Doppler of varicose vein and treatment

2. DEFINITION
• Varicose veins are defined as dilated, elongated, tortuous
and palpable superficial veins as a result of venous
hypertension.
• 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.

4. Venous System of lower limb
Consists of:
• Deep system of veins which
lies below the deep fascia.
• Superficial system of veins
which lies outside the deep
fascia (carry 10% blood)
• Perforating veins which
pass through the deep
fascia joining the superficial
to the deep system of
veins.

6. Long saphenous vein
• Originates at the medial border of the foot.
• It passes 1-1.5 inches anterior to the medial
malleolus over the distal 1/3rd of the tibia.
• It is accompanied by the saphenous nerve below the
knee joint
• Travels close to the deep fascia except at the knee
joint, where it may become subcuticular
• In the thigh it passes antero-superiorly to reach the
saphenous opening which is 3.75 cm below and
lateral to the pubic tubercle.
• The vein of Giacomini joins LSV to SSV in thigh ,
responsible for recurrences.

8. 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

9. 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)

10. Location of perforators
Six Perforators joining the superficial
to deep venous system are located at
constant positions which are:
• 2, 4 and 6 inches above the
medial malleolus (Cockett’s
perforator)
• Just below the Tibial
tubercle(Boyd’s)
• In the adductorcanal of the
thigh(Dodd’s perforator)
• Level of Mid-thigh(Hunter’s)
• Around 200 perforators are
described most of them
unnamed

11. Short Saphenous vein
• Arises on the lateral border of the foot by joining of
lateral marginal vein and lateral deep venous arch.
• Passes behind the lateral malleolus
• Runs up in the midline posteriorly in the intra fascial
compartment.
• Pierces the deep fascia in the upper part of the calf,
and terminates in the popliteal vein in the midline
4cm below the popliteal skin crease.
• It is accompanied by the Sural nerve, lymphatics and
popliteal nerve along its course.

13. The short saphenous vein (V) is 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

14. Location of short saphenous
perforators
• Bassi’s perforator- 5 cm above
calcaneous
• Soleus point perforator
• Gastroenemius point perforator

15. Valves in the veins
• Valves present in superficial veins.
• Prevent flow of blood from proximal to distal
and from deep to superficial
• Absent from above groin level
• Valves can resist pressure up to 300 mm of
Hg.

16. • A normal valve in the superficial femoral vein.

17. Dr Ahmed
SFJ Pre-terminal Valve
/ Terminal Valve
Pre-Terminal Valve
Saphenous Ligament

18. Interfascial Veins
GSV Egyptian Eye
Leaflets of the Valve

19. Varicose presentation
• More common in males in India
• Left lower limb more commonly involved
• Long saphenous system affected in 2/3 rd of cases

20. • Negative pressure in thorax during inspiration to -6
mm.
• Calf muscle pump: Normal venous pressure in
relaxed state 20mm of Hg.Rises to 80-100 mm of
Hg during muscle contraction.
• Vis a tergo : arterial pressure transmitted to venous
side through capillary bed
• Competent valves
• Venae commitants: lie by the side of artery, helped
by arterial pulsation to propel blood.
Factors Helping in Venous return

21. 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

22. 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
Congenital abnormalities (Klippel - Trenaunay - Weber Syndrome)
Artery-Venous valvular incopetence
Primary
Secondary
Impaired venous drainage
Varicose veins etiology
Reflux (most common)

23. Klippel Trenaunay syndrome
• Varicose veins
• Limb
hypertrophy
• Port wine Stains

24. Complications due to
vericosity
• Bleeding
• Thrombophlebitis
• Venous Hypertension leading to
venous ulcer
• Calcification
• Talipes Equinovarus deformity of
foot
• Eczematoid dermatitis and
pigmentation
• Periostitis of subcutaneous
surface of tibia
• Carcinoma in long standing
venous ulcer-Marjolins ulcer

25. 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

26. Telangectasia
Dermis
Reticular vein
Varicose vein
Perforators
Sup. fascia
Deep fascia
Deep vein
Superficial & Deep connections

27. Dr Ahmed Esawy
Type Class Size Color
I Telangectasia
/spiders
0.1-1 mm Red
II Venul-ectasia 1-2 mm Violet
III Reticular veins 2-4 mm Blue
IV Non-
saphenous
varicose
3-8 mm Blue
V Saphenous
varicose
7-8 mm Blue
varicose veins Classification

28. 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

29. 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.

30. 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.

