Okay, so I'm gonna be speaking about venus insufficiency and surveillance after under venus intervention has mentioned. So just a couple of technical points, venus insufficiency protocol. Usually Again we're evaluating the lower extremities. So we're going to be using a linear transducer with a 9-12 MHz frequencies. We want to optimize the gain the depth and the location of the target. This this can vary certainly by body habits. And so you wanna get a nice crisp picture and you want to adjust your depth to get that area of focus or the vessel that you're looking at in the center of the image. You don't want to look at a superficial vein and have, you know, the depth, look all the way down to the bone. So that takes away from the quality of your evaluation of the structure that you're looking at. You want to place a target vessel again at the center of the image, you can use a curvilinear pro with a lower megahertz frequency and the patient with a larger adam, idris or obese leg. The preferred method is one to do, to do a venus insufficiency study with a patient standing. This can be challenging. Certainly for an elderly patient, it's very hard for them to stand. It's also more um ergonomically challenging um to do so when you are able to do it uh standing, the patient should really lean most of their weight to the contra lateral leg. This will allow the muscle to relax and allow for those veins to be better evaluated shy of this. The other options include reverse turned Schellenberg, which is what we most commonly institute and our protocols and you want to try to place this patient in reverse turn. Della Berg as much as is safe and feasible. There are certainly beds with a platform at the bottom which facilitate an even more steep, reverse turned Schellenberg and that says, you know, kind of fall somewhere in the middle when evaluating the lower extremity on the bed. You want the knee bent and slightly rotated outward, especially so you can get a good view of that papa teal and distal femoral vein venus evaluation should occur from a set flat to coddle progression. You want to have manual distal compression uh low to your probe or distal to your probe every 1-2 cm. If you have automated rapid cuffs that certainly can replace the manual compression, you never want to compress proximal or above your probe as that will give you a false positive your cuffs, if you have cuffs should be at 100 to 1 50 millimeter. Mercury With rapid deflation is within .3 seconds. Um Val salva. So a comment about the val salva maneuver its best and most effective at the common femoral vein and at the saffron femoral junction distal to this, it can be unreliable. So let's say there's a competent valve in between the segments that you're evaluating and so that may uh produce uh inability that will have inability to evaluate distantly. So really val salva maneuver should be mostly performed at these locations. Here's an example of what can happen in a val salva maneuver. So on the screen left we have respiration occurring. We have val salva uh maneuver occurring in the middle of the uh spectral flow path and there is no reflux so that is a competent valve and then respirations resume and staying below the baseline. In a patient with an incompetent valve. As we see here at the saffron informal junction. During devel salva maneuver, you'll have reversal of flow consistent with reflux venus insufficiency. Obviously there's indications and and this uh important part of this includes really getting a sense of when you're having the patient come for evaluation, understanding why they're there. Where are their symptoms or their global, is it a Dema or they're localized to a certain part of their legs? Um This helps not just to for someone requesting the study, understand why we're getting the study. But when you're performing the study, once you perform the basic parts of the protocol, perhaps taking an uh and and maybe your test was negative uh taking that probe and putting it on that area of pain to just get a more focal evaluation just to assure that you're not missing. Perhaps an atypical uh venus insufficiency or another a cause for their local pain. So you want to consider the clinical presentation, consider the local symptoms. Um And certainly when you have a patient who is being referred for venus insufficiency evaluation with atypical or non axl varicose cities. You want to consider other sources of reflux such as pelvic sources. And so here we have a dis uh table showing the typical distribution of Saffron is reflux patterns um based on various studies uh 65 to about 50-80% of the time. It's the greater staff in this vein as a source of insufficiency. Small staff in this vein is about 10-20% and non staff resources can be as high as 15-20%. The protocol has a minimum standard in terms of the I. A. C. And what it requires both in transverse. Um So across these three different categories and that includes the transverse grayscale imaging, spectral Doppler waveforms and transverse grayscale measurements. So with regards to the grayscale images, this is with and without transducer compression And the about 78 things they're mentioned. Common femoral vein down to small staff in this vein are the minimum requirements for I A. C. Additional requirements which we obviously have in our vascular laboratory. So we do more expensive evaluation really can be protocol driven and local, locally driven with regards to spectral Doppler waveforms. Uh These are done in the dependent position and the minimum required areas of evaluation are noted there, which can be certainly extended based on local protocols as well as a similar noted there, the minimum requirements for the transverse grayscale imaging measuring depths and diameters again in the dependent position. Here we have just an example of an evaluation of the common femoral vein with and without val salva showing a nice respite, aphasic um wave form with the val salva maneuver right in the middle of the spectral flow and the right side of the screen um With val salva and no reflux induced apologize for the name. Um Here we have just an image showing that there is compression of the small staff in this vein. You have that nice elliptical location uh for the small staff in this vein under the state's sub national and on the screen right uh evaluation and longitudinal view with the cursor in the middle of the vessel showing reflux at the proximal portion of the small staff in this vein. Bottom screen also just shows a more detailed evaluation