Venous insufficency may be acurately assesed by DUS

1. Duplex Assessment
of Venous
Hemodynamics
Claude FRANCESCHI, Roberto DELFRATE
Paris France, Cremona Italy

2. Hemodynamics knowledge is the
backbone of nowadays
performance in Diagnosis and
Treatment of Arterial and Cardiac
disease
Hemodynamics ignorance is the
reason for the still raw diagnosis
and treatment of the Venous
Disease despite the advanced
technologies that cannot
compensate theoretical lacks

3. Venous Hemodynamics
knowledge demands a peculiar
intellectual effort because:
Not teached in most universities
Weakly promoted ( known?) by
the majority of Phlebology
Opinion Leaders and Scientific
Societies
More complex than arterial

4. Duplex assessment of
venous
hemodynamics is the
key point for a better
diagnosis and
appropriate treatment
strategy
IF lighted by rational
and coherent
theoretical models

5. Duplex aims at
assessing the
hemodynamic
changes of the
venous system
According to the
various
hemodynamic
configurations

6. Pressure and Flow Overloading is
responsible for TMP EXCESS
TMP Excess is Responsible for
-Veins Dilatation ( Varicose)
-Drainage impairment ( trophic changes :
edema, hypodermitis, ulcer…)

7. Pressure and Flow Overloading is due
to
Venous Block responsible for
-Permanent Venous Pressure Excess
-Compensatory collaterals (Open Shunts)
Valve Incompetence responsible for
-Deep Reflux ( various grades)
-Superficial Reflux
- -Closed Circuits ( Closed Shunts)
- -Deviated Flows ( Open deviated Shunts)

8. DUPLEX is able to assess all these
complex configurations made of
blocks and shunts
IF performed according to appropriate
data assessments
So providing accurate diagnosis and
consequently appropriate treatment

9. Hemodynamic Manoeuvres
Are Mandatory to elicit the
hemodynamic impairments

10. Hemodynamic Manoeuvres
Upright Position
Valsalva: Thoraco-abdominal
Pump Stress Test
Squizing, Paranà , Wundsdorf:
Valvo-muscular Pump Stress Test
Supine Position
Venous Pressure: Hemodynamic
obstacles assessment

11. Hemodynamic Manoeuvres
Upright Position
Valsalva: Thoraco-abdominal
Pump Stress Test
Squizing, Paranà , Wundsdorf:
Valvo-muscular Pump Stress Test
Supine Position
Venous Pressure: Hemodynamic
obstacles assessment

12. Valsalva Manoeuvre:
May be performed easily and properly
blowing into a blocked straw

13. Valsalva Manoeuvre:
Increases the Toraco-abdominal venous
pressure
and reverses downwards the pressure
gradient but not the flow when blocked by
the valves closure

14. Valsalva Manoeuvre:
Valsalva is negative when the valves are
Competent
Flow is blocked by blowing ( systole)
and appears at release (diastole)
At
rest
Systole
=
blowing
Relax
Diastole

15. Valsalva Manoeuvre:
Valsalva is Positive when valves are
Incompetent Valve
Reverse Flow appears when blowing
( systole) and at release (diastole)
At
rest
Systole
=
blowing
Relax
Diastole

16. Exception!!!!!
Contrary to the majority of the veins,
AT DESCENDING TRIBUTARIES OF THE
SAPHENA ARCH
Positive Valsalva flow fed by pelvic leaks
doesn’t reverse direction
o P
c P
p P
s g P
ig P
i P i P
o P
c P
p P
gs P
g s P
At
rest
Systole
=
blowing
Relax
Diastole

17. Hemodynamic Manoeuvres
Upright Position
Valsalva: Thoraco-abdominal
Pump Stress Test
Squizing, Paranà , Wundsdorf:
Valvo-muscular Pump Stress Test
Supine Position
Venous Pressure: Hemodynamic
obstacles assessment

18. Purpose:
Assessing
VALVE COMPETENCE
VALVE INCOMPETENCE
Grades:
-Total, Partial, Segmental
Haemodynamic effect:
- -Closed Shunts (closed circuit )
-Open Deviated Shunt ( open circuit )
VENOUS BLOCKS AND BY-PASSING VEINS
-Open Vicarious Shunt ( open circuit )

19. Purpose:
Assessing
VALVE COMPETENCE
VALVE INCOMPETENCE
Grades:
-Total, Partial, Segmental, Closed Shunt
Haemodynamic effect:
-Open Deviated Shunt ( open circuit )
-Closed Shunts (closed circuit )
VENOUS BLOCKS AND BY-PASSING VEINS
-Open Vicarious Shunt ( open circuit )

20. Paranà:
Physiologic
Active Systole of the VMP and
plantar pump
BY
Proprioceptive reflex contraction
triggerd by a light push-pull at the
waist

21. Paranà:
Physiologic
Active Systole of the VMP and
plantar pump
BY
Proprioceptive reflex contraction
triggerd by a light push-pull at the
waist

22. Paranà:
Physiologic
Active Systole of the VMP and
plantar pump
BY
Proprioceptive reflex contraction
triggerd by a light push-pull at the
waist

23. Paranà:
Physiologic
Active Systole of the VMP and
plantar pump
BY
Proprioceptive reflex contraction
triggerd by a light push-pull at the
waist

24. Purpose:
Assessing
VALVE COMPETENCE
VALVE INCOMPETENCE
Grades:
-Total, Partial, Segmental
Haemodynamic effect:
-Closed Shunts (closed circuit )
- Open Deviated Shunt ( open circuit )
VENOUS BLOCKS AND BY-PASSING VEINS
-Open Vicarious Shunt ( open circuit )

25. Ilio-femoro-popliteal TOTAL incompetence
At
rest
Popliteal Vein
Diastolic
Reflux
coequal to
Systolic
S
coequal
D

26. SEGMENTAL Popliteal incompetence
Above Femoral Valve Closure
At
rest
Decreases the Reflux
Diastole
S
D
Diastolic
Reflux
Peak
lower than
Systolic

27. PARTIAL Popliteal incompetence
At
rest
Small valve leak
S
D
Low and
Lasting
Diastolic
Reflux

28. Purpose:
Assessing
VALVE COMPETENCE
VALVE INCOMPETENCE
Grades:
-Total, Partial, Segmental
Haemodynamic effect:
- -Closed Shunts (closed circuit )
-Open Deviated Shunt ( open circuit )
VENOUS BLOCKS AND BY-PASSING VEINS
-Open Vicarious Shunt ( open circuit )

29. Deep CLOSED SHUNT
Diastolic Reflux overloaded by a competent
collateral vein flow
At
rest
Femoral Example
Femoral Example
Diastolic
Reflux Peak
and volume
Higher than
Systolic

30. Superficial CLOSED SHUNT
Superficial Diastolic Reflux overloaded by a deep
vein flow
At
rest
Great Saphena Example
Great Saphena Example
Diastolic
Reflux Peak
and volume
Higher than
Systolic
S
D

31. Superficial CLOSED SHUNT
Superficial Diastolic Reflux overloaded by a deep
vein flow
At
rest
Great Saphena Example
Great Saphena Example SHUNT 1
Diastolic
Reflux Peak
and volume
Higher than
Systolic
S
D
Positive (+)
Valsalva

32. Superficial CLOSED SHUNT
Superficial Diastolic Reflux overloaded by a deep
vein flow
Other Closed Shunts have the same
hemodynamic features but are different
according to the deep leak point that
feed them their and the re-entry point
that drain them and the involved
network

33. i P i P
o P
c P
p P
s g P
ig P
o P
c P
p P
gs P
g s P
Sapheno-femoral Junction
Sapheno-popliteal Junction
Pelvis leak points
Various Perforators
Networks:
N1, N2, N3, N4

34. Purpose:
Assessing
VALVE COMPETENCE
VALVE INCOMPETENCE
Grades:
-Total, Partial, Segmental
Haemodynamic effect:
- -Closed Shunts (closed circuit )
-Open Deviated Shunt ( open circuit )
VENOUS BLOCKS AND BY-PASSING VEINS
-Open Vicarious Shunt ( open circuit )

35. Superficial OPEN DEVIATED SHUNT
Superficial Diastolic Reflux overloaded by a
deep
other vein flow
superficial collateral veins flow
At
rest
Great Saphena Example
Great Saphena Tributary Example
Diastolic
Reflux Peak
and volume
Higher than
Systolic
S
D
Negative (-)
Valsalva

36. Purpose:
Assessing
VALVE COMPETENCE
VALVE INCOMPETENCE
Grades:
-Total, Partial, Segmental
Haemodynamic effect:
- -Closed Shunts (closed circuit )
-Open Deviated Shunt ( open circuit )
VENOUS BLOCKS AND BY-PASSING VEINS
-Open Vicarious Shunt ( open circuit )

37. Superficial OPEN VICARIOUS SHUNT
Superficial Systolic Diastolic flow Reflux overloaded overloaded by by deep
a deep
vein flow
Great Saphena Example
At
rest
Great Saphena By-Passing a popliteal
Rest, Systolic
Peak and
Diastolic
antegrade
flow
S
block Example
venous flow
D

38. o P
c P
p P
s g P
ig P
i P i P
o P
c P
p P
gs P
g s P
Networks and their Connections are
checked up :
Flow direction and modulation
- -at rest
- under hemodynamic stress
manoeuvres
Selected according to the peculiar status of
each patient
In order to depict a taylored topo-hemodynamic
feature

39. Hemodynamic Manoeuvres
Upright Position
Valsalva: Thoraco-abdominal
Pump Stress Test
Squizing, Paranà , Wundsdorf:
Valvo-muscular Pump Stress Test
Supine Position
Venous Pressure: Hemodynamic
obstacles assessment

40. Venous Pressure Measurement:
Veins Patency Test
Supine Position
Normal ≤ 25 mm Hg
Cuff
inflation/deflation
Posterior Tibial Vein
flow

41. For a comprehensive information

43. Duplex assessment of
venous
hemodynamics
Lower limbs
Venous network
Dynamic Stress Manoeuvres
Hemodynamic Obstacles and Open
Vicarious Shunts
Hemodynamic Valve Incompetence
and Closed/Open Derivate Shunts
Protocole Assessment
Hemodynamic Mapping

44. Duplex assessment of
venous
hemodynamics
Lower limbs
Venous Networks (N)
Dynamic Stress Manoeuvres
Hemodynamic Obstacles and Open
Vicarious Shunts
Hemodynamic Valve Incompetence
and Closed/Open Derivate Shunts
Protocole Assessment
Hemodynamic Mapping

45. Venous Networks ( N )
1988
Skin
Sub-
Cut.
Tissue
Duplicated
Apon.
fascia
Sub-Apon.
Compart.

46. Venous Networks ( N )
1988
N3 sub-cut.
veins
N2 intra-fasc.
veins
N1 deep
veins

47. Venous Networks ( N )
1988
Hierarchical draining
N3 N2 N1

48. Venous Networks ( N )
1988
Draining Veins
N1
N2
N3
Deep veins
TRUNKS
Ant.Saph.
Great saph.
GiacominiV.
Small saph.
Saph. and Extra
Saph. tributaries

49. Venous Networks ( N )
1988
Draining Veins
N4
N2 ► N2
Connecting
Veins

50. Venous Networks ( N )
N2 ►N1 collectors
Sapheno-Femoral Junction
Sapheno-Popliteal Junction

51. Venous Networks ( N )
N2 ►N1 main
perforators
LEGS

52. Venous Networks ( N )
N3 ►N1 some
perforators
LEGS

53. Venous Networks ( N )
N3 ►N1 perforators
Pelvis
6 perforators
Perineal V P Point
Rd Ligt V I Point
Clit. V C Point
Obt. V O Point
I Glut.V IG Point
S Glut. V SG Point
o P
c P
p P
s g P
ig P
i P i P
o P
c P
p P
gs P
g s P
Franceschi C, Bahnini A. (2005) Treatment of
lower extremity venous insufficiency due to pelvic
leaks points in women; Ann vasc Surg; 19; 284-88

54. Networks and their Connections
are checked up :
Flow direction and modulation
- at rest
- under hemodynamic
stress manoeuvres
Selected according to the
peculiar status of each patient
In order to depict a taylored
topo-hemodynamic feature

