calf vein imaging - siecsiec.zenix.it/dispense/corso_ecografia_vascolare/lezioni pn 2014... · gsv:...

• Le Vene

ITER DIAGNOSTICO

- Lo scopo dell’esame è l’accertamento di un venosa trombosioppure di una reflusso

superficiale e/o profonda.

- Nei due casi l’ iter diagnostico e procedure sono differenti.

- Il circolo venoso profondo deve sempre essere valutato.

L' esame venoso è indicato:

- Sospetto clinico di trombosi venosa profonda

- Sospetto clinico di trombosi superficiale

- Insufficienza valvolare del circolo profondo

- Insufficienza valvolare circolo superficiale

- Indicazioni terapeutiche

- Controlli a distanza

Doppler US in DVT

Anatomy of lower extremity veins

Normal venous flow

Doppler US techniques in lower extremities

Doppler US in DVT: acute – chronic

Differential diagnosis

Anatomy of lower extremity veins

Lower extremity veins

system

Lin EP et al. Ultrasound Clin 2008 ; 3 : 147–158.

Sistema venoso Superficiale

- Safena interna

- Safena esterna

- Vene perforanti

- Vene collaterali

Profondo

- Compartimento soprainguinale

- Compartimento femorale (tra il cavo popliteo e il legamento inguinale)

-Compartimento surale

Venous anatomy of lower extremity

• Deep Accompanied by artery – larger than artery

Calf veins duplicated or triplicated

Popliteal & femoral may be duplicated

Valves: calf (1 every inch) – IVC (no valve)

• Superficial Not accompanied by arteries

GSV: Longest vein- 10-20 valves-duplicated

SSV: Anatomy extremely variable

• Perforators

The long saphenous vein

Thrush A, Hartshorne T. Peripheral vascular ultrasound: How, why and when.

Elsevier Churchill Livingstone, London, 2nd edition, 2005.

• Distal LSV located in front of MM

• Runs up medial aspect of calf & thigh

• Number of superficial tributaries

• Number of major perforating veins

• Drains into the CFV at SFJ

2.5 cm below inguinal ligament

Perforator veins

Myers KA & Clough A. Making sense of vascular ultrasound. Arnold, London, 2004.

Flow from superficial to deep veins

Do not connect directly to main trunks of LSV or SSV

Communicate via side branches of main trunks

Major perforators in the LSV

Crocket’s perforators

Lower medial calf

6, 13 & 18 cm above medial malleolus

Connect branches of LSV to PTV

Boyd’s perforator

Upper calf – 10 cm below knee joint

Connect LSV or its branches to PTV

Dodd’s perforator

Middle third of the thigh

Connect LSV or its branches to SFV

Thrush A et al. Peripheral vascular ultrasound. Elsevier Churchill Livingstone, 2nd edition, 2005.

Anatomy of the saphenofemoral junction

At least 6 other tributaries draining to LSV at level of SFJ

Can be source of primary or recurrent varicose veins



The short saphenous vein

Anatomy of SSV extremely variable



• Arises behind lateral malleolus

• Runs up posterior calf

• Number of perforating veins

• Drains to PV at popliteal fossa (60%)

• Vein runs as continuation of SSV along

posterior thigh (Giacomini vein)

Normal venous flow

Normal venous flow

Spontaneity Spontaneous flow without augmentation

Phasicity Flow changes with respiration

Compression Transverse plane

Augmentation Compression distal to site of examination

Patency below site of examination

Valsalva Deep breath, strain while holding breath

Patency of abdominal & pelvic veins

Phasicity

Flow changes with respiration

Slow Apnea Rapid

Normal venous flow








Compressibility of veins

Do not press too hard since the normal vein collapses

very easily making it difficult to find

External compression of the veins

Compression Relaxation

Normal venous flow








Augmented flow in popliteal vein

Aug Valve closed

Competent

vein

Normal venous flow








Valsalva’s maneuver

A V

At rest

A V

Valsalva

Valsalva’s maneuver

End

Valsalva

Start

Valsalva

Competent vein

Venous valve

Two cups of a valve clearly seen

It is uncommon to see venous valves with this clarity

Stasis of blood evident behind one of the valve cups

Venous reflux

Significant venous reflux

of > 2 sec duration

Augmentation

or Valsalva

Grading of venous reflux

Grade

Reflux duration

Normal valve function

Reflux duration of < 0.5 sec

Rapid closure of venous valves

Moderate reflux

Reflux duration of 0.5 – 1 sec

Mild to moderate retrograde flow

Significant reflux

Reflux duration of > 1 sec

Large volume of retrograde flow



Venous stasis

Echogenic speckle pattern of a deep calf vein

Movement of blood is visible in real time

Echogenic

Blood

Doppler US techniques in lower

extremities

Examining femoral veins & popliteal fossa

Leg bent at the knee & rotated outward

Best exposure of the femoral veins & the popliteal fossa

Ma OJ, Mateer JR, Blaivas M. Emergency Ultrasound, 2nd edition.

