Refluxul venosRefluxul venos

Alexandru AndritoiuSpitalul Militar Craiova

Anatomia venoasa Anatomia venoasa o noua taxonomieo noua taxonomie

Mozes 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 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-PJonctiunea S-P

Hemodinamica venoasaHemodinamica venoasa

• Aprox. 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 venosFiziologia fluxului venosIntoarcenea venoasa este guvernata

de• Presiunea arteriala• Pompa musculo-venoasa• Gravitatia• Pompa toraco-abdominala• Valvele venoase (pompa valvo-

musculara)

Distributia anatomica a sistemului Distributia anatomica a sistemului venosvenos

1. Tegument2. Fascia superficiala3. Fascia musculara4. Compartimentul profund5. Compartimentul v. safene (interfascial)6. Compartimentul subcutanat (vv colaterale sau tributare)

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

Directia fluxului normalDirectia fluxului normal(curgere ierarhica)(curgere ierarhica)

R 3R 3 R 2R 2 R1R1

perforantetributare(comunicante)

Directia fluxului Directia fluxului incompetentincompetent

R 3R 3 R 2R 2 R1R1

perforantetributare(comunicante)

Fluxul normal vs Fluxul normal vs IncompetentIncompetent

Fluxul venos normalDirectie cefalicaDinspre superficial spre profund

Fluxul venos incompetentDirectie retrogradaDinspre profund spre superficial

Fiziologia IVCFiziologia IVC

• Afectarea pompei musculare • Obstructie Venoasa• Incompetenta valvulara1. 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, USA

MEDICOGRAPHIA, VOL 30, No. 2, 2008

Tipuri de valve venoaseTipuri de valve venoase

A). unicuspid B) bicuspid C) tricuspid D) quaricuspid

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

Functionarea normala Functionarea normala vs anormala a valvelor vs anormala a valvelor

venoase venoase

Despre reflux…Despre reflux…

• Refluxul 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 Metode de diagnostic non-invaziv in evaluare RVin evaluare RV

1. Fotopletismografia2. Pletismografia cu aer3. Flebografia descendenta4. Duplex scan5. B-flow6. CEUS (in studiu)

Saliba O et al. J Vasc Bras. 2007;6(3):266-75.

Testele sunt complementare

Teste de stress efectuate Teste de stress efectuate ptr evidentierea RVptr evidentierea RV

• Manevra Valsalva (activeaza pompa toraco-abdominal)-variante

• Augmentatia manuala distala• Augmentatia distala cu pompa de presiune

automata (automatic pressure cuff)• Activarea pompei musculare gambiere prin

flexie plantara • Manevra Parana

Pozitia pacientului ptr Pozitia pacientului ptr evaluarea RVevaluarea RV

• Verticala (standing)• Reverse-Trendelemburg (RT)• Decubit dorsal (No!-doar ptr diagn.

trombozei)

Pozitia pacientului in timpul Pozitia pacientului in timpul examinarii sistemului venos examinarii sistemului venos

superficial superficial

(A) Examinarea VSM (B) Examinarea VSm

Augmentation/Compresie Augmentation/Compresie distaladistala

Neil 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 Vena competenta vs incompetenta

A) v. competenta B) V. incompetenta

Duplex sampling sitesDuplex 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): 37–45

Diagrama refluxuluiDiagrama refluxului

Mapping venos superficial

J Vasc Surg 2005;41:645-51

RV in VSm (pattern-uri)RV in VSm (pattern-uri)

Engelhorn C et al. J Vasc Surg 2005;41:645-51

RV in VSmRV in VSm

Forma anvelopei RVForma anvelopei RV

Gradele duratei RV si Gradele duratei RV si Peak Reverse Flow VelocityPeak Reverse Flow Velocity

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

Peak reverse flow velocity seems to reflect venous malfunction more appropriately

590 mm. infer.590 mm. infer. 326F-CEAP 2 326F-CEAP 2

Reflux 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 VSm

Engelhorn C et al. J Vasc Surg 2005;41:645-51

Unde incepe RV? (escape Unde incepe RV? (escape points)points)

• RV poate apare in oricare dintre vv superficiale sau profunde la pacienti asimptomatici sau cu varice proieminente

• infra-supragenicular • RV local sau multifocal • RV axial sau segmentar

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

Sursele refluxuluiSursele refluxului

Diametrul v safene scde distal de o tribura incompetenta

(urmareste prezenta v. safene in compartiment)

Axial ultrasound image of great saphenous vein Axial ultrasound image of great saphenous vein ((asterisk)asterisk) in saphenous compartment and adjacent in saphenous compartment and adjacent

tributary (tributary (arrowheadarrowhead) superficial to saphenous ) superficial to saphenous compartmentcompartment

KhilnaniN M. AJR 2014; 202:633–642

Variabilitatea undelor de Variabilitatea undelor de refluxreflux

Progresia refluxuluiProgresia refluxului

Efectul temporal Efectul temporal asupra refluxuluiasupra refluxului

• Tarrant 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: 261-369

• Meissner,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

J Vasc Surg 2012;55:437-45

• 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.

RV primar superficial asociat cu RV primar superficial asociat cu trunchi safen competent trunchi safen competent

Labropulous N. Eur J Vasc Endovasc Surg 1999 (18): 201–206

Originea refluxului inaltOriginea refluxului inalt

• JSF• Tributare ale JSF• VSAA• Originea pelvina• Vv varicoase supra-pubiene• Ileo-femurale

RV Profund vs SuperficialRV Profund vs Superficial

A) Single system/multilevel reflux (only superficial)B) Multisystem/multilevel reflux (deep and superficial)

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

Semnificatia RV profundSemnificatia RV profund

• Localizarea 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) Refluxul profund (axial) un important contributor la aparitia un important contributor la aparitia

tulburarilot trofice cutanate (ulcer) in tulburarilot trofice cutanate (ulcer) in IVCIVC

• Continuous 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 perforanteRV 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 perforanteLocatia VV perforante

V. perforanta cu refluxV. perforanta cu reflux

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

Progresia RVProgresia RV

• Aprox. 1/3 dintre pts cu RV au o evolutie progresiva a CVD–evaluare 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 varicelor

Refluxul in vv pelviene (ovariene, iliace interne) • 25-30% dintre femeile care au nascut• frecv. 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;34,107-111

Stonebridge et al. Br J Surg 1995

RV si relatia cu ulcerul RV si relatia cu ulcerul venosvenos

• Ulcerul venos se asociaza mai frecvent cu• refluxul in vv infrageniculare decat

suprageniculare• refluxul multisistemic/multilevel• refluxul in sistemul profund si vv

perforante (sdr post-trombotic)• v. perforanta dilatata si incompetenta

adiacenta ulcerului

Vascular Health and Risk Management 2012:8 59–64

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 Duplex US in ghidajul ablatiei termice a Vv Safene (RFA/EVLA)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 The Hemodynamic MappingMapping

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

Shunturile veno-venoaseShunturile veno-venoaseCircuite venoase anormale intre diferitele compartimente • profund-superfical• safene –tributare

• Shunt inchis• Shunt deschis• Shunt vicarios• Shunt sistolic/diastolic/sistolo-diastolic

• Puncte de scapare• Puncte de reintrare (P)

Shunt tip 1 (30%)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%)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 Diferentierea Shunt-ului tip 1 vs 3Shunt-ului tip 1 vs 3

ConcluziiConcluziiDuplex scan venos:• evaluare anatomica• evaluare hemodinamica• mapping venos superficial si profund• RV o componenta cruciala in

stabilirea managementului terapeutic al pts. cu CVD

• RV multilevel/multisystem asociat std. 4-6 CEAP