55. Duplex assessment of
venous
hemodynamics
Lower limbs
Venous Networks (N)
Dynamic Stress Manoeuvres
Hemodynamic Obstacles and Open
Vicarious Shunts
Hemodynamic Valve Incompetence
and Closed/Open Derivate Shunts
Protocole Assessment
Hemodynamic Mapping

56. Hemodynamic Manoeuvres
Upright Position
Valsalva: Thoraco-abdominal
Pump Stress Test
Squizing, Paranà , Wundsdorf:
Valvo-muscular Pump Stress Test
Supine Position
Venous Pressure: Hemodynamic
obstacles

57. Hemodynamic Manoeuvres
Upright Position
Valsalva: Thoraco-abdominal
Pump Stress Test
Squizing, Paranà , Wundsdorf:
Valvo-muscular Pump Stress Test
Supine Position
Venous Pressure: Veins Patency
Test

58. Valsalva Manoeuvre:
Systolic Block of Thoraco-abdominal Pump
increases
the Toraco-abdominal venous pressure

59. Valsalva Manoeuvre:
Systolic Block of Thoraco-abdominal Pump
increases the Toraco-abdominal venous
pressure
So reversing downwards the pressure
gradient without flow reversal thanks to the
peripheral valves closure

60. Valsalva Manoeuvre:
Toraco-abdominal Pump Systolic Block
increases the Toraco-abdominal venous
pressure
So reversing downwards the pressure
gradient it produces a reversal reflux flow
when the peripheral valves are incompetent

61. Valsalva Manoeuvre:
How to achieve Valsalva Manoeuvre
easily and effectively :
Blowing into a KNOTTED STRAW
Blow!

62. Valsalva Manoeuvre:
Negative Valsalva = Competent Valve
VALVE COMPETENCE = NO SYSTOLIC REFLUX

63. Valsalva Manoeuvre:
Negative Valsalva = Competent Valve
VALVE COMPETENCE = NO SYSTOLIC REFLUX
At rest, Permenant and Slow Upwards
flow due to Residual Pressure
At
rest

64. Valsalva Manoeuvre:
Negative Valsalva = Competent Valve
VALVE COMPETENCE = NO SYSTOLIC REFLUX
then the flow is blocked by the Valsalva
At
rest
systole
Systole
=
blowing

65. Valsalva Manoeuvre:
Negative Valsalva = Competent Valve
then the flow is blocked by the Valsalva
At
rest
systole
Systole
=
blowing

66. Valsalva Manoeuvre:
Negative Valsalva = Competent Valve
VALVE COMPETENCE = NO SYSTOLIC REFLUX
Then at release, le blood flows upwards
again thanks to the thoraco-abdominal
At
rest
pump diastole
Systole
=
blowing
Relax
Diastole

67. Valsalva Manoeuvre:
Positive Valsalva = Incompetent Valve
VALVE INCOMPETENCE = ONLY VALSLVA SYSTOLIC
REFLUX

68. Valsalva Manoeuvre:
Positive Valsalva = Incompetent Valve
VALVE INCOMPETENCE = ONLY SYSTOLIC REFLUX
Normal at rest
At
rest

69. Valsalva Manoeuvre:
Positive Valsalva = Incompetent Valve
VALVE INCOMPETENCE = ONLY SYSTOLIC REFLUX
Systolic reflux
At
rest
Systole
=
blowing

70. Valsalva Manoeuvre:
Positive Valsalva = Incompetent Valve
VALVE INCOMPETENCE = ONLY SYSTOLIC REFLUX
Normal at Diastole
At
rest
Systole
=
blowing
Relax
Diastole

71. Valsalva Manoeuvre:
Positive Valsalva = Incompetent Valve
VALVE INCOMPETENCE = ONLY SYSTOLIC REFLUX
Normal at Diasole
At
rest
Systole
=
blowing
Relax
Diastole

