tortous

, no history of DVT)

Intrinsic weakness of smooth

muscle media layer of vein wall

(hereditary, hormonal, endothelial

damage)

Intrinsic “leakiness” of valve

secondary varicose (deep system

2ry to obstruction or

incompetence )with ankle

oedema venous ulcer at ankle)

Post–thrombotic damage to valve

leaflets

Dr Ahmed Esawy

Reflux (most common)

Calf muscle pump dysfunction

muscle wasting

neuromuscular disease

deep fasciotomies

local vein valve failure within the muscle

fascia sheath

Venous obstruction

DVT / Post-thrombotic syndrome

Mass

artery

Venous valvular incompetence

Primary

Secondary

Congenital abnormalities (Klippel - Trenaunay - Weber Syndrome)

Impaired venous drainage

Varicose veins etiology

Dr Ahmed Esawy

Klippel - Trenaunay - Weber Syndrome:

Congenital absence of the deep veins

Causes numerous superficial varicosities and clusters of varicosities

Dr Ahmed Esawy

Varicosities color duplex

examination objectives

• 1-ascertian whether the deep or superficial system

is patent

• 2-identify,localize,grade reflux in deep and

superficial system

• 3-to determine the source of blood flow to varicose

segment , evaluation of cause of varicosities

• 4-to evaluate the potential benefits for occluding

the source of inflow to varicose segment

• 5- extent of post-thrombotic abnormalities

Dr Ahmed Esawy

VARICOSE VEIN

superficial system

Extra-axial

Deep system

Axial

Dr Ahmed Esawy

Varicose vein

Telangectasia

Dermis

Reticular vein

Perforators

Sup. fascia

Deep fascia

Deep vein

Superficial & Deep connections

Dr Ahmed Esawy

ColorSizeClassType

Red0.1-1 mmTelangectasia

/spiders

I

Violet1-2 mm Venul-ectasiaII

Blue2-4 mm Reticular veins III

Blue3-8 mm Non-saphenous

varicose

IV

Blue7-8 mm Saphenous

varicose

V

varicose veins Classification

Dr Ahmed Esawy

deep venous system

incompetence

• an enlargement of the deep venous system,

which increases in standing position,

• consequently slow venous flow.

• Typical symptoms are restless legs, calf pain

during the night, and severe muscle cramps.

• The degree of dilatation can be measured easily

with M-mode during Valsalva maneuver.

Dr Ahmed Esawy

Evaluation of valvular competence in

the deep venous system

• evaluated in thrombosis with a swollen lower extremity.

• With valvular competence, no significant retrograde is

observed (a brief and low amplitude physiologic flow

reversal may occur prior to valve closure).

• With valvular incompetence, high amplitude flow

reversal will be observed during the entire period of

abdominal compression. A long waveform

corresponding to venous emptying will follow.

Dr Ahmed Esawy

Evaluation of valvular competence in the

deep venous system

At the level of the thigh

With the patient in decubitus,

the Doppler sampling volume is

placed within the femoral vein

and pressure is applied on the

abdomen or the patient is

asked to do a Valsalva

At the level of the calf

With the patient erect, muscular

compression should only result in

minimal flow reversal, again

related to normal valve closure.

Prolonged and large flow reversal

is suggestive of valvular

incompetence.

Dr Ahmed Esawy

Evaluation of valvular competence in the

deep venous system

qualitative assessment

On color Dopplerobserving reversal of color-saturation, corresponding to forward and reversed flow directions, especially during functional maneuvers

Quantitative assessment

relative to the duration of flow

reversal can be obtained with

spectrum

Dr Ahmed EsawyNORMAL VEIN VALVE

Dr Ahmed Esawy

Evaluation of valvular

competence in the

superficial venous system

Dr Ahmed Esawy

Dr Ahmed Esawy

Dr Ahmed Esawy

Veins have leaflet valves to prevent blood from flowing backwards

(retrograde flow).

the leaflets of the valves no longer meet properly allows blood to flow

backwards and they enlarge even more

this backflow will dilate the supple superficial veins making them tortuous

and dilated (varicose veins).

Valve damage Incompetence with reversal of flow, pooling and venous

hypertension.

Familial factors with 'lax' veins. These distend slightly allowing the valve

leaflets to no longer oppose each other.

Injury or thrombosis. Both of these can lead to adherence of valve

leaflets to the vein wall, rendering the valve useless.

Varicose veins (valvular)

Dr Ahmed Esawy

Dr Ahmed Esawy

B shows a varicose vein with a

deformed valve, abnormal blood flow,

and thin, stretched walls. The middle

image shows where varicose veins

might appear in a leg.

The illustration shows how a

varicose vein forms in a leg.

Figure A shows a normal

vein with a working valve and

normal blood flow.

Dr Ahmed Esawy

In the normal cicumstance, the superficial system drains the subcutaneous tissues

and periodically empties into the deep system via perforating veins.

Flow direction should always be:

Cephalad Superficial to deep.

Dr Ahmed Esawy

INCOMPETENT FLOW

With distal augmentation, flow initially goes cephalad. It then refluxes back down the

leg through the malfunctioning valve.

An incompetent perforating vein also allows blood to flow from the deep veins to the

surface veins.

This combination of back pressure causes dilation and tortuosity of the veins (ie

varicosites).

Dr Ahmed Esawy

Varicose

veins

• Varicose veins are a common condition in the United States, affecting up to 15 percent of men and up to 25 percent of women.

Dr Ahmed Esawy

For many people, varicose veins and spider veins a common, mild and medically insignificant variation of varicose veins — are simply a cosmetic concern. For other people, varicose veins can cause aching pain and discomfort

Dr Ahmed Esawy

Sometimes the condition leads to more serious problems.Varicose veins may also signal a higher risk of other disorders of the circulatory system.

Dr Ahmed Esawy

Dr Ahmed Esawy

Dr Ahmed Esawy

different pathways of saphenous incompetence

Incompetence confined to the saphenous trunks at the two levels imaged by

ultrasonography would reveal an enlarged vein in the saphenous sheath at both levels

Dr Ahmed Esawy

different pathways of saphenous incompetence

Incompetence spills into a tributary vein, which is enlarged in the subcutaneous

space in the lower of the two levels imaged. In this case the saphenous vein is visible

but more normal in size at the lower imaging level

.

Dr Ahmed Esawy

different pathways of saphenous incompetence

Incompetence spills into a tributary vein, which is enlarged in the subcutaneous space in

the lower of the two levels imaged. In this case the saphenous vein is not visible at the

lower level

.

Dr Ahmed Esawy

Diagram of the pathways of reflux

Reflux begins at the saphenofemoral junction (SFJ)

and extends down the great saphenous vein (GSV) to

the thigh.At this point the reflux spills into a varicose

tributary (point A)

The incompetent tributary then refills the GSV at a lower

level (point B) and leads to an additional segmental

incompetence of the GSV.

The GSV between the takeoff and reentry of the

tributary is not incompetent.

If this segment of GSV is visible to Doppler

ultrasonography , it is probably traversable and a single

access (near point C) may be all that is required for

treatment of both the higher and lower segments

If this segment is not visible, two punctures are needed

(near points A and C) to treat both incompetent

segments of the GSV.

Dr Ahmed Esawy

B-mode appearance of varicose

veins and perforators

• Varicose veins are relatively easy to identify on the B-mode image.

• They appear as single or multiple dilated tortuous vessels that vary randomly in diameter .

• They are superficial and may be located in the thigh as well as the calf.

• The main trunk supplying varicose areas, such as the LSV in the thigh, may be dilated but often has a reasonably even caliber and is frequently not visible on the skin surface.

Dr Ahmed Esawy

• Occasionally a large localized dilation can be seen in the main trunk, called a varix.

• Sometimes the supplying vein may appear reasonably small, but reflux is demonstrated with color and spectral Doppler.

• The easiest way of locating perforators is to run the transducer steadily along the trunk of the superficial vein in transverse section.A break in the fascia will be seen on the B-mode image as the perforator runs between the subcutaneous and subfascial areas .

Dr Ahmed Esawy

Normally, the vein is 4 mm in diameter. Veins >7 mm have a

high incidence of reflux.

Reflux can occur in smaller veins but is usually clinically

unimportant.

Peripheral to the takeoff of incompetent tributary veins, the

caliber of the vein often decreases.

Conversely, the caliber of the GSV generally increases at the

level of a significant incompetent perforator vein

careful search should be made at points of GSV dilatation for

this important source of reflux

Dr Ahmed Esawy

Incompetent

GSV

normal

GSV

Dr Ahmed Esawy

GSV standingGSV supine

Dr Ahmed Esawy

A- the long saphenous vein (V) lies in The superficial compartment ,bounded by deep

muscular fascia (upward arrow) and the saphenous fascia (downward arrow)

long saphenous vein

Dr Ahmed Esawy

B-the short saphenous vein (V) is also bounded by the deep fascia (upward arrow)

and saphenous fascia (downward arrow). The medial gastrocenemius muscle (MG)

and lateral gastrocenemius (LG) are shown on this image of the right leg

Dr Ahmed Esawy

Longitudinal scan of a sapheno-femoral junction. The

superficial long saphenous vein (LSV) joins the deep

superficial femoral vein (SFV) to form the deep common

femoral vein (CFV)

Dr Ahmed Esawy

The blue in the long saphenous vein shows flow towards the heart.

The blood velocity waveform shows flow towards the heart as the thigh is

squeezed and the flow continues in the same direction as the squeeze is released.

A normal sapheno-femoral junction

on squeeze/ release.

Dr Ahmed EsawyAnterior accessory great veins

Dr Ahmed Esawy

Interfascial Veins

GSV Egyptian Eye

Leaflets of the Valve

Dr Ahmed Esawy

SFJ Pre-terminal Valve

/ Terminal Valve

Pre-Terminal Valve

Saphenous Ligament

Dr Ahmed Esawy

Reflux of the Pre-Terminal Valve (Color ) ;

while the terminal Valve appeared Competent (NO color)

Dr Ahmed Esawy

GSV normal diameter and Huge Varicosities “Large tributary”

Dr Ahmed Esawy

compensatory Anterior accessory GSV

Hypo plastic GSV

Dr Ahmed Esawy

Duplicated GSV

Dr Ahmed Esawy

Echogenic lining

Sclerosed vein

Sluggish Flow by B-Mode

Dr Ahmed Esawy

Thrombosed GSV

Dr Ahmed Esawy

Transverse image of tortuous

dilated varicose veins

Dr Ahmed Esawy

Reflux

Retrograde Reversed flow due to Delayed

closure of the valve

1ry or 2ry

CUT off Values of NORMAL LIMIT 0.5

seconds

Dr Ahmed Esawy

Reflux

Velocity Volume( Venous Filling index >

2ml/sec)

Duration

Dr Ahmed Esawy

Superficial Venous reflux types

Isolated

ostial

reflux

SFJ

SPJ

combined ostial

,perforating

reflux.

perforating

reflux

GSV SSV

reflux

Dr Ahmed Esawy

Evaluation of valvular competence in the superficial venous system: evaluation of varicose veins while patient erect

Dr Ahmed Esawy

examined Reflux sites

deep thigh Veins

CFV

Deep Femoral Vein

Proximal & Distal SFV

perforating

vein

deep Veins

Proximal & Distal Popliteal Vein

Gastrocnemius Veins

Posterior Tibial Veins

Anterior Tibial Veins

Superficial Veins

Sapheno-femoral Junction

Great Saphenous Vein *GSV (Thigh /upper & lower leg)

Sapheno-popliteal junction (SPJ)

Small Saphenous Vein *SSV (mid leg)

Dr Ahmed Esawy

• the duration and volume of reflux can be evaluated with spectrum analysis or with color duplex but last is more expedient method

Dr Ahmed Esawy

venous reflux grading

grade1 reflux defined as retrograde venous flow that lasts only for 0.5-2 seconds

grade1V reflux reversed

flow persist as long as

valsalva effort is

maintained

grade11 reflux lasts

slightly longer for 2-

3 seconds

grade111 reflux produces prominent reversed flow

phase that persists 4-6 seconds

< 0.5 sec NO reflux

Dr Ahmed Esawy

Augmentation of flow toward the heart

is seen in both instances (velocities

mapped below the x-axis).

However,upon release of external

compression, flow directed toward the

feet is seen in incompetent segments

(velocities above the xaxis).

Dr Ahmed Esawy

Relationship Between Reflux

and SV diameter is present

• The normal limit of the calibre of

GSV 5 mm and SSV 3 mm in upright

• Sudden caliber change of the

vessels is an important marker of

regurgitant flow within that segment

Dr Ahmed Esawy

• Perforating veins with diameters

greater than 3.5 mm can also be

taken as a sign of significant reflux

Dr Ahmed Esawy

Competent vein

Incompetent vein

Dr Ahmed Esawy

Spectral Doppler evaluation shows persistent retrograde flow beyond 0.5 second in

the great saphenous vein suggestive of venous reflux. Retrograde flow can be seen

up-to 3 seconds in (A) and 4 seconds in (B).

Dr Ahmed Esawy

Normal flow pattern of the saphenous vein

during Valsalva: flow stops during the

maneuver; there is a very short, physiological

reflux peak caused by the closing of the valve

Dr Ahmed Esawy

Dr Ahmed Esawy

Reflux tips &tricks

• Length of refluxed segment to 1.5m

• Distal compression is standard for forward flow

• But proximal compression or valsalva can be

used but will demonstrate reverse flow as far

as the first comptent valve so underlying

incomptent valve is missed

• Reflux seen by color and spectrum

• Reflux make turbulance as result of forward

and reverse flow appear together

Dr Ahmed Esawy

During Valsalva maneuver there is abnormal reversal blood flow demonstrated by the change to red. This is secondary to the development of venous insufficiency due to previous DVT.

Longitudinal image of the duplicated superficial femoral veins (blue) demonstrates that the blood flows in the normal direction towards the groin in the resting state.

Venous incompetence in duplicated superficial femoral veins.

Dr Ahmed Esawy

Prblem in quantifying reflux as in this example .the LSV

was very large (8) mm in diameter but the duration of

reflux (0.9) is shorter

blood flow during reflux is probably very significant due to

the size of the vein

it should be noted that volume flow calculation are not

routinely used in venous examination

Dr Ahmed EsawyB: venous reflux (R) of 2 s duration is seen across SFJ

A. venous reflux of 0.55 s duration is recorded across the SFJ following distal

augmentation

Dr Ahmed Esawy

Spectral and color Doppler-US image shows the velocity and duration of the reflux

in a collateral from the GSV.

Dr Ahmed Esawy

A : partial incompetence of a venous valve is demonstrated by an area of

retrograde flow (arrow) between the two valve cusps

B : Spectral Doppler demonstrated trickle or low velocity reflux in the popliteal

vein following distal augmentation (S)

Dr Ahmed Esawy

NO reflux with Valsalva

Dr Ahmed Esawy

Reflux of 0.5 sec duration

Dr Ahmed Esawy

1.3 sec duration

Dr Ahmed Esawy

Prolonged duration with Valsalva

Dr Ahmed Esawy

Spectral and color Doppler-US image shows the velocity and duration of

the reflux in an incompetent perforator in the calf area.

Dr Ahmed Esawy

NO REFLUX SEVERE REFLUX

Dr Ahmed Esawy

SPJ incompetence

Distal augmentation

flow toward heart

Following squeeze release

retrograde flow in SSV

Dr Ahmed Esawy

B mode and color Doppler-US: Reflux in the saphenofemoral junction and in a

tributary vein from the pelvis

Dr Ahmed Esawy

Incompetent SFJ

Mickey Mouse view

LSV is very large ,small branches are

Dividing from junction

LSV (L) ,anterolateral branch (arrow)

SFV=V

SFA=A

Dr Ahmed Esawy

CFV proximal LSV=S SFJ=J

Superior tributary is seen draining to the LSV ,just proximal to the junction (arrow)

.it is aften not possible to image the CFV distal to the SFJ in the same plane

B . An image of an abnormally large SFJ (J) which was found to be incompetent

Dr Ahmed Esawy

Transverse image of the left popliteal fossa showing an abnormally large

sapheno-popliteal junction (arrow) ,proximal SSV (S) ,popliteal vein (V) and

popliteal artery (A) .note that the junction is located to the medial side of the

popliteal vein in this example but its position can vary

Dr Ahmed Esawy

Longitudnal image of the popliteal fossa demonstrating a dilated saphenopopliteal

junction and Proximal SSV .there is small deep vein (arrow) jioning the SSV at the

level of the junction (J) to the popliteal vein (PV) .the popliteal artery (PA) is shown

below the vein .it is not always possible to see the junction in this plane or this clarity

,especially if it lies to the medial or lateral side of the popliteal vein

Dr Ahmed Esawy

• A large incompetent upper thigh perforator. The large perforator joins the deep superficial femoral vein (SFV) to the superficial long saphenous vein (LSV). On release of a thigh or calf squeeze, blood would flow from the deep vein through the incompetent perforator into the superficial system.

Dr Ahmed Esawy

An incompetent long saphenous vein.

There is normal forward flow on squeezing the lower thigh (SQ), but the flow reverses when the squeeze is released (REL).

The reverse flow persists for more than two seconds, indicating significant incompetence.

Dr Ahmed Esawy

Greater saphenous vein valvular incompetence.

Dilated vein with forward flow at rest.

Dr Ahmed Esawy

Greater saphenous vein valvular incompetence.

Flow reversal in the arch and proximal vein during Valsalva

Dr Ahmed Esawy

Reversed Color Flow

Dr Ahmed Esawy

B-Mode and color Doppler-US images showing incompetent collaterals that were

responsible for the varicose veins that the patient presented in the physical exam

Dr Ahmed Esawy

• Important dilatation of the femoral vein during Valsalva

the diameter of the vein nearly doubles

• Measurement should be made carefully, applying only minimal pressure with the probe, so that the dilatation of the vein is not hindered.

Dr Ahmed Esawy

diameter of the common femoral vein in the groin of > 14 mm at rest (patient lying down)

and of > 20 mm after Valsalva is to be considered as an important

degree of deep venous insufficiency, and seems to correlate well with the typical clinical symptoms.

Dr Ahmed Esawy

• The region of most interest in examining varices

is the cross of the great saphenous vein. On this

image we see the typical configuration; excellent

vascular filling in Power Doppler mode

Dr Ahmed Esawy

• Dilatation of the cross during Valsalva, with

clear visualization of the closed valve.

Dr Ahmed Esawy

• Characteristic image of incompetent valve of the saphenous cross.

• Color Doppler: dilatation of the cross, reverse flow, turbulent flow (color

mosaic).

• Pulsed Doppler: reversal of the flow direction.

Dr Ahmed Esawy

• Reflux in the saphenous vein: pulsed Doppler shows initially

a turbulent, but later on a more "stable" flow pattern. The

spectral spread of velocities is made very clear by using

color spectral display.

Dr Ahmed Esawy

• Reflux in the V saphena magna: because Color Doppler

gives color-coded directional information in real time, the

reflux at the cross can easily be observed in real time.

Confirmation is registered with pulsed Doppler.

Dr Ahmed Esawy

• There are a lot of anatomical variations of the greater saphenous vein, which can be doubled or can have large side branches (anterolateral and posteromedial). There can be reflux in a side branch, with a normal distal trunk. The image shows reflux in a superficial side branch, because there is a valve on the main trunk just below the bifurcation; the valve is closing normally

Dr Ahmed Esawy

• Chronic reflux gives dilatation and tortuous deformity

of the superficial veins, with typical "cork screw"

appearance; infra-valvular aneurysms are also

common.

Dr Ahmed Esawy

Color Doppler-US image of an incompetent collateral that drained into the GSV

in the thigh area.

collateral

GSV

Dr Ahmed Esawy

• Enlargement of the vein is not always present, especially in the early stages of disease.

• Saphenous vein: diameter of only 3 mm (patient standing, Valsalva), with clear demonstration of reflux.

Dr Ahmed Esawy

• The popliteal fossa should also be evaluated in case of

varices. Lesser saphenous vein (VSP) and gastrocnemius

veins (GCNM) are frequently incompetent. They should be

studied with the patient standing.

Dr Ahmed Esawy

• Cross section of the popliteal fossa: dilatation of

the lesser saphenous vein in case of

incompetence.

Dr Ahmed Esawy

• Characteristic reflux flow pattern of the saphena parva in standing position. Distal compression causes augmentation of the flow, and release of the pressure gives immediately reversal of the flow direction.

Dr Ahmed Esawy

The normal sapheno-femoral junction showing

complete color fill-in across the vein lumen

Dr Ahmed Esawy

• A normal valve in the superficial femoral vein.

Dr Ahmed Esawy

Reflux occurring at the sapheno-femoral junction on

colour Doppler. (a) forward flow; (B) reverse flow

Dr Ahmed Esawy

B-Mode and Color Doppler-US images that show reflux in sapheno-popliteal

junction and in the small saphenous vein

Dr Ahmed Esawy

• Incompetent calf perforating vein

Dr Ahmed Esawy

Perforating Veins

Dr Ahmed Esawy

Perforating Veins

Dr Ahmed Esawy

Most incompetent perforating veins are located on

the medial side of the leg (see diagram).

The Cockett veins are the most common

incompetent veins.

Dr Ahmed Esawy

• Method to scan transversly to calf or lower thigh and the see perforators

• Calf vein incompetence is difficult or impossible to assess so if dilated mean incomptence

• Judicious compression on varices will show course of vein and reflux

Dr Ahmed Esawy

Perforating Veins> 3 mm thickness Retrograde flow Traverse fascial plane

Dr Ahmed Esawy

Perforating veins evaluation:

patient erect. With compression of the calf, forward flow (blue, away from the

transducer) is detected in the greater saphenous vein (top), SFV (bottom), and

one perforating vein between them —. Because of its spiral configuration, the entire

length of the perforating vein cannot be visualized on a single 2D image

Dr Ahmed Esawy

Perforating veins evaluation: patient erect.

Following removal of the tourniquet, high amplitude reflux (red,

towards the transducer) is noted through the perforating vein —

towards the saphenous vein. No reflux is seen in the SFV

(absence of red saturation).

Dr Ahmed Esawy

perforator incompetence

• isolated perforator incompetence at

distal thigh but also occur in calf

from branches of ant or post arch

vein

Dr Ahmed Esawy

In those selected cases where

hemodynamic correction of varicose

veins (CHIVA) is considered,

detection of incompetent perforating

veins is essential.

Dr Ahmed Esawy

• In search of pathological perforating veins, the saphenous

vein is scanned over the whole length in transverse section.

Perforating veins, which form the communication between the

deep and superficial systems, are easy to detect this way.

Dr Ahmed Esawy

• Perforating vein coming through the fascia.

Dr Ahmed Esawy

• Dynamic demonstration of flow in two directions

(normally only flow from superficial to deep) using

Color Doppler.

Dr Ahmed Esawy

• Pulsed Doppler confirmation of bidirectional flow

in the incompetent perforating vein.

Dr Ahmed Esawy

• Recurrence of varicosis after surgery occurs in most cases in the groin, or at the level of perforating veins, which become incompetent.

• This image shows recurrence at the level of the former sapheno-femoral junction; reflux is demonstrated using Color Doppler

Dr Ahmed Esawy

VARICOSITY

DISTRIBUTIONS

Dr Ahmed Esawy

• Varicose patterns on the leg often

indicate the source of the problem

• Determining the source of the

varicosities is important for treatment

Dr Ahmed Esawy

• junctional tributaries are often the

site of varicosities

• Saphenous nerve close contact

with the GSV below the knee

Dr Ahmed Esawy

Zone of Influence

of GSV

Varicose Veins

Terminal and subterminal valves at the SFJ

Leaks cause VV

Often causes varicosities in the tributaries

Zone of influence GSV medial aspect

Dr Ahmed Esawy

Varicose Veins

GSV Reflux

medial aspect

Dr Ahmed Esawy

Varicose Veins

Anterior Circumflex (ATL) Reflux

varicose areas on the anterior aspect of the thigh and lateral calf supplied from incompetence of the anterolateral vein from the saphenofemoral junction . The main proximal trunk of the LSV can be competent or incompetent in this situation.

Dr Ahmed Esawy

Varicose Veins Pudendal

Reflux

Dr Ahmed Esawy

Zone of Influence of

SSV and VG

The saphenopoliteal junction is often the origin

of reflux in the SSV

The excess blood volume entering the SSV from the

deep system causes varicosities to form in

tributary braches that course along the posterior

Calf

Reflux in the VG often leads into the GSV and

varicosities often occur in the posterior thigh

Dr Ahmed Esawy

Varicose Veins

Small Saphenous Reflux

varicosities to form in tributary braches that course along the posterior Calf

Dr Ahmed Esawy

Varicose Veins

Varicosities of the Vein of Giacomini

Dr Ahmed Esawy

Zone of Influence of

LSVS

The network of abnormal reticular vein

demonstrate reflux

A focal source of reflux often can not be found

with ultrasound

Spider veins often occur along the lateral aspect

of the thigh and calf

Large varicosities can occur

Dr Ahmed Esawy

Varicose Veins

Lateral Subdermic Venous System

Dr Ahmed Esawy

unusual distributions

Varicose at the anterior aspect of the calf or lateral aspect of the thigh . The supply is frequently from varicose branches of the LSV or SSV, depending on the location of the varicose areas.

varicose veins running along the lateral aspect of the thigh and calf can be related to isolated perforators located on the lateral aspect of the upper thigh.

Dr Ahmed Esawy

Varicose veins in the lower posterior and posteromedial thigh can be supplied by the Giacomini vein.

In this unusual situation, blood flows in a loop, across an incompetent saphenopopliteal junction and up the Giacomini vein, which then feeds the superficial varicosities running down the leg. This is a ‘paradoxical’ situation, in which the thigh veins are filled by ‘anti gravitational’ flow, but in fact the flow will eventually make its way down into the calf via the incompetent veins, in the correct gravitational direction

unusual distributions

Dr Ahmed Esawy

In some patients, it may be impossible to clearly define the source of the varicose veins

especially if they are very small, are diffusely distributed and generally run into very small superficial tributaries.

Dr Ahmed Esawy

RECURRENT

VARICOSE

VEIN

Dr Ahmed Esawy

Possible causes of LSV recurrences

Incomplete Ligation SFJ

Neo-vascularization (cavernoma)

Incomplete stripping of the LSV trunk in the thigh

(Remnants of GSV)

Duplicated GSV

incomplete removal of incompetent Thigh or calf perforators

failure to differentiate lesser from greater saphenous

vein incompetence (incompetence of the SSV)

Incompetent tributaries

Secondary varicose veins

Dr Ahmed Esawy

Possible causes of SSV recurrences

• incomplete ligation of the

saphenopopliteal junction

• lncompetent Giacomini vein

• Incompetent perforators

• LSV incompetence

• Diffuse varicosities in the popliteal

fossa

Dr Ahmed Esawy

Difficulty in competency assess

• the assessment of patients with venous ulcers.

• continuous high-volume flow (hyperemic flow) in the superficial and deep veins due to infection.

• The high-volume flow toward the heart can lead to a reduction in reflux duration

• The leg can be reassessed when the hyperemia subsides (by antiobiotic therapy).

Dr Ahmed Esawy

Saphenous pulsation on duplex may be a marker

of severe chronic superficial venous insufficiency

Duplex tracing of a typical saphenous pulse (SP) waveform

Etiology may be AV connections (arterial varices)

Dr Ahmed Esawy

SUPERFICIAL

PHLEBITIS

Dr Ahmed Esawy

Color Doppler examination is frequently carried out to see if there is thrombus, or to evaluate the extension of the thrombus in the deep system.

Example: thrombosis of the greater saphenous vein with extension of the thrombus (arrows) in the femoral vein

Dr Ahmed Esawy

• Due to inflammatory infiltration of the surrounding

subcutaneous fat, a hyperechoic halo is visible

around the inflamed vein in case of phlebitis

Dr Ahmed Esawy

A marked inflammatory hyper-vascularization is always visible

around the inflamed part of the vein, with hypertrophic

arterioles which are not visible in normal conditions.

Dr Ahmed Esawy

A typical low-resistance inflammatory flow is seen in these tiny arterioles.

.

Dr Ahmed Esawy

Sonographic triade of superficial phlebitis

hyperechoic halo

small arterioles around the vein

low-resistance flow