Extremity Venous Sonographic Evaluation

or those who are writing the SPI- Ultrasound physics exam. I have notes for sale it is about 2000 multiple choices sets for ARDMS -spi exam = 50 USA DOLLARS. I study those notes and passed my exam 670/700 . If you want to buy i can copy the notes and send them to you in e mail or by mail   you can reach me at drsteveramsey@gmail.com . I will also include some of the ideas about the 12 simulation questions.  The payment with  PayPal      to drsteveramsey@gmail.com  ,  fetal gender , Saad Ismail   .

Some of these points are part of the ARDMS vascular exam . So if you are preparing to write your vascular exam these points will help you allot, as many questions will be in anatomy, physiology, techniques and color flow. I wish you you good luck to pass the vascular exam.

Extremity Venous Anatomy and Sonographic Evaluation

 VENOUS ANATOMY:

• Thin walled, collapsible
• Still allows for some dilatation and constriction
• Media layer thinner than artery
• Walls of the upper extremity veins contain much less muscle than walls of the veins in the lower extremity and especially the feet; this is due to hydro- static pressure
• Progressive increase in size as they get closer to heart
• Contain valves
• Veins originate distally as venules in the extremity(hands/feet) and travel to right atrium
• Capillary beds are composed of intima only and connect to venules
• Venules are composed of intima and adventitia layers only (no media layer)

80% of the blood in the body is found in the venous system

Remember proximal used to be defined as closest to the point of origin.BUT current vascular nomenclature refers to proximal as being closest to the heart  EX: The “proximal” SFV is in the upper thigh and closer to the heart than the “distal” SFV in the lower thigh

Vein walls are composed of the same three layers as an artery but the media layer is much thinner. The venous valves are extensions of the intimal layer.

Central Veins:

• Inferior Vena Cava IVC – confluence of iliac veins
• Hepatic veins
• Superior Vena Cava SVC – confluence of innominate veins
• Portal vein-confluence of SMV and splenic vein

 Lower Extremity Deep Veins:

Deep digital veins > metatarsal veins > PTVs and peroneal veins > tibioperoneal trunk > ATVs > popliteal vein > superficial femoral vein > common femoral vein > external iliac vein

• Veins in the lower extremity originate at the confluence of the venules of the deep digital veins
• Metatarsal veins drain the blood from the foot
• Deep venous arches empty their blood into tibial veins

• Calf and forearm veins are referred to as venae comitantes because 2 veins of the same name follow the same course as a single artery of the same name

Anterior Tibial Veins:

• 2 veins originates at the plantar arches
• Course cephalad anterolateral to the tibial bone and the interosseous membrane to reach the tibioperoneal trunk
• Travels between the tibial head and fibula head
• Best scan approach is anterior calf with slightly lateral probe position

Posterior Tibial Veins:

• 2 veins originate at the confluence of the plantar arches
• At the ankle the PTVs course posterior to the medial malleolus and anterior to the Achille’s tendon then course cephalad through the calf posterior to the tibial bone

• For  PTV  the Best scan approach is to place probe on the medial calf, angling through to the lateral side; PTVs most anterior on image and peroneals visible beneath them

Peroneal Veins:

• In the lower calf/ankle 2 veins course lateral to the PTVs and medial to the fibula,
• Continue in a cephalad course up the midline of the posterior calf, posterior to the fibula
• 2 peroneal veins and 2 posterior tibial veins merge to form a single tibio-peroneal trunk in the upper calf
• Best scan approach is to place probe on the medial calf, angling through to the lateral side; PTVs most anterior on image and peroneals visible beneath them

Popliteal Vein:

• Tibioperoneal trunk merges with the two anterior tibial veins to form the popliteal vein in the popliteal fossa
• Courses posterior to the popliteal artery
• Becomes the femoral vein at adductor hiatus in the distal thigh
• Best scan approach is to place probe on the posterior popliteal fossa; popliteal vein demonstrated ANTERIOR to the popliteal artery on the image due to the scan approach

• Femoral Vein:
• AKA superficial femoral vein (SFV); nomenclature recommendations remove the term superficial to alleviate confusion regarding this deep vein

• Extends from adductor hiatus to join the profunda femoral vein at the groin
• Courses posterior to the femoral artery

Profunda Femoral Vein:

• AKA deep femoral vein (DFV); nomenclature recommendations remove the terms superficial and deep to alleviate confusion regarding both of these veins being part of the deep venous system

• Joins the femoral vein to form the common femoral vein just below inguinal ligament
• Drains the muscles in the thigh (quadriceps)

Common Femoral Vein:

• Becomes external iliac vein just above inguinal ligament
• Courses medial and posterior to common femoral artery

