Lower Extremity Venous Sonography Harry H Holdorf Ph
- Slides: 49
Lower Extremity Venous Sonography Harry H. Holdorf Ph. D, MPA, RDMS (Ob/Gyn, Ab, BR), RVT, LRT(AS)
Hholdorf. com October, 2015
Hholdorf. com October, 2015
Hholdorf. com October, 2015
Hholdorf. com October, 2015
Factors Affecting Venous Flow • Venous-Skeletal muscle pump ‘Venous heart’ • The GREAT MUSCLE PUMP = Calf muscle • Muscle contraction squeezes vein propelling blood upward-forward Hholdorf. com October, 2015
Effective Calf Muscle Pump • Blood moves from superficial system (s) to deep system (D) • Competent valves prevent reflux • Venous volume and pressure decreases • Venous return to heart increases Hholdorf. com October, 2015
Ineffective Calf Muscle Pump • Incompetent valves cause reflux • Venous volume and pressure increases • Results in venous pooling and ambulatory venous hypertension. Hholdorf. com October, 2015
Respiration Inspiration (Phasic) • Decrease in intra-thoracic pressure • Increases blood flow from upper extremities • Increase in intra-abdominal pressure • Decreases blood flow from lower extremities Hholdorf. com October, 2015
Respiration Exhalation • Increase in intra-thoracic pressure • Decreases blood flow from upper extremities • Decrease in intra-abdominal pressure • Increases blood from lower extremities Hholdorf. com October, 2015
Valsalva Maneuver Patient takes in deep breath & holds it, then bears down (as if having a bowel movement) Intra-thoracic and intra-abdominal pressure increases significantly All venous return halted Veins will enlarge Hholdorf. com October, 2015
Vein Valves Hholdorf. com October, 2015
Superficial Veins - GSV Hholdorf. com October 2015
Importance of the Greater Saphenous Vein • The great saphenous vein (GSV), previously also called the long saphenous vein, is a large, subcutaneous, superficial vein of the leg. It is the longest vein in the body running along the medial length of the leg. Clinical significance • Pathology of the great saphenous vein is relatively common, but in isolation typically not life-threatening. • Varicose veins: The great saphenous vein, like other superficial veins, can become varicose; swollen, twisted and lengthened, and generally considered to be unsightly. • Thrombophlebitis The GSV can thrombose. This type of phlebitis of the GSV is usually not life-threatening in isolation; however, if the blood clot is located near the sapheno-femoral junction or near a perforator vein, a clot fragment can migrate to the deep venous system and to the pulmonary circulation. Also it can be associated with, or progress to a deep vein thrombosis which must be treated. The vein is often removed by cardiac surgeons and used for auto transplantation in coronary artery bypass operations, when arterial grafts are not available or many grafts are required, such as in a triple bypass or quadruple bypass. Hholdorf. com October 2015
Vein Mapping for Coronary Artery bypass graft surgery • • • A tourniquet is placed around the upper thigh or the patient is placed in reverse Trendelenberg to aid in venous filling. The LSV is carefully traced onto the exterior of the leg using a surgical marker. Beginning distally at the medial malleolus, a generous amount of ultrasound gel is applied to the donor leg. The focus is set to a depth of 2. 8 cm to the scan area below the knee and may be adjusted to greater depths as the thigh is reached. The vein is identified and confirmed on the ultrasound screen as a tubular, compressible structure. The LSV is accurately followed up the medial aspect of the leg and marked for the entire length of its course. The caliber of the vein is assessed and measured at multiple sites and adjustment is made for distension. Hholdorf. com October 2015
Superficial Veins - GSV Images courtesy of Phillips - ATL Hholdorf. com October, 2015
Superficial Veins - GSV Sheath Greater saphenous sheath Hholdorf. com October, 2015
Superficial Veins – Groin Tributaries Hholdorf. com October, 2015
Superficial Veins Hholdorf. com October, 2015
Superficial Veins - Giacomini Vein Hholdorf. com October, 2015
Deep Veins – Full Length Hholdorf. com October, 2015
Deep Veins – Gastrocnemius Veins Hholdorf. com October, 2015
Deep Veins – Popliteal Vein Hholdorf. com October, 2015
Deep Veins – Sural Tributaries Thrombosed soleal veins With compression Normal gastrocnemius veins No compression Image courtesy of Phillips - ATL Hholdorf. com October, 2015
Deep Veins – Iliac Veins Hholdorf. com October, 2015
Inferior Vena Cava Hholdorf. com October, 2015
Perforator Veins – Flow Direction Hholdorf. com October, 2015
Perforator Veins – Types I and II Hholdorf. com October, 2015
Perforator Veins – Types III and IV Hholdorf. com October, 2015
