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Us Doppler in evaluarea refluxului venos

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  • Refluxul venosAlexandru AndritoiuSpitalul Militar Craiova

  • Anatomia venoasa o noua taxonomieMozes G, Gloviczki P. New discoveries in anatomy and new terminology of leg veins: clinical implications. Vasc Endovasc Surg 2004; 38:367-74.121 Supra/infrainghinaleSupra/infrageniculare

  • Jonctiunea S-F Vv pudendale

    V. epigastrica inferioara

    V. iliaca circumflexa

    Vv. safene accesorii

    Von Lantz T, Wachsmuth W. Praktische Anatomie, Springer, Berlin, 1959, I

  • Jonctiunea S-P

  • Hemodinamica venoasaAprox. 75% din sangele circulant este distribuit prin sistemul venos Intelegerea mecanismelor prin care sangele venos se intoarce spre inima este cruciala in intelegerea fiziologiei sistemului vascular venos

  • Fiziologia fluxului venosIntoarcenea venoasa este guvernata dePresiunea arterialaPompa musculo-venoasaGravitatiaPompa toraco-abdominalaValvele venoase (pompa valvo-musculara)

  • Distributia anatomica a sistemului venosTegumentFascia superficialaFascia muscularaCompartimentul profundCompartimentul v. safene (interfascial)Compartimentul subcutanat (vv colaterale sau tributare)

    R (N) 3- colateraleR (N) 2- vv safene- GiacominiR (N) 1- vv profunde

  • Directia fluxului normal(curgere ierarhica)R 3R 2R1perforantetributare(comunicante)

  • Directia fluxului incompetentR 3R 2R1perforantetributare(comunicante)

  • Fluxul normal vs IncompetentFluxul venos normalDirectie cefalicaDinspre superficial spre profundFluxul venos incompetentDirectie retrogradaDinspre profund spre superficial

  • Fiziologia IVCAfectarea pompei musculare Obstructie VenoasaIncompetenta valvulara

    1. Incompetenta perforantelor2. Incompetenta vv superficiale (safene)3. Incompetenta vv profunde

  • John BERGAN, MDThe Vein Institute of La JollaDepartment of SurgeryUCSD School of Medicine La Jolla, CA, USAMEDICOGRAPHIA, VOL 30, No. 2, 2008

  • Tipuri de valve venoaseA). unicuspid B) bicuspid C) tricuspid D) quaricuspid

  • Classification of valvular lesionsFunctional valve lesions (type I)Traumatic organic valve lesions (type II)Inflammatory organic lesions (type III)Valvular vestiges (type IV)

  • Functionarea normala vs anormala a valvelor venoase

  • Despre refluxRefluxul in vv superficiale (safene si tributare)cea mai frecventa anomalie fiziologica la pacientii cu CVD.Flux retrograd

    -axial/segmentar-multilevel/multisystem-spontan/provocat-descendent/ascendent

  • Metode de diagnostic non-invaziv in evaluare RVFotopletismografiaPletismografia cu aerFlebografia descendentaDuplex scanB-flowCEUS (in studiu)Saliba O et al. J Vasc Bras. 2007;6(3):266-75.Testele sunt complementare

  • Teste de stress efectuate ptr evidentierea RVManevra Valsalva (activeaza pompa toraco-abdominal)-varianteAugmentatia manuala distalaAugmentatia distala cu pompa de presiune automata (automatic pressure cuff)Activarea pompei musculare gambiere prin flexie plantara Manevra Parana

  • Pozitia pacientului ptr evaluarea RVVerticala (standing)Reverse-Trendelemburg (RT)Decubit dorsal (No!-doar ptr diagn. trombozei)

  • Pozitia pacientului in timpul examinarii sistemului venos superficial Examinarea VSM (B) Examinarea VSm

  • Augmentation/Compresie distalaNeil M. Khilnani, Robert J. Min. Seminars in Interv Radiology, 2005;(22):3

  • VenaPulse Hands-Free Augmentation Device

  • Cuff measurements were more accurate in diagnosing deep venous reflux than manual measurements, and more reproducible

  • Vena competenta vs incompetenta A) v. competentaB) V. incompetenta

  • Duplex sampling sites

    The patient below demonstrates primary varicose veins in the GSV territory with several tributaries.Arrows indicate the few locations which need to be tested.