Head of Mickey mouse

Superficial & deep femoral vessels

Confluence of the SFV & PFV

Normal SFA & SFV

Compression test at level of adductor canal

Compression test inadequate at level of adductor canal

Rather, examiner additionally presses the vein against

transducer from below with flat hand

Schäberle W. Ultrasonography in vascular diagnosis.

Springer-Verlag, Berlin Heidelberg, 2004

Examining popliteal & leg veins

Leg allowed to hang over the edge of the bed with the

probe positioned in the popliteal fossa

Ma OJ, Mateer JR, Blaivas M. Emergency Ultrasound, 2nd edition.

Variations in formation of popliteal vein

Quinlan DJ et al. Radiology 2003 ; 228 : 443 – 448.

True duplication

of PV At knee joint Distal to

knee joint

Proximal to

knee joint

Calf vein imaging

Calf veins imaging

Posterior tibial & peroneal veins

Normal posterior tibial veins

Augmentation Systole Diastole

Tripple posterior tibial veins

Evaluating valve competence of saphenous veins

Compression-decompression test



Long saphenous vein Short saphenous vein

Normal sapheno-femoral junction

Color Doppler Black & white

Sapheno-femoral junction

SFJ

LSV

Superior

tributary



Normal greater saphenous vein

Transverse image

Useche JN et al. RadioGraphics 2008 ; 28 : 1785 – 1797.

Echogenic elliptical fascial sheath

Stylized ‘‘Egyptian eye’’

Normal sapheno-popliteal junction

Color Doppler Black & white

The Giacomini vein

Giacomini V SSV

PV

GV

SPJ



It is possible to confuse posteromedial branch of LSV

with Giacomini vein

Sapheno-popliteal junction incompetence



Distal augmentation

Flow toward the heart

PV

SSV

SPJ

Following squeeze release

Retrograde flow in SSV

PV

SSV

SPJ

Vein scan report

Use of diagrams makes it easier for clinician to interpret

findings of a venous duplex examination

Thrush A et al. Peripheral vascular ultrasound. Elsevier Churchill Livingstone, London, 2005.

Referto eco-Doppler

Doppler US in DVT: acute – chronic

Clinical presentation of symptomatic DVT

• Calf-popliteal DVT (> 90 %)

Pain, swelling, warmth & redness in calf of one leg

Increase with ambulation & improve with rest

Symptoms persist 7 days before seek care

• Iliofermoral DVT (< 10 %)

Pain in buttock &/or groin region, extend to medial thigh

If untreated, leg become swollen, painful, & dusky

Phlegmasia cerulea dolens

Causes of isolated iliofemoral DVT

< 10 % of patients with DVT

• Peripartum period ( > 90 % in left leg )

• Pelvic mass

• Recent pelvic surgery

• Oral contraceptive use

• Antiphospholipid antibody syndrome

Phlegmasia Cerulea Dolens (PCD)

Extreme cases of DVT – Surgical emergency

Thrombosis involves deep, superficial, & collateral veins

Thrombosis extends into capillaries in 40 – 60 % of patients

Irreversible ischemia, necrosis, & gangrene

Unilateral & bilateral DVT

• Unilateral DVT

DVT usually develops in only one leg at a given time

• Bilateral DVT

Metastatic adenocarcinoma

Thrombus extends proximally to involve the IVC

Diagnosis of DVT

• Clinical evaluation Positive in only 50%

• D-dimers Sensible – not specific

• Plethysmography Not reliable

• Nuclear medecine Not reliable

• MRI High cost – limited availability

• Contrast venogram Used to be gold standard

Minor & severe adverse effects

• Color Doppler Procedure of choice now

Causes of a positive D-Dimer test

• Thrombogenesis

• Infection

• Inflammation

• Vasculitis

• Pregnancy

• Trauma

• Surgery

Lin EP et al. Ultrasound Clin 2008 ; 3 : 147–158.

