Who needs more testing beyond venous duplex?

IVC 2014 Miami Beach FL

William Marston MDProfessor and Chief, Division of

Vascular SurgeryUniversity of N. Carolina Hospitals

Disclosures

• Scientific Consultant– Veniti– Volcano– Organogenesis

• Clinical Trial Investigator– Smith and Nephew/Healthpoint

Deriving maximum information from duplex ultrasound

• Venous duplex report– No acute DVT– Reflux in GSV– No deep reflux

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

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

Duplex limitations - anatomic

• Operator dependent – Nicos vs the rest of

the world

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

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

Plethysmography

Venous Filling Index (VFI, normal < 2 cc/sec), the value determined by 90% of VV divided the time required to reach 90% of VV

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

CT venogram and APG

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

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

Additional testing: pelvic symptoms, groin VV

• Labial VV• Pelvic congestion

symptoms• Nutcracker syndrome

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

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)

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?

Or go straight to venous intervention - IVUS

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

intervention600-0003.42/001

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