Internal Iliac Vein:

• Courses medial to the external iliac vein
• Drains the pelvic organs (NOT the gonads)

External Iliac Vein:

• Courses lateral to the internal iliac vein and anterior to the external iliac artery
• Joins the internal iliac vein to form the common iliac vein

Common Iliac Vein:

• Courses anterior to the common iliac artery
• Right and left common iliac veins merge at the level of L5 to form the IVC
• IVC empties into the right atrium

•  Klippel – Trenaunay – Weber Syndrome:
• 
• Congenital absence of the deep veins
• Causes numerous superficial varicosities and clusters of varicosities

•  Lower Extremity Superficial Veins:
• Located within 2 cm of the skin surface
• Course within the subcutaneous fat layer of the leg
• Veins of the superficial system always course between the superfical fascial layers; use this characteristic location to differentiate from dilated tributaries of the superficial system

• Great Saphenous Vein (GSV):
• Longest vein in the body
• Originates on the dorsum of the foot travelling anterior to the medial malleolus

• Ascends medial thigh with the great saphenous nerve
• Ends at the groin at the common femoral vein junction
• Also connects to deep system through multiple perforating veins
• Superficial epigastric vein is the most proximal tributary of the GSV and usually descends into groin to join the GSV near the saphenofemoral junction
• Commonly used as a bypass graft for cardiac and arterial bypass surgery

• Anterior Accessory Saphenous Vein (AASV):
• Most easily identified at the groin
• Ascends along the thigh to join the GSV near the groin
• Differentiated from the GSV by its course anterior to the femoral artery instead of medial to it (GSV)
• Not visible in all patients; can be a sign of dilated superficial system and reflux

Short Saphenous Vein (SSV):

• AKA small saphenous vein
• Dorsal vein of the little toe joins the dorsal venous arch to form the SSV
• Originates posterior to lateral malleolus
• Ascends along the midline aspect of posterior calf
• Usually joins the popliteal vein in knee/distal thigh area but many variations in termination possible
• Course of the vessel on the posterior calf described as a “stocking seam”
• Numerous perforators connect the SSV to the GSV in the calf

 Perforators:

• Connect superficial and deep systems to equalize pressure between the two systems
• PTV connected to distal GSV near ankle
• Posterior arch vein extends superior from the ankle to the GSV in the mid calf; plays a major role in venous stasis; connected to 3 ankle perforators called Crockett’s Perforators
• Boyd’s Perforators located in the knee area; connect GSV to POP
• Dodd’s Perforators located in distal thigh; connect GSV to SFV
• Hunterian Perforators located in proximal thigh; GSV to SFV
• Lateral perforator connects to SSV near the mid calf
• Each leg normally has about 100 perforators
• Normally <2 mm diameter, >4 mm usually has reflux
• Flow is normally from superficial system to deep system****
• Ankle perforator damage/dilatation involved in stasis ulcers
• Dilated perforators can occur in response to DVT formation

 Sural Veins (sinusoid or saccular veins):

• Dilated vessels between soleal and gastrocnemius muscles of the calf
• Serve as blood reservoirs for the legs
• Important for calf muscle pump and lower extremity venous flow
• Gastrocnemius veins; have an accompanying artery with each set; usually seen as two pairs, lateral and medial sets; may see three pairs; most commonly drain into the popliteal vein
• Soleal veins are thick walled reservoirs within the soleal muscle; no artery with them; do NOT contain valves; drain into either the posterior tibial or peroneal veins

Valves:

• Extensions of the intimal layer
• Valves contain two leaflets (bicuspid)
• Allow unilateral flow direction in veins
• Helps keep flow moving from superficial to deep system and from peripheral to deep veins

 Venous valves normally allow flow to move in one direction in the vessel, toward the heart.Note the thin echogenic flaps of the venous valve as it opens and closes.

Upper Extremity Venous Anatomy:

Deep venous flow: Venules > deep digital veins > metacarpal veins > deep venous arches > radial/ulnar veins > brachial vein(s) > axillary vein > subclavian vein > innominate vein > SVC > right atrium

• Veins of the upper extremity originate at the confluence of the venules of deep digital veins of the fingers
• Metacarpal veins to deep venous arches which converge into the radial and ulnar veins at the wrist
• Calf and forearm veins are referred to as venae comitantes because 2 veins of the same name follow the same course as a single artery of the same name
• 2 radial veins join 2 ulnar veins just distal to elbow to form the brachial vein(s) can be one or two brachial veins
• Brachial vein(s) courses through anterior upper arm to meet the medial basilic vein at the axilla to become the axillary vein
• Axillary vein meets the cephalic vein to form the subclavian vein adjacent to lateral clavicle
• Internal jugular vein drains blood from the head/neck and joins the subclavian vein to form the innominate vein (brachiocephalic vein)
• 2 Innominate veins(Right and Left), 1 innominate artery (first branch of aortic arch)
• Right and left innominate veins merge to form the superior vena cava (SVC) which empties into the right atrium of the heart