US diagnostic criteria of DVT

• Intramural thrombus

• Incompressibility +++

• ↑ in vein diameter

• No flow in pulsed Doppler

• No flow in color Doppler

Direct signs

• Loss of phasicity:

Proximal thrombosis

Venous compression

• Loss of augmentation:

Distal thrombosis

Indirect signs

Incompressibility = Thrombus

Do not compress vein more than necessary in acute thrombus

Fear of detaching thrombus to cause PE

Myers KA & Clough A. Making sense of vascular ultrasound. Arnold, London, 2004.

Transverse compression of veins

Normal vein

Complete collapse

Nonocclusive thrombosed vein

Partial collapse

Completely thrombosed vein

No collapse

Hamper UM et al. Radiol Clin N Am 2007 ; 45 : 525 – 547.

Types of thrombus

Occlusive Flottant Marginal Recanalisation

Thrombus in the CFV

Compression Relaxation

Occlusive DVT

Right femoral vein

Lin EP et al. Ultrasound Clin 2008 ; 3 : 147 – 158.

Free-floating thrombus

Free-floating thrombus in LFV extending into CFV


Partially occluding acute thrombus

Duplicated SFV

Normal Thrombus

Long saphenous vein in DVT

High-volume spontaneous flow demonstrated in LSV

of a patient with PV & SFV obstruction

Calf vein thrombosis

Controversy about its clinical significance

• Most resolves spontaneousely with few sequelae

• 10 percent propagate to above-knee veins

• No pulmonary embolism if PV & SFV intact

• Benefit of treatment is uncertain

• If present repeat the exam every 2 – 3 days

• Sensibility of Doppler: 70 %

• Specificity of Doppler: 95 – 100 %

DVT of the PTV & PV

Thrombosis of gastrocnemius vein



Thrombosed GC vein Protrudes into the PV

Superficial thrombophlebitis

N Engl J Med, 2001 , 344 ; 1214.

Superficial thrombophlebitis

Saphenous-femoral junction

Should be treated if extends to within 2 cm of deep system

Accuracy of US for diagnosis of

lower extremities DVT

Specificity

Sensibility

Location

Symptoms

98%

95 %

Proximal leg veins

Symptomatic

90 – 100%

70 %

Isolated calf veins

98 %

60 %

Proximal leg veins

Asymptomatic

25 %

< 60 %

Isolated calf veins

The ideal patient for US evaluation has

symptoms that extend above the knee

Predicting pretest probability of thrombosis

Wells 1997

Clinical feature Score

Active cancer + 1

Leg immobilization (cast, paralysis) + 1

Bedridden 3 days, postoperative + 1

Leg swelling (unilateral) + 1

Calf swelling 3 cm + 1

Pain along distribution of veins + 1

Dilated superficial collateral veins + 1

Clinical findings or history of other disease that

explains symptoms or is more likely than thrombosis

– 2

Score 1 to 2: Moderate risk of thrombosis

Score > 2: High risk of thrombosis

Diagnosi paziente sintomatico

Diagnosi di recidiva

Indications of contrast venogram in DVT

• Indications Impossibility to realize quick Doppler

Difficult color Doppler exam

Before position of vena caval filter

• No indications Pulmonary embolism

Difficulty to see upper pole of thrombus

• Frequency Phlebography necessary in only 10%

Diagnosis done by Doppler in 90%

•Il trombo si evidenzia come un difetto di riempimento, visibile in almeno due

immagini successive

•Non è un test diagnostico di prima linea: invasivo, costoso, non sempre agevole o di

facile esecuzione ed interpretazione

Indicazioni

• Se non disponibili altri test

• Se CUS negativa, Dimero D positivo ed alta probabilità clinica

Flebografia con mdc

Contrast venogram in DVT

No longer diagnostic test of choice

Limitations Skilled radiologist – Cooperative patient

Large volume of contrast agents (200 ml)

10% failed to depict segment of venous sys

Adverse effects Minor Pain-skin reactionthrombophlebitis

Severe Skin necrosis – allergic reaction

Impaired renal function

Post-injection DVT

Contraindications Renal failure

Severe reaction to contrast agents

TC mdc •Diagnosi di trombosi venosa addominale

• Panoramicità

• Eventuali anomalie vascolari

• Non operatore-dipendente

RMN

Permette di evidenziare le TVP prossimali con buona accuratezza

Consente di valutare l’eventuale estensione iliaco-cavale della trombosi

Utile per la valutazione del mediastino

Indicata, in alternativa alla flebografia/TC, nei pazienti con allergia o controindicazioni al mezzo di contrasto e/o con insufficienza renale

Asymptomatic DVT

DVT are asymptomatic Most postoperative

Most postoperative DVT isolated to calf veins (50-80%)

Very small thrombi (in some cases < 1 cm in length)

