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VENOUS INCOMPETENCE (Varicose vein)
ULTRASOUND - Normal
Venous Incompetence (VI) and Chronic Venous Insufficiency (CVI) are interchangable terms
FLOW DYNAMICS


NORMAL FLOW
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:
1. Cephalad.
2. Superficial to deep.
Normal venous flow and valve movement,



Click image to enlarge.
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 (ie varicosites).

Incompetent valve & perforator leading to venous reflux.



NORMAL VEIN VALVE


Normal venous valve.



A video clip of a normal vein valve (LS) A video clip of a normal vein valve (TS)


LEG VEIN ANATOMY

Nomenclature

For a comprehensive document on the international consensus of leg vein
labelling.

REF: Journal Of Vascular Surgery, Special Communication, 2005. (215kB PDF file)
We recommend reviewing this thorough document.
Importantly, to avoid confusion, the 'Long Saphenous' is now the 'Great Saphenous'.

What are Varicose veins?

Below is a basic outline of the anatomy and function of the veins and what constitutes venous
incompetence. Be aware however that there are numerous anatomical variations.

Valves
The veins contain a series of valves along their course, preventing retrograde flow back down the
leg. These valves operate like two plastic doors opening up the leg. If back pressure is applied,
they swing closed, pushing against each other, blocking reverse flow down the leg.
If functioning normally, it is a competent valve. If blood is able to pass backwards though the
valve, it is deemed incompetent.
Depending on the extent of incompetence, this backflow will dilate the supple superficial veins
making them tortuous and dilated(varicose veins).
Causes include:
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 adherance of valve leaflets to the vein wall,
rendering the valve useless.
The Deep Veins
Are the primary route for returning blood to the heart. They collect the venous blood from all the draining
muscular and superficial veins.
In the lower limb the deep veins are: (from groin to ankle)
Common Femoral Vein (CFV)
Superficial Femoral Vein (SFV)- also called just the Femoral Vein.
Popliteal vein (POPV)
Anterior tibial (ATV)
Posterior tibial (PTV
Peroneal veins (Per V)
The latter 3 are calf veins that generally run in pairs (venous commantantes)
Click here for a diagram of leg deep vein anatomy.

The Superficial Veins
There are 2 main superficial veins draining the subcutaneous tissue of the lower leg:
The Great Saphenous vein (GSV) runs from the medial malleolus, up the medial aspect of the
leg, draining into the CFV at the groin as the Sapheno-femoral junction (SFJ).
The Short Saphenous vein (SSV) runs up the posterior midline of the calf. It may drain into the
proximal POPV above the knee crease as the Sapheno-Popliteal junction (SPJ). Commonly
however, it may continue up the posterior thigh as the Giacomini vein. This will terminate either
into the mid/distal SFV or ascend to drain into the proximal LSV.
Incompetence of the SFJ and SPJ are the two primary sources of varicose veins.
Sapheno-femoral Junction
The termination of the Great Saphenous Vein (GSV) into the Common Femoral vein (CFV) in the
groin.
Is the primary source of venous incompetence and varices of the lower limb.


Sapheno-Femoral Junction Anatomy
Deep Veins
Common femoral vein (CFV)
Superficial femoral vein (SFV)
Proffunda femoris vein (Proffv)

Superficial Veins:
Long (Great) Saphenous vein
(LSV)
Medial accessory saphenous vein
(MASV)
Lateral accessory saphenous
vein (LASV)
Insert caption here

Sapheno-popliteal junction
The termination of the Short Saphenous Vein (SSV) into the Popliteal vein (POPV) in the popliteal
fossa.
The SPJ is absent in 25% of the population, continuing up the posterior thigh as the Giacomini
vein.
Only 15% of people have a midline SPJ. The remaining junctions are medial/lateral, often via a
gastrocnemius vein.
(BOTH REF: "The Vein Book" Author: John J. Bergan)

The Sapheno-Popliteal
Junction
Determine competency and the relationship
to the knee crease.
The junction is commonly into the lateral
aspect of the popliteal vein.

Common variations are:
Via muscular veins.
No SPJ - Giacomini vein variant up to
the SFV or LSV in the thigh.

Sapheno-popliteal (SPJ) anatomy diagram.



Diagram of transverse calf showing the 'eye-like' fascia containing the
SSV.
Insert caption here


The Short Saphenous Vein may terminate in the Giacomini
vein with no Sapheno-popliteal junction.
Alternatively it may divide, with a normal SPJ and a Giacomini
vein (as in this case).



Venous Incompetence Ultrasound -Protocol

*** NOTE: A comprehensive thorough scan can take an hour to complete. ***
Role of Ultrasound
To identify the source and course of varicosities in the lower limb.
To assess these veins pre-operatively as a cause for:
o Venous ulcers
o Lower limb oedema
o Venous ezcema
o Self image

Limitations
Ideally the scan should be performed with the patient erect or as upright as possible. Some
patient will have difficulty with this.
Markedly oedematous legs or open ulcers will impede scan quality.

Equipment Selection
Use of a medium to high frequency(7-10MHZ)linear array probe is preferrable to visualise the
superficial veins.
You may need to resort to a lower frequency probe to assess the deep veins, depending on the
patient's body habitus.
Doppler settings should be low PRF and low wall filter with medium to high persistance.
Set the u/s machine to display triplex - usually, when spectral doppler is on, there is a
'simultaneous' option

Patient position
Ideally the scan should be performed with the patient erect or as upright as possible. Some
patient will have difficulty with this, occasionally becoming faint or weary.
Use of a tilt table will make the scan easier for both you and the patient.
Position the patient on their back. Gently flex their knee and externally rotate their leg with their
unaffected leg kept straight to take the majority of their weight.


Scanning Technique
DEEP VEINS
Post thromotic syndrome in patients with a past history of DVT can lead to deep venous incompetence.
Deep venous incompetence or current DVT is important to exclude as a cause for the patients symptoms.
1. Begining at the groin in transverse, identify the common femoral vein(CFV) at the point where it
bifurcates into the superficial femoral vein(SFV) and proffunda femoris vein(PFV).Check
compresibility in transverse and image in longitudinally with colour flow.
2. The external iliac vein (and often CFV) do not have valves so need not be checked for
incompetence.
3. Check the competency of the SFV proximally:In longitudinal, using colour and spectral doppler.
Ask the patient to strain down and make a fat tummy. If incompetent, flow reversal will be evident
throughout the strain. NOTE: Due to valve spacing you can get up to 0.5 seconds of reversed
flow in deep veins.
4. Check the patency and competency of the SFV distally: If the SFV was incompetent proximally,
valsalva can be used again, otherwise a short, firm squeeze of the proximal calf (called
Augmentation) should be used.
5. Check the patency and competency of the Popliteal vein(POPV). Place the probe transversely in
the popliteal fossa at the knee crease. The POPV and artery will be easily seen (Be cautious not
to mistake the several muscular veins in the area for the POPV). Check it's competency as per
the distal SFV.

THE GREAT SAPHENOUS VEIN (GSV)
Sometimes referred to as the Long Saphenous vein (LSV).
Follow from the Sapheno-femoral junction (SFJ) groin to the ankle using distal augmentation to
assess for incompetence.
If there are changes in competence, note the distance from landmarks such as the groin or knee
crease.

THE SHORT SAPHENOUS VEIN
Similar to the GSV, in longitudinal, follow the SSV from the Sapheno-Popliteal Junction (SPJ) in
the knee crease, down the midline of the calf.
Use distal augmentation to assess for incompetence.
If there are changes in competence, note the distance from landmarks such as the malleoli or
knee crease.
The Sural nerve runs parallel to the SSV from mid calf down to the heel. If the SSV is
incompetent, make note in the report if the Sural nerve is in intimate contact with the vein. They
can be confused one for the other in surgery.

PERFORATING VEINS
A perforating vein joins the superficial veins to the deep veins. By definition a perforating vein must
breech the fascia between the superficial fat and the muscle fascia.
In transverse, scan in a methodical patternup and down the medial calf. Begin with the toe of the probe
on the Tibia and do vertical sweeps until you reach the SSV.

Flow should always be superficial to deep (competent).
If flow is observed deep to superficial, the vein is incompetent. Any incompetent perforating veins (IPVs)
or competent perforators >3mm should be noted in the report.
Click image to enlarge
Common Perforators

The most common perforating veins are shown. The
'Cocketts' are by far the most common. These are medial,
paratibial in the distal 2/3 of the lower leg.




Basic Hard Copy Imaging
A CVI study should include the following minimum images:
CFV bifurcation
SFV proximal and distal demonstrating patency and competency
POPV demonstrating patency and competency
SFJ demonstrating patency and competency
SPJ (if present) demonstrating patency and competency
Any incompetent perforators noting their diameter, depth and position relative to a surface
landmark
Any significant or atypical junctions of varices to the 'normal' system
Any incidental pathology such as thrombus, Bakers cyst or popliteal aneurysm.


Anatomy
Nomenclature
Scan protocol
Scan Technique
Perforating veins