    Necas M. AJUM 2010; 13 (4): 3745

  • Diagrama refluxului

    Mapping venos superficial

  • J Vasc Surg 2005;41:645-51

  • RV in VSm (pattern-uri)Engelhorn C et al. J Vasc Surg 2005;41:645-51

  • RV in VSm

  • Forma anvelopei RV

  • Gradele duratei RV si Peak Reverse Flow Velocity Danielson G et al. J Vasc Surg 2003;38:1336-41Peak reverse flow velocity seems to reflect venous malfunction more appropriately

  • 590 mm. infer. 326F-CEAP 2Reflux detectat in 80%17% reflux in VSM si VSm, 60% reflux numai in VSM, 3% reflux numai in VSm,

    Prevalenta totala:77% in VSM 20% in VSmEngelhorn C et al. J Vasc Surg 2005;41:645-51

  • Unde incepe RV? (escape points) RV poate apare in oricare dintre vv superficiale sau profunde la pacienti asimptomatici sau cu varice proieminenteinfra-supragenicular RV local sau multifocal RV axial sau segmentar

    Labropoulos N et al. J Vasc Surg 1997;26:736-42.)

  • Sursele refluxuluiDiametrul v safene scde distal de o tribura incompetenta(urmareste prezenta v. safene in compartiment)

  • Axial ultrasound image of great saphenous vein (asterisk) in saphenous compartment and adjacent tributary (arrowhead) superficial to saphenous compartmentKhilnaniN M. AJR 2014; 202:633642

  • Variabilitatea undelor de reflux

  • Progresia refluxului

  • Efectul temporal asupra refluxuluiTarrant G, Clark, J et al. Differences in Venous Function of the Lower Limb by Time of Day: A Comparison of Chronic Venous Insufficiency Between and Afternoon and Morning Appointment by Duplex Ultrasound. J.Vasc. Ultrasound 2008;32(4):187-192.Zamboni, P, Cisno, C et al. Reflux Elimination without and Ablation of Disconnection of the Saphenous Vein. A Haemodynamic Model for Venous Surgery: Eur J Vasc Endovasc Surg 2001; 21: 261-369Meissner,M, Moneta, G,et al. The hemodynamics and diagnosis of venous Disease. J Vasc Surg 2007; 46:4S-24S

    INVEST STUDY: Reports should include time of day, patient position and reflux provoking maneuver used

  • Standardization of duplex ultrasound detection of venous reflux can improve reliability.Reports should be standardized to include information on the time of the test, the position of the patient, and the provoking maneuver used. The repeated scans can be performed in the same settings, improving reliability. Adopting a uniform criterion of 0.5 second for pathologic reflux can significantly improve the reliability of reflux measurement and interpretation.

    J Vasc Surg 2012;55:437-45

  • RV primar superficial asociat cu trunchi safen competent Labropulous N. Eur J Vasc Endovasc Surg 1999 (18): 201206

  • Originea refluxului inaltJSFTributare ale JSFVSAAOriginea pelvinaVv varicoase supra-pubieneIleo-femurale

  • RV Profund vs SuperficialSingle system/multilevel reflux (only superficial)Multisystem/multilevel reflux (deep and superficial)

    Neglen P.et al. J Vasc Surg 2004;40:303-310

  • Semnificatia RV profundLocalizarea si gradul RV sunte elemente cruciale in stabilirea managementului clinic al pts. cu CVI. Refluxul in sistemul venos profund joaca un rol major in progresia IVC spre ulcer venos.Refluxul venos in sistemul profund se asociaza stadiilor avansate CEAP si Sdr post-trombotic.

    Welch H et al. J Vase Surg 1996;24:755-62

  • Refluxul profund (axial) un important contributor la aparitia tulburarilot trofice cutanate (ulcer) in IVCContinuous axial deep venous reflux is a major contributor to increased prevalence of skin changes or ulcer in patients with chronic venous disease compared with segmental deep venous reflux above or below the knee only. The total peak reverse flow velocity score is significantly higher in patients with skin changes or ulcer.

    Danielson G et al. J Vasc Surg 2003;38:1336-41

  • RV in venele perforante Refluxul in VvP apare numai in prezenta unor vv superficiale incomptenete care actioneaza ca un capacitor pentru refluxul provenit din perforante.VV P incompetemnte au calibru marit peste 3,5 mm ca o consecinta a cresterii presiunii venoase hidrostatice.Fluxul este bidirectional Prevalenta VvP insuficiente creste odata cu agravarea clinica a CVD (CEAP 4-6)-2/3 pts

    Labropoulos N et al. J Vasc Surg 2006;43:558-62

  • Locatia VV perforante

  • V. perforanta cu reflux

    Chander RK, Monahan TS. Journal of Vascular Diagnostics 2015:3;25-31

  • Progresia RV Aprox. 1/3 dintre pts cu RV au o evolutie progresiva a CVDevaluare dupa 6 Mo.

    Pts. supusi unui tratament venos trebuie reevaluati prin CDUS exam.

    Labropoulos N et al. J Vasc Surg 2005;41: 291-5

  • Cauzele de recurenta a varicelorRefluxul in vv pelviene (ovariene, iliace interne) 25-30% dintre femeile care au nascutfrecv. neinvestigat inainte de interventie (CDUS TV)

    Tratament suboptimal Reflux in JSF, Vv. Perforante, vv tributare, vv. accesorii Neovascularizatie in aria tratata

    Refluxul venos rezidual dupa ablatia v. safene nu se asociaza cu riscul de recurenta a ulcerului venos

    Whiteley A et al. J Vasc Surg: Venous and Lum Dis 2014;2:411-5.

    Kulkarni S et al. Eur J Endovasc Surg 2007;34,107-111Stonebridge et al. Br J Surg 1995

  • RV si relatia cu ulcerul venosUlcerul venos se asociaza mai frecvent curefluxul in vv infrageniculare decat supragenicularerefluxul multisistemic/multilevelrefluxul in sistemul profund si vv perforante (sdr post-trombotic)v. perforanta dilatata si incompetenta adiacenta ulcerului

  • Vascular Health and Risk Management 2012:8 5964

  • Venous segmental disease score (Based on venous segmental involvement with reflux)

    Rutherford RB, Padberg FT Jr, Comerota AJ, Kistner RL, Meissner MH, Moneta GL. Venous severity scoring: an adjunct to venous outcome assessment. J Vasc Surg 2000;31:1307-12.

  • Varicose Vein AblativeProcedures:

    Thermal ablation, stripping, ligation and excision of the great saphenous vein and small saphenous veins are considered reconstructive and medically necessary when ALL of the following criteria are present (1, 2, 3 and 4): 1. Junctional Refluxa. Ablative therapy for the great or small saphenous veins will be considered reconstructive and therefore medically necessary only if junctional reflux is demonstrated in these veins;b. Ablative therapy for accessory veins will be considered reconstructive and medically necessary only if anatomically related persistent junctional reflux is demonstrated after the great or small saphenous veins have been removed or ablated. 2. Member must have one of the following functional impairments: a. Skin ulceration; or b. Documented episode(s) of frank bleeding of the varicose vein due to erosion of/or trauma to the skin; or c. Documented superficial thrombophlebitis or documented venous stasis dermatitis; or d. Moderate to severe pain causing functional/physical impairment. Venous Size:The great saphenous vein must be 5.5 mm or greater when measured at the proximal thigh immediately below the saphenofemoral junction via duplex ultrasonography b. The small saphenous vein or accessory veins must measure 5 mm or greater in diameter immediately below the appropriate junction. 4. Duration of reflux, in the standing or reverse Trendelenburg position that meets the following parameters: a. Greater than or equal to 500 milliseconds (ms) for the great saphenous, small saphenous or principle tributaries b. Perforating veins > 350 ms c. Some duplex ultrasound readings will describe this as moderate to severe reflux which will be acceptable.

  • Duplex US in ghidajul ablatiei termice a Vv Safene (RFA/EVLA)

    CDUS-identificarea accesului venos la cel mai decliv nivel de reflux evidentiat in trunchiul safen incompetent. Cel mai frecvent, RV al VSM apare in regiunea subinghinala si coboara spre gamba unde fuge spre o tributara din care rezulta segmentul varicos. In acest caz, accesul venos este stabilit la locul abusarii tributarei.

  • Echipa Sp. Clinic Militar CraiovaDr Silosi CristianDr Alexandru AndritoiuAblatia prin RF a vv safene

  • The Hemodynamic Mapping

    CHIVA method-identification of Shunts in order to plan their disconnection

  • Shunturile veno-venoaseCircuite venoase anormale intre diferitele compartimente profund-superficalsafene tributare

    Shunt inchisShunt deschisShunt vicariosShunt sistolic/diastolic/sistolo-diastolic

    Puncte de scaparePuncte de reintrare (P)

  • Shunt tip 1 (30%)RV incepe la JSF avand reintrare printr-o v. perforanta care leaga teritoriul safen de sistemul profund.O v. tributara cu reflux poate fi adesea descoperita v. perforanta este situata distal de originea tributarei.Caracteristic, diametrul v. safene scade sub originea tributarei incompetente in timp ce refluxul persista pana la locul de reintrare.

  • Shunt tip 3 (60%)RV incepe la JSF si progreseaza spre o v. tributara avand punctul de reintrare in sistemul venos profund via v. perforanta in vena tributara. In acest caz, lipseste refluxul distal de v. tributara incompetenta.

    90% dintre pts prezinta tipul 1 si 3 de shunt veno-venos

  • Diferentierea Shunt-ului tip 1 vs 3

  • ConcluziiDuplex scan venos:evaluare anatomicaevaluare hemodinamicamapping venos superficial si profundRV o componenta cruciala in stabilirea managementului terapeutic al pts. cu CVD RV multilevel/multisystem asociat std. 4-6 CEAP

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