31. Evaluation of valvular competence in the
deep venous system
Qualitative assessment
On color Doppler
observing 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.

33. Evaluation of valvular
competence in the
superficial venous system

35. 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 due to 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)

36. Dr Ahmed
B shows a varicose vein with a
deformed valve, abnormal blood flow,
and thin, stretched walls. The middle
image shows where varicosevein 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.

37. 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.

38. 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
varicosites).

40. 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.

41. 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.

42. • 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 .

43. 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

44. Incompetent GSV
normal GSV

45. GSV standing
GSV supine

46. 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.

47. Anterior accessory GSV

48. cCompensatory Anterior accessory GSV
Hypo plastic GSV

49. Duplicated GSV

50. Echogenic lining
Sclerosed vein

51. Thrombosed GSV

52. Transverse image of tortuous
dilated varicose veins

53. Reflux
Retrograde Reversed flow due to Delayed
closure of the valve
1ry or 2ry
CUT off Values of NORMAL LIMIT 0.5
seconds

54. Reflux
Velocity Volume
( Venous Filling index >
2ml/sec)
Duration
The duration and volume of reflux can be evaluated with spectrum analysis
or with color duplex.

55. Superficial Venous reflux types
Isolated
ostial
reflux SFJ
SPJ
combined ostial
,perforating
reflux.
perforating
reflux
GSV /SSV
reflux

56. 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 & lowe
Sapheno-popliteal junction (SPJ)
Small Saphenous Vein *SSV (mid leg)

57. venous reflux grading
grade I reflux
defined as
retrograde
venous flow
that lasts only
for 0.5-2
seconds
grade IV reflux reversed
flow persist as long as
valsalva effort is
maintained
gradeII reflux lasts
slightly longer for 2-
3 seconds
gradeIII reflux produces prominent reversed flow
phase that persists 4-6 seconds
< 0.5 sec NO reflux

58. 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 x-axis).

59. Relationship Between Reflux
and diameter of the vein.
• 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
Perforating veins with diameters greater than 3.5 mm
can also be taken as a sign of significant reflux

60. 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).

61. 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

62. Dr Ahmed Esawy

63. Reflux tips &tricks
• 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

64. 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)
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

65. B: 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

66. Partial incompetence of a venous valve is demonstrated by an
area of retrograde flow (arrow) between the two valve cusps

67. NO reflux with Valsalva

68. Reflux of 0.5 sec duration

69. Prolonged duration with Valsalva

70. Dr Ahmed Esawy
SPJ incompetence
Distal augmentation
flow toward heart
Following squeeze release
retrograde flow in SSV

71. Incompetent SFJ
Mickey Mouse view
LSV is very large ,small branches are
Dividing from junction
LSV (L) ,anterolateral branch (arrow)
CFV=V
CFA=A

72. 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) .
popliteal vein in this example but its position can vary

73. • 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.

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

75. • Chronic reflux gives dilatation and tortuous deformity
of the superficial veins, with typical "cork screw"
appearance; infra-valvular aneurysms are also
common.

76. • 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.

77. • The popliteal fossa should also be evaluated in case of
varices. Short saphenous vein (VSP) and
gastrocnemius veins (GCNM) are frequently
incompetent. They should be studied with the patient
standing.

78. • Cross section of the popliteal fossa: dilatation of
the short saphenous vein in case of
incompetence.

79. Reflux occurring at the sapheno-femoral junction on
colour Doppler. (a) forward flow; (B) reverse flow

80. Perforating Veins

81. • 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

82. Perforating Veins between Post tibial V.
and GSV
> 3 mm thickness Retrograde flow Traverse fascial plane

84. 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 .—Becauseof its spiral configuration, the entire
length of the perforating vein cannot be visualized on a single 2D image.

85. Perforator incompetence
• isolated perforator incompetence at
distal thigh but also occur in calf
from branches of ant or post arch
vein
In those selected cases where hemodynamic
correction of varicose veins(CHIVA) is considered,
detection of incompetent perforating veins is essential

86. • Perforating vein coming through the fascia.

87. • Pulsed Doppler confirmation of bidirectional flow
in the incompetent perforating vein.

88. • 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

89. VARICOSITY
DISTRIBUTIONS

90. • Varicose patterns on the leg often
indicate the source of the problem
• Determining the source of the
varicosities is important for treatment

91. • Junctional tributaries are often
the site of varicosities
• Saphenous nerve close contact
with the GSV below the knee

92. Zone of Influence of
GSV
Terminal and subterminal valves at the SFJ
Leaks cause VV
Often causes varicosities in the tributaries
Zone of influence GSV medial aspect

93. Zone of Influence of
SSV and VG
The sapheno-politeal 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
VG-vein of giacomini

94. Varicose Veins Small
Saphenous Reflux
varicosities to form in tributary braches that course along the posterior aspect.

95. Varicosities of the Vein of Giacomini

96. 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
LSVS-Lateral Subdermic Venous System

97. Varicose Veins
Lateral Subdermic Venous
System

98. 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.

99. 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,
Unusual distributions

100. 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.

101. RECURRENT
VARICOSE
VEIN

102. Possible causes of GSV recurrences
• Incomplete Ligation SFJ
• Neo-vascularization
(cavernoma)
• Incomplete stripping of the GSV 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

103. Possible causes of SSV recurrences
• incomplete ligation of the
saphenopopliteal junction
• lncompetent Giacomini vein
• Incompetent perforators
• GSV incompetence
• Diffuse varicosities in the popliteal
fossa

104. 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).

105. Saphenous pulsation on duplex may be
marker of severe chronic superficial ven
insufficiency
Duplex tracing of a typical saphenous pulse (SP) waveform
Etiology may be AV connections (arterial varices)

106. SUPERFICIAL
PHLEBITIS

107. 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.

108. • Due to inflammatory infiltration of the surrounding
subcutaneous fat, a hyperechoic halo is visible
around the inflamed vein in case of phlebitis

109. 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.

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

111. Sonographic triad of superficial phlebitis
1)Hyperechoic halo
2)small arterioles around thevein
3)low-resistance flow

113. Conservative management
Elastic crepe bandage –stockings
30-40mmHg
Elevation oflimbs
Above the level ofheart
Graded compressionstockings

114. Contd..
Unnaboot
Nonelasticcompression
Zinc oxide, calamine, andglycerine
Dressing changed once in aweek
Infection should not bethere
Compressionmethods
Reduce ambulatory venous
pressure
Trans capillaryleakage
Improve cutaneous micro
circulation

115. Medications
Calciumdobesilate
Improves lymph flow, reduceedema
Diosmin
Protects venous valves / anti
inflammatory
Not proven muchbeneficial

116. USG guided Sclerotherapy

117. Sclerotherapy
Complete sclerosis of the venouswall
Indications
• Uncomplicated perforatorincompetence
• Smallervarices
• Recurrentvarices
• Isolatedvarices
• Aged/unfitpatients

118. Contd…
• Sodium tetradecyl sulphate
• Sodium morrhuate
• Ethanolamine oleate
• Polidocanol
• Aseptic inflammation
• Perivenous fibrosis
• Endothelial damage
• Obliteration by intimal approximation

119. Ultrasound guided foam
sclerotherapy
• Under Ultrasound guidance.
• Polidocanol is used
• Polidocanol converted in foam by mixing
air using three way tap.
• Spread of foam monitored under USG guidance
as it spreads.
• Apex of saphenous opening compressed by
probe to prevent foam entering deep veins.
• Leg also elevated

120. Contd…
• Saphenofemoral incompetence
• DVT
• Peripheral arterial disease
• Hypersensitivity
Contraindication
• OPD
procedure
• No anesthesia
Advantages
• Anaphylaxis/shock
• Abscess
• Thrombophlebitis
• Intravenous hematoma
• Temporary ocular disturbances
Disadvantages

121. Radiofrequency Ablation
• The intima of smaller veins can be destroyed by
heat generation and denaturation of collagen
using a probe consisting of a bipolar heat
generator.
• Performed under ultrasound guidance and
position of the probe is confirmed near the
Saphenofemoral junction.
• Probe is heated to 85 degrees and gradually
retracted down at a constant rate of 2-
3cm/minute.
• must be avoided in presence of dilated veins,
veins with aneurysms and thrombosed veins.

122. Endovenous Laser
Ablation
- EVLA
US guidance LSV canulated above knee jt
Guide wire passed beyond SFJ
Tip is placed 1cm distal to SF junction
Laser fibre inserted upto the catheter
Diode laser used for firing
Veins of all sizes can be treated with this procedure

123. RFA and Endovenous Laser

124. Contd…
Thermal damage of endothelium – occlusion of vein
Laser energy acts on blood – in turn heats the vein
wall.
Complications
Pain / ecchymosis
Hematoma
Skin burns
DVT

125. Interventional Procedures
Relievecomplaints
Pain /discomfort
Reversecomplication
Cosmesis