Chronic Venous Insufficiency (CVI)
What is the main purpose of CVI testing?
Demonstrate if there is reversal of flow or reflux.
*If valves aren't working properly, then it will lead to an increase in blood volume within the legs.
List possible ways a patient can be positioned for the exam
-Standing
-Sitting with legs hanging off the bed
-Reverse Trendelenburg: Head of the bed elevated
Describe where the GSV starts and how it courses through the leg.
It starts at the ankle posterior to the medial malleolus. It will course up the calf near the tibia and around the medial side of the knee. It continues up the medial thigh and terminates into the CFV.
Describe the course of the vein within the leg
Begins medial and lateral to the achilles tendon and travels up the middle of the posterior side of the calf. It may terminate in the popliteal vein.
What type of fascia do the perforator veins penetrate through?
Muscular fascia to reach the deep system
List the three categories of lower extremity venous valve disorders
1. Venous valve agenesis: born without valves or superficial veins
2. Venous valve damage: caused by a DVT or age
Venous valve leakage during venous dilation: Veins lose the ability to decrease in diameter size causing the valve leaflets to not work properly.
List symptoms of CVI
Discomfort/pain, heaviness, cramping, leg weakness, skin changes, ulcerations, aching, burning, throbbing, restless leg syndrome
1. Sephano-femoral junctin
2. High thigh
3. Mid thigh
3. Low thigh
4. Knee
5. High calf
6. Mid calf
7. Low calf
If the SSV continues to course up the thigh, what is this vein called?
Cranial extension of the SSV or vein of Giacomini. It can terminate in the femoral vein, gluteal vein, or GSV
Do perforator veins contain valves?
Yes, the valves make sure that blood is only flowing from the superficial to the deep system.
List the risk factors associated with CVI
Congenital, Older age, Varicose veins, Previous DVT, Occupating, Family history, Obesity, Inactivity, Muscle weakness, Pregnancy, Injury to legs, Cancer, Gender (female)
List the contraindications/limitations
Open wounds/ulcers, intense pain, cast/bandages, obesity, edema, recent surgery, inability to stand for a long time.
In transverse plane, describe how we should document the vein
-Dual screen with vein open and compressed
-Measure AP diameter of the vein and measure from the skin's surface to the vessel.
In transverse plane, describe how we should document the vein
-Dual screen with vein open and compressed
-Measure AP diameter of the vein and measure from the skin's surface to the vessel.
Where do perforators usually drain into?
Gastrocnemius or peroneal veins
List the clinical indications for CVI
Edema/swelling (Increases through the day and standing), purple or red visible veins, redness (rubor), brownish discoloration/hyperpigmentation (gaiter zone), Venous stasis ulceration, varicosities, venous hypertension or valve damage.
List patient history/physical exam
Patient history: Persistent leg/calf swelling, previous DVT, localized pain (burning or itching), tired, heavy legs, restless leg syndrome
Physical exam: Edema, tenderness, warmth or redness, hyperpigmentation, ulcers, dermatitis, spider veins, varicose veins
In longitudinal plane, how should we document the vein
Vein should be lengthen out with color and pulse wave Doppler. We should either do distal augmentation or patient does the valsalva maneuver.
Reflux is measured if its greater than 0.5 seconds
In longitudinal plane, how should we document the vein
Vein should be lengthen out with color and pulse wave Doppler. We should either do distal augmentation or patient does the valsalva maneuver. Reflux is measured if its greater than 0.5 seconds
*If SSV doesn't confluence with the popliteal vein, then we should follow it as superior as possible
*If the SSV continues up the thigh and has varicosities, then it should be labeled as vein of giacomini.
How many seconds until its considered superficial valvular incompetence?
Greater than or equal to 0.35 seconds
Describe what is primary and secondary venous insufficiency
Primary: Congenital absence of valves affecting the superficial system only
Secondary: Obstructive conditions or previous DVT affecting the deep system
Describe venous ulcers
Browny discoloration, wet/oozy, warm, mildly painful, seen in the gaitor zone
How many seconds until it's considered valvular incompetence?
Greater than or equal to 0.5 seconds
How many seconds until it's considered superficial valvular incompetence?
Greater than or equal to 0.5 seconds.
Describe the scanning protocol for perforator veins
1. Measure the AP diameter where the vein perforates the deep fascia
2. Measure from the skin's surface to the anterior wall of the vein
3. Ensure that blood flow is going from superficial to deep