Often do not cause vein occlusion

Don’t follow typical distribution seen in symptomatic pts

Most resolve spontaneously without specific symptoms

Natural history of DVT

• Spontaneously lyse

• Propagate or embolize

• Recanalize over time

• Permanently occlude the vein

Acute & chronic thrombus

Signs interpreted according to clinical history

• Anechoic or hypoechoic Brightly echogenic

• Homogenous Heterogenous

• Poorly attached or floating Well attached

• Smooth borders Irregular borders

• Spongy & deformable More rigid

• Increase in vein diameter Small & contracted vein

• Small collaterals Large collaterals

Acute thrombus Chronic thrombus

Post-thrombotic syndrome

50% within 10 years after a major DVT

• Disabling pain

• Leg swelling

• Skin pigmentation

• Skin ulceration

• Superficial varicose veins

Clinical evaluation

Triplex Doppler

• Wall thickening

• Persistent occlusion

• Collaterals

• Valvular incompetency

• Superficial varicose veins

Venous webs in the CFV

Post-thrombotic syndrome

Chronic retracted

thrombus

Irregular wall

thickness Atretic occluded

vein

Collateral veins near popliteal vessels

Chronic calcific thrombus in calf vein

Differential diagnosis of DVT


• 7 of 10 patients could have a cause other than DVT

• Ancillary finding detected in only 10% of Doppler study

• 90% of incidental findings related to patient symptoms

• Anatomic approach is the most useful strategy for dd


Make every effort to establish a diagnosis

when DVT is ruled out


Anatomic approach

• Groin From inguinal ligament to 10 cm below

• Thigh From this line to Hunter canal

• Popliteal From Hunter canal to 10 cm below pop crease

• Lower leg 10 cm from popliteal crease to ankle



Regions


Inguinal

Hernias: femoral – inguinal

Iliopsoas & ileopectineal bursitis

Adenopathy (inflammatory & neoplastic)

Pseudoaneurysm – AVF – anticoagulation hematoma

Thigh

Sports-related lesions (contusions, muscle tears, hematoma)

Muscle herniation – myositis – abscess

Popliteal

Ruptured Baker’s cyst

Parameniscal cyst – pes anserinus bursitis

Popliteal artery: thrombosis – aneurysm – adventitial cyst

Lower leg

PA entrapment syndrome – thrombophlebitis

Tennis leg

Cardiac and renal failure


Muscular abscess


Normal femoral vessels Abscess

Staphylococcus aureus infections are the most common

Intramuscular hematoma

Intramuscular hematoma (*)

Edema of the muscle fibers of

the gracilis (arrowheads)



Regions


Inguinal





Thigh



Popliteal




Lower leg


Tennis leg



Baker’s cyst

Jamadar DA et al. AJR 2002 ; 179 : 709 – 716.

Anechoic fluid distends SM – GC bursa

Characteristic neck between SM tendon & medial GC muscle & tendon

Semimembranosus

tendon

Medial gastrocnemius

tendon

Medial gastrocnemius

muscle


Pseudo-thrombophlebitis


Debris in inferior

portion of cyst

Anechoic fluid tracking

distally in subcutaneous

tissues

Longitudinal scan through distal aspect of Baker’s cyst

Popliteal artery aneurysm

Partial thrombosis

Transverse color Doppler US Sagittal color Doppler US


Popliteal artery aneurysm

Complete thrombosis


Thrombosed popliteal aneurysm occluding PA

Patency of the vein clearly demonstrated


Regions


Inguinal





Thigh



Popliteal




Lower leg


Tennis leg



Calf neoplasm

Longitudinal sonogram of medial calf


Heterogeneous soleus muscle mass with indistinct margins

g = gastrocnemius muscle

Congestive heart failure

Venous flow signals recorded in a patient with

CHF demonstrate a pulsatile flow pattern

Common femoral vein

Inverted W wave

Interstitiel edema

Fluid edema demonstrated in subcutaneous tissues

as numerous anechoic channels (arrows) splaying the tissue

Lymphedema

Grainy appearance in subcutaneous tissues

Superficial tissue relatively thick

Degraded image quality typical of this disorder

Thank You

Diagnostic management of DVT of the leg

Perrier A. Lancet 1999 ; 353 : 190.

Suspected thrombosis

D-dimer test

Compression ultrasound

+

No thrombosis

–

Venography

High risk

Thrombosis

+ –

Low/moderate risk

–

calf vein imaging - siecsiec.zenix.it/dispense/corso_ecografia_vascolare/lezioni pn 2014... · gsv:...

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