Deep Veins:

• Radial/Ulnar: 2 veins with 1 artery, originate at wrist and converge to form brachial vein(s) at antecubital fossa; radial vein courses up the lateral aspect of the forearm (anatomic position); ulnar vein courses up the medial aspect of the forearm
• Brachial: can have one or two vessels at the origin, courses up anterior upper arm to join basilic vein superiorly at axilla
• Axillary Vein: segment formed from the brachial/basilic junction until it joins with cephalic vein more superiorly
• Subclavian Vein: formed by axillary and cephalic junction, ends when  internal jugular vein merges with it to form the innominate in Superficial Veins:

• Basilic:  originates medially in wrist, adjacent to ulnar bone, courses superiorly along the medial arm to join brachial vein in  axilla
• Cephalic:  originates laterally in wrist, adjacent to radial bone, courses superiorly along the lateral aspect of the arm to join axillary vein at shoulder; most common upper extremity vein used for arterial bypass
• Antecubital:  Connects cephalic and basilic veins in antecubital fossa, commonly used to draw blood; AKA median cubital vein

 SIGNS AND SYMPTOMS OF VENOUS DISEASE:

 Risk Factors:

• High Risk for DVT

        #1 – recent hip or knee replacement

        Bed rest

• Increased incidence of left DVT due to extrinsic compression by RIGHT iliac artery (May – Thurner Syndrome)
• Smoking has demonstrated a increased risk of DVT formation, especially when accompanied with oral contraceptive use and or sedentary lifestyle

 Virchow’s Triad:

1. Trauma – endothelial damage, intrinsic (drugs) or extrinsic (falling down)
2. Stasis – bed rest, MI, CHF, hypotension, COPD, obesity, pregnancy, surgery, paraplegia
3. Hypercoagulability – pregnancy, cancer treatment, estrogen intake, myeloproliferative disorders

 Signs and Symptoms of Venous Disease:

• Pain
• Swelling/Edema – acute unilateral DVT usually presents with >2cm difference in calf circumference
• Redness/rubor
• Warmth
• Pitting Edema due to fluid accumulation from thrombosis, electrolyte imbalance, renal dysfunction or CHF; fluid accumulation due to lymphedema leads to fluid accumulation that will resist depression and pulls the skin taught (non-pitting edema)
• Pallor with phlegmasia alba dolens
• Cyanosis with phlegmasia cerulea dolens
• Venous HTN – increased venous volume causes fluid to leak into interstitial spaces between tissues; causes edema; associated with heart failure, pregnancy, thrombus, venous insufficiency
• Ulcers – 75% lower extremity ulcers are venous

       ¨ Wet, oozing, usually NOT painful

       ¨ Caused by chronic venous disease

       ¨ Stagnant blood causes RBC and fluids to leak into tissues

       ¨ Brawny color in “gaitor zone” from broken down RBCs and improper    tissue nutrition

Note the excessive hand swelling and arm redness associated with DVT. Note the size and color difference of extremities which is a classic sign of acute DVT. Note the size difference between the two extremities which can be a sign of acute DVT, if it has an acute onset.Note the mild swelling, purple/brown discoloration and wet, oozing ulceration consistent with chronic venous disease. These characteristics can be related to chronic DVT and venous .As venous outflow is reduced by DVT formation, fluid/waste escapes through the vessel walls into the surrounding tissues.As venous outflow is reduced by DVT formation, fluid/waste escapes through the vessel walls into the surrounding tissues purple, wet oozing ulcer = venous disease; disease gray/brown, crusty, dry ulcer = arterial disease

Venous Evaluation Techniques:

• Ultrasound with Doppler Evaluation for DVT
• Ultrasound with Doppler Evaluation for Insufficiency
• Vein Mapping
• Photoplethysmography
• Air/Strain/Impedance Plethysmography

 Upper Extremity Evaluation for DVT:

• Patient should be evaluated in the semi-erect (reverse Trendelenburg) position to increase gravitational pressures to fill veins with blood; the affected arm should be in the dependent position and externally rotated
• Evaluate the internal jugular, subclavian, axillary, brachial, basilic and cephalic veins; deep forearm veins (radial and ulnar) may also be a part of the protocol
• Internal jugular vein and subclavian vein can be assessed for comprehensibility by asking the patient to sniff
• Deep veins of the shoulder and upper arms should normally demonstrate spontaneous and phasic flow
• Cardiac pulsatility can normally be found in the IJV and subclavian veins