72. Valsalva Manoeuvre:
Contrary to the majority of the veins,
DESCENDING TRIBUTARIES OF THE
SAPHENE ARCHS flow
downwards
and its refluxes are not reverse flows
SO Valsalva is Positive when it
produces a no reverse systolic
downwards flow
The reflux is fed by one of the pelvic
leak points
o P
c P
p P
s g P
ig P
i P i P
o P
c P
p P
gs P
g s P

73. At
rest
Valsalva Manoeuvre:
Contrary to the majority of the veins,
DESCENDING TRIBUTARIES OF THE
SAPHENE ARCHS flow
downwards
and are not reverse flows nor reflux when
at rest

74. Contrary to the majority of the veins,
DESCENDING TRIBUTARIES OF THE
and are not reverse flows nor reflux at rest .
The absence of reflux is attested by absence of
flow during the Systole
At
rest
Valsalva Manoeuvre:
SAPHENE ARCHS flow
downwards
Systole
=
blowing

75. Contrary to the majority of the veins,
DESCENDING TRIBUTARIES OF THE
and are not reverse flows nor reflux when
at rest and during the diastole
At
rest
Valsalva Manoeuvre:
SAPHENE ARCHS flow
downwards
Systole
=
blowing
Relax
Diastole

76. Valsalva Manoeuvre:
DESCENDING TRIBUTARIES OF THE
SAPHENE ARCHS
PositiveValsalva = Systolic Downwards flow
WITHOUT REVERSE FLOW
REFLUX FROM INCOMPETENT PELVIC PERFORATORS

77. At
rest
Valsalva Manoeuvre:
DESCENDING TRIBUTARIES OF THE
SAPHENE ARCHS
PositiveValsalva = Systolic Downwards flow
WITHOUT REVERSE FLOW

78. DESCENDING TRIBUTARIES OF THE
PositiveValsalva = Systolic Downwards flow
WITHOUT REVERSE FLOW
At
rest
Valsalva Manoeuvre:
SAPHENE ARCHS
Systolic
REFLUX
=
blowing
REFLUX FROM
INCOMPETENT PELVIC
PERFORATORS

79. At
rest
Valsalva Manoeuvre:
DESCENDING TRIBUTARIES OF THE
SAPHENE ARCHS
PositiveValsalva = Systolic Downwards flow
WITHOUT REVERSE FLOW
Relax
Diastole
Systolic
REFLUX
=
blowing

80. Valsalva Manoeuvre:
Positive Valsalva = Incompetent Valve
At
rest
Systole
=
blowing
Relax
Diastole

81. Hemodynamic Manoeuvres
Upright Position
Valsalva: Thoraco-abdominal
Pump Stress Test
Squizing, Paranà , Wundsdorf:
Valvo-muscular Pump Stress Test
Supine Position
Venous Pressure: Veins Patency
Test

82. Squizing, Paranà , Wundsdorf:
Valvo-muscular Pump Stress Test
Purpose:
Elicit
VALVE COMPETENCE
VALVE INCOMPETENCE
Features:
-Total, Partial, Segmental, Closed Shunt
Haemodynamic effect:
-Open Deviated Shunt ( open circuit )
-Closed Shunts (closed circuit )
VENOUS BLOCKS AND BY-PASSING VEINS
-Open Vicarious Shunt ( open circuit )

83. Squizing, Paranà , Wundsdorf:
Valvo-muscular Pump Stress Test
Purpose:
Elicit
VALVE COMPETENCE
VALVE INCOMPETENCE
Features:
-Total, Partial, Segmental, Closed Shunt
Haemodynamic effect:
-Open Deviated Shunt ( open circuit )
-Closed Shunts (closed circuit )
VENOUS BLOCKS AND BY-PASSING VEINS
-Open Vicarious Shunt ( open circuit )

84. Squizing, Paranà , Wundsdorf:
Valvo-muscular Pump VMP Stress
Test
Squizing:
Not physiologic
Passive Systole of the VMP
+
N2 and N3 emptying

85. Squizing, Paranà , Wundsdorf:
Valvo-muscular Pump VMP Stress
Test
Paranà:
Physiologic
Active Systole of the VMP and
plantar pump
BY
Proprioceptive reflex contraction
triggerd by a light push-pull at the
waist

86. Squizing, Paranà , Wundsdorf:
Valvo-muscular Pump VMP Stress
Test

87. Squizing, Paranà , Wundsdorf:
Valvo-muscular Pump VMP Stress
Test

88. Squizing, Paranà , Wundsdorf:
Valvo-muscular Pump VMP Stress
Test

89. Squizing, Paranà , Wundsdorf:
Valvo-muscular Pump VMP Stress
Test

90. Squizing, Paranà , Wundsdorf:
Valvo-muscular Pump VMP Stress
Test

91. Squizing, Paranà , Wundsdorf:
Valvo-muscular Pump VMP Stress
Test
At rest, very low upwards flow
At
rest

92. Squizing, Paranà , Wundsdorf:
Valvo-muscular Pump VMP Stress
Test
Pull 2 cms back but quickly
In order to trigger a Systole by
Proprioceptive reflex contraction of
the calf
At
rest

93. Squizing, Paranà , Wundsdorf:
Valvo-muscular Pump VMP Stress
Test
Then Push ahead 2 cms but quickly
In order to relax the
Proprioceptive reflex contraction of
the calf (Diastole)
At
rest

94. Squizing, Paranà , Wundsdorf:
Valvo-muscular Pump Stress Test
Purpose:
Elicit
VALVE COMPETENCE
VALVE INCOMPETENCE
Features:
-Total, Partial, Segmental, Closed Shunt
Haemodynamic effect:
-Open Deviated Shunt ( open circuit )
-Closed Shunts (closed circuit )
VENOUS BLOCKS AND BY-PASSING VEINS
-Open Vicarious Shunt ( open circuit )

95. At
rest
Squizing, Paranà , Wundsdorf:
Valvo-muscular Pump VMP Stress
Test
Ilio-femoro-popliteal TOTAL incompetence
Popliteal Vein
At rest

96. Squizing, Paranà , Wundsdorf:
Valvo-muscular Pump VMP Stress
Test
Ilio-femoro-popliteal TOTAL incompetence
Systole
At
rest
Popliteal Vein

97. At
rest
Squizing, Paranà , Wundsdorf:
Valvo-muscular Pump VMP Stress
Test
Ilio-femoro-popliteal TOTAL incompetence
Popliteal Vein
Diastole
S
coequal
D

98. At
rest
Squizing, Paranà , Wundsdorf:
Valvo-muscular Pump VMP Stress
Test
SEGMENTAL Popliteal Incompetence
Popliteal Vein
At rest

99. Squizing, Paranà , Wundsdorf:
Valvo-muscular Pump VMP Stress
Test
SEGMENTAL Popliteal Incompetence
Systole
At
rest
Popliteal Vein

100. At
rest
Squizing, Paranà , Wundsdorf:
Valvo-muscular Pump VMP Stress
Test
SEGMENTAL Popliteal Incompetence
Popliteal Vein
Diastole
S
D peak
D
<
S peak
Femoral Valve
Closure
Decreases the
Reflux

101. At
rest
Squizing, Paranà , Wundsdorf:
Valvo-muscular Pump VMP Stress
Test
PARTIAL Popliteal Incompetence
Popliteal Vein
At rest

102. Squizing, Paranà , Wundsdorf:
Valvo-muscular Pump VMP Stress
Test
PARTIAL Popliteal Incompetence
Systole
At
rest
Popliteal Vein

103. Squizing, Paranà , Wundsdorf:
Valvo-muscular Pump VMP Stress
Test
At
rest
PARTIAL Popliteal Incompetence
Popliteal Vein
Diastole
S
D
D peak
<
S peak
D time
>
S time

104. At
rest
Squizing, Paranà , Wundsdorf:
Valvo-muscular Pump VMP Stress
Test
Deep Closed Shunt Example
Incompetent Fem-Popliteal V
+ Competent Collat.V ( may be Deep Fem.)
Popliteal Vein
Diastole
D peak
>
S peak

105. At
rest
Squizing, Paranà , Wundsdorf:
Valvo-muscular Pump VMP Stress
Test
Ilio-femoro-popliteal TOTAL incompetence
Great Saphenous vein
At rest

106. Squizing, Paranà , Wundsdorf:
Valvo-muscular Pump VMP Stress
Test
Ilio-femoro-popliteal TOTAL incompetence
Systole
At
rest
Popliteal Vein

107. At
rest
Squizing, Paranà , Wundsdorf:
Valvo-muscular Pump VMP Stress
Test
Ilio-femoro-popliteal TOTAL incompetence
Popliteal Vein
Diastole
S
coequal
D

108. Hemodynamic Manoeuvres
Upright Position
Valsalva: Thoraco-abdominal
Pump Stress Test
Squizing, Paranà , Wundsdorf:
Valvo-muscular Pump Stress Test
Supine Position
Venous Pressure: Veins Patency
Test

109. Venous Pressure Measurement:
Veins Patency Test
Supine Position
Normal ≤ 25 mm Hg
Cuff
inflation/deflation
Posterior Tibial Vein
flow

110. Duplex assessment of
venous
hemodynamics
Lower limbs
Venous Networks (N)
Dynamic Stress Manoeuvres
Hemodynamic Obstacles and Open
Vicarious Shunts
Hemodynamic Valve Incompetence
and Closed/Open Derivate Shunts
Protocole Assessment
Hemodynamic Mapping

111. Hemodynamic Obstacles
The hemodynamic significance of a
block in terms of drainage quality is
inversely proportional to the collateral
compensatory veins developing

112. N1
N2
N3
N4L
N4T
Collectors:
N2 -N1: SFJ, SPJ
N3 -N1: Perineal V P Point
Rd Ligt V I Point
Clit. V C Point
Obt. V O Point
I Glut.V IG Point
S Glut. V SG Point
Internetworks connections
Perforators:
N2 -N1: saphenous truncks→deep Veins
N3 -N1:Saphenous tributaries and
others→deep Veins
Connectors:
N2 –N2: saphenous truncks
N3 -N1:Saphenous tributaries and others

113. N1
N2
N3
N4L
N4T
Collectors:
N2 -N1: SFJ, SPJ
N3 -N1: Perineal V P Point
Rd Ligt V I Point
Clit. V C Point
Obt. V O Point
I Glut.V IG Point
S Glut. V SG Point
Internetworks connections
Perforators:
N2 -N1: saphenous truncks→deep Veins
N3 -N1:Saphenous tributaries and
others→deep Veins
Connectors:
N2 –N2: saphenous truncks
N3 -N1:Saphenous tributaries and others

114. Draining network from skin to suprafascial veins (Network 3) then intrafascial veins
(Network 2) then deep subfascial veins (Network 1)
Common Femoral Vein
Great Saphenous Arch
Anterior Saphena
Deep Femoral Vein
Great Saphenous Trunk
Superficial Femoral Vein
Giacomini Vein
Small Sahenous Arch
Popliteal Vein
Small Sahenous Trunk
N2
N3
N4L
N4T
1988
N1

116. Dynamic manoeuvres
Valsalva manoeuvres
Active calf pump test
Passive calf pump test
Networks N1,N2,N3,N4
Obstacle assessments
Dynamic Obstacle assessments
Demodulatlion
collateral by-pass
doppler ankle pressure
Anatomic Obstacle assessments
Color
Compression

117. Assessment protocole
Mapping
Strategies
Tactics
Valve competence
assessment
Valve incompetence
assessment : value
SHUNTS: venous segment
overloaded by extra
volume/pressure fed by Escape
points and redirected into Re-entry
points :
Sapheno-femoral junction
Sapheno-Popliteal junction
Pelvic leak points
Perforators
Open vicarious shunts
Open derivating shunts
Closed shunts
superficial : type
1 to 6
deep
Mixt shunts

118. N1
N2
N3
N4L
N4T
Collectors:
N2 -N1: SFJ, SPJ
N3 -N1: Perineal V P Point
Rd Ligt V I Point
Clit. V C Point
Obt. V O Point
I Glut.V IG Point
S Glut. V SG Point
Internetworks connections
Perforators:
N2 -N1: saphenous truncks→deep Veins
N3 -N1:Saphenous tributaries and
others→deep Veins
Connectors:
N2 –N2: saphenous truncks
N3 -N1:Saphenous tributaries and others