Perforator Veins – Above Popliteal Space Communicating veins – Above the Popliteal Space Connects External Landmarks Upper third of thigh 1/3 Perineum Middle 1/3 of thigh Lower 1/3 of thigh, adductor canal Name Superficial Deep Proximal terminal Terminal portion of the long saphenous Femoral vein Perineal Long saphenous trunk and its posterior branches via a Giacomini vein Uterine and ovarian veins of the Hypogastric network Distal terminal Long saphenous network Femoral vein Dodd's Long saphenous network Femoral vein Hholdorf. com October, 2015
Perforator Veins – Below Popliteal Space Communicating veins – Above the Popliteal Space Connects External Landmarks Upper third of thigh 1/3 Perineum Middle 1/3 of thigh Lower 1/3 of thigh, adductor canal Name Superficial Deep Proximal terminal Terminal portion of the long saphenous Femoral vein Perineal Long saphenous trunk and its posterior branches via a Giacomini vein Uterine and ovarian veins of the Hypogastric network Distal terminal Long saphenous network Femoral vein Dodd's Long saphenous network Femoral vein Hholdorf. com October, 2015
Perforator Veins – Topographical Anatomy Hholdorf. com October, 2015
Perforator Veins – Cockett’s Perforators Hholdorf. com October, 2015
Duplex-Color Flow Imaging • Identify venous thrombosis – help differentiate acute from chronic • Evaluate non-occluding/partial thrombus • Detect calf lesions • Distinguish between extrinsic compression and intrinsic obstruction • Evaluate soft tissue masses • Detect venous incompetence • Document re-canalized channels or collateralization Hholdorf. com October, 2015
Limitations of Duplex Imaging • Sources of false-Positive studies include: – Extrinsic compression: e. g. , tumors such as SVC syndrome, ascites, pregnancy – Peripheral arterial disease (PAD): decreased venous filling – Chronic obstructive pulmonary disease COPD: Elevated central venous Pressure – Improper Doppler angle or probe pressure Hholdorf. com October, 2015
Patient Positioning • Peripheral veins: Lower Extremities – Facilitate venous filling: i. e. , reverse Trendelenburg – Diminish extrinsic compression: e. g. , extreme Left lateral decubitus position Hholdorf. com October 2015
Technique • Coaptation: From the Latin word meaning “To fit together” is another word for compressibility Hholdorf. com October 2015
Venous Flow Patterns • Evaluate venous Doppler signals in sagittal view: Spontaneous Phasic (with respiration) Augment with distal compression Augment with proximal release Hholdorf. com October 2015
Cross-Section of the Femoral vein High thigh: left leg Hholdorf. com October 2015
MICKEY MOUSE SIGN Common Femoral Artery, Common Femoral Vein, and Sapheno-Femoral Junction: Right Leg Hholdorf. com October 2015
Longt Normal Superficial Vein and Superficial Femoral Artery Hholdorf. com October 2015
Longt: Superficial Femoral Vein with clot Note: Femoral Artery anterior Hholdorf. com October 2015
Cross-Section Popliteal Vein Hholdorf. com October 2015
Popliteal vein and Artery: “Double scoop ice cream cone” sign Hholdorf. com October 2015
Distal Augmentation • With distal augmentation of the calf area, flow in the femoral vein initially goes cephalad. • With the release of the calf area, flow should not reflux back down the leg. • This maneuver demonstrates competent venous valves. Hholdorf. com October 2015
Compression Technique Hholdorf. com October 2015
Deep Vein Thrombosis of the superficial femoral vein Hholdorf. com October 2015
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- Deep veins of the leg
- Lower extremity appendicular skeleton
- Pnf patterns
- Tibia pulse
- Left lower extremity
- Dorsal venous arch
- Lower extremity muscles
- Decorticate posture
- Perforating veins
- Carotid doppler velocity chart
- Main lobar fissure of the liver
- Ouhsc sonography
- Sonography means
- Yokochi
- Maggie knott pnf
- Conclusion of restraints
- Hospital wristbands color codes
- What are closed chain exercises
- The biomechanics of the human upper extremity
- Biceps femoris origin and insertion
- Lifting and moving patient in bed
- Axillary artery
- East bay hand & upper extremity
- Capilary beds
- A venous network that drains the gi tract
- Jvp measurement
- Systemic veins
- Border of heart
- Virchows triad
- Posterior scalp
- 3 parts of esophagus
- Vbg interpretation
- Most common complication of central venous catheter
- Git venous drainage
- Suboccipital triangle roof
- Lumen distal y proximal
- Venous vs arterial blood
- Small saphenous vein
- Venous clinical severity score
- Subdural hemorrhage
- Common femoral vein
- Morrissey's cough impulse test
- Blood plasma and interstitial fluid
- Sinus venous thrombosis prevalence
- Eye muscles actions
- Superior nasal concha
- Risk for venous thromboembolism nanda
- Venous drainage of the upper limb
- May and kuster perforator
- Normal blood gas