 Lower Extremity Evaluation for DVT:

• Patient should be evaluated in the reverse Trendelenburg position to increase hydrostatic and intra-abdominal pressures to fill veins with blood; the affected leg should be externally rotated with the knee slightly bent

• Evaluate the common femoral, superficial femoral, proximal profunda and popliteal veins; deep calf veins (tibials and peroneals) may also be a part of the protocol
• Deep veins of the thigh should normally demonstrate spontaneous and phasic flow
• Cardiac pulsatility is abnormal if identified in the lower extremities

 US of Extremity Veins for DVT:

• 5-10 MHz linear probe or 3.5 MHz curved probe for obese patients or edematous legs
• 2D Images – Transverse plane compression views

       ¨ Lack of compressibility most reliable finding for DVT diagnosis

       ¨ Surrounding tissue may provide resistance; try several probe and/or patient positions

• Color/PW Doppler – Longitudinal plane with augmentation maneuvers

       ¨ Phasicity – respiratory variation

       ¨ Spontaneity – flow heard at all sites in deep veins

       ***calf veins and superficial venous system normally will not demonstrate flow without augmentation***

       ¨ Proximal Augmentation – Valsalva

       ¨ Distal Augmentation – calf/forearm compression

       ¨ IF THE PATIENT IS POSITIVE FOR DVT. NO AUGMENTATION MANEUVERS ARE PERFORMED

       ¨ Pulsatility – vibrations from cardiac movement normally cause pulsatile flow in the IVC, SVC, Hepatic, Innominate and Subclavian veins; if pulsatility identified in the lower extremities, Congestive Heart Failure suspected

 Limitations:

• Obesity, edema
• Surrounding structures – subclavian vein is normally unable to be compressed due to the clavicle; use sniff technique
• Mistaken identity of vessel
• Duplication of system
• Superficial location of some of the veins can lead to easy compression with light probe pressure, may make vessels hard to find
• History of DVT
• Low flow volume inhibits augmentation display

Note the full compressibility of the vein during the compression maneuver.Note the non-compressibility of the vein and the echogenic material within the venous lumen Normal venous response to the Valsalva maneuver is cessation of venous flow toward the heart.Flow reversal upon release of the Valsalva maneuver indicates the presence of reflux. If flow reversal occurs at the onset of the Valsalva, the duration of the reflux flow must be measured.The distal augmentation maneuver is used to confirm the absence of DVT following the compression maneuvers. Normally the flow will increase in velocity toward the heart with the distal augmentation. If DVT is present there will be little to no response to the maneuver.Distal augmentation can also be used to evaluate the presence/absence of valvular insufficiency. The flow will increase toward the heart with distal augmentation but will reverse in direction after the initial increase.

Some sample ardms questions ;

Question 1: The most commonly used artery for catheter insertion to perform arteriography of the carotid circulation is the:

1. Superficial femoral artery
2. Common femoral artery
3. Axillary artery
4. Brachial artery

Correct answer: #2 Common femoral artery

Question 2: A patient presents with a pseudoaneurysm following arterial puncture. For ultrasound-guided compression of the pseudoaneurysm, how long would each compression last before checking for cessation of flow into the pseudoaneurysm?

1. 1 minute
2. 10 minutes
3. 30 minutes
4. 45 minutes

Correct answer: #2 10 minutes

Question 3 : The point at which aliasing occurs is known as the:

 1. Nyquist Limit

2. Poiseuille’s Point

3. Bernoulli’s Equation

4. Reynolds Number

Correct answer: #1 Nyquist limit.

Question 4: An abnormal sound heard on auscultation caused by flow turbulence is a:

 1. Bernoulli

2. Bruit

3. Poiseuille

4. Thrill

Correct answer: #2, Bruit
Question 5 : On the spectral display, time is displayed on the:

 1. x-axis

2. y-axis

3. z-axis

4. All of the above

Correct answer: #1
Question 6 : Neurological symptoms that are of short duration, completely resolving in less than 24 hours , are termed:

 1. CVA

2. RIND

3. TIA

4. HTN

Correct answer: #3

 Thank you for reading.

Steve Ramsey, PhD- Public Health.     MSc- Medical Ultrasound.

BSc – Diagnostic Imaging. 

Calgary, Alberta, Canada.

Picture in the old days sonography, when I used to work with Contact scanner .

 

I didn’t include the carotids us ,renal Doppler stenosis, transplant renal us , t tips and other vascular sonography , I will put them separately. If you have any other Quiz ,exam questions, and extra idea please add them in the comments. 

Thank you  for readng

Steve Ramsey, PhD – Calgary , Alberta