of the staff know pop junction and so this is actually very interesting and I'll talk a little bit about anatomy but it's always nice to try to trace back that axial vein to its sources. There are vary abilities a little bit more detail about the protocols. So vein diameter measurements again, always done in transverse with the calipers on the outer wall, anterior and posterior venus flow should be documented below the baseline. Um When uh taking your picture prior to the augmentation to validate that there was indeed reversal flow. The calipers will help give us an exact measurement of the reflux time you want to trace back any superficial reflux that is identified to its source. Usually with the junction of the deep veins. Perhaps a perforate er or other pelvic atypical sources. Color flow. Doppler examination, examines Luminal flow direction and areas of obstruction. You want to optimize your settings for this and uh the longitudinal axis plane should be at a 45 to 60 degree angle of instigation. With about a two millimeter sample volume abnormalities should get just a little bit of an extra look. So when you start seeing things that need further detail in the report, take a couple of extra views both in axial and longitudinal views. And you want to document the location and the extent of this for the provider and the the clinician who is trying to make a decision on regards to management. You want to note findings such as tortuous city and original changes or dilation, post robotic changes And you want to measure large tributaries that are over 3.5 mm as they may have clinical implication. Here we see a left pop a teal van which was not compressible on the top right image when the scene was playing. Um And this was then looked in longview to denote and depict a little better the post robotic changes consistent with the Nikkei and the reflux uh secondary to the valvular damage. So some words on venus anatomy. Um so there's quite a variability. Uh so based on this, the most common veins that we evaluate in our venus insufficiency protocol, there is a 16% rate described of GS via play Asia. So I think you know this is important to note a because when you're describing the path of the axial veins, you want to be clear on when the vein comes out of the fashion, is there still a residual lumen? Is it completely a tragic and gone? What is the course of this axle vein as the referring provider? As the interventional ist? Certainly for me that has an implication for the type of therapy. I can offer my patients as some As you can see here from the bottom left screen. This patient had what looked to be a type six play asia in terms of its classification. And so the G. S. V. Really came out of the fashion, very close to the junction, it's essentially a tributary and it's a dermal based GS V. And this is not a candidate for heat based ablation and my uh paradigm. And so you know, I'm gonna have a very different discussion with the patient um regarding management. G. S. V. Duplication occurs in about 2% of cases and this is um it can have a common junction to the junction or its own junction and these changes with regards to the variability can be above and below the knee, the small staff in this vein. So this is sort of a very interesting uh an atomic variability that should be considered when evaluating the small staff in this vein. And I think when you just try to get approximately of the small staff in this vein, it really limits um your evaluation of the anatomy and which is why it's important to follow that small safina's vein up. So about 80% of the time, 85% of the time. This small staff in this vein will join the political vein at the crease the rest of the time. There is a significant variability. So you can have where the small staff in its veins a little bit joins higher up from the crease and that's about 6% of the time. And then you have some extensions above the knee into the thigh. You can have what's described as the vein of Jack Amini which is a small staff, which is the extension of the small staff. This vein above the pop a vein and that can have a direct connection to the pop a vein or no direction to the pop a vein And then where it joins in the thigh can vary, it can join into the greater staff in this vein, the posterior thigh of the muscles, the femoral vein. Um uh And so these uh if you can see them, it's nice to note that and note the junction. Um And so these are the other varieties that can uh be present on view here. We see the small staff in this vein on the top screen joining the papa till most common junction. Then you have um bottom screen left where the small staff in this vein continues up into the thigh. We don't see the outflow but we do see that this has a persistent connection still with the pop a vein. And on the screen bottom right it's a small staff in this vein bypassing the uh papa till what would be a standard location for papa till junction and going just up into the thigh. Other axial veins to consider and to evaluate if present and noted include the anti accessory vein and the posterior accessory gsp perforate ear's. Um This is just a quick note and a diagram to again consider the anatomy. There are variable locations to perforate ear's. But what's certainly important when we think about the patient with venus disease and particularly advanced venus disease. If you have a patient who comes with an ulcer, you want to really evaluate that perry ulcer bed because there might be a pathologic perforate. Er And so you can have perforations in the thigh down by the calf and then by the ankle at both anterior posterior and lateral locations. Other things to consider. As I mentioned some sources of a typical varicose cities. And you want to consider patients who may have a pelvic source for insufficiency and you want to try to trace back that re flexing vein or that dilated veins or that symptomatic vein. Again the patient will have a reason to be there. Um And you want to try to at least describe as best as possible the non sappiness source for that very Casati. Um As this may be related to what's described as pelvic escape points with the primary source being pelvic insufficiency. You want to look a little bit closer to patient with prior interventions as they may have neo vascular ization changes that uh now are consistent with recurrent disease. And certainly as dr Evans mentioned when you have a continuous amount of physic flow there may be a suggestion of an outflow obstruction or something up in the iliac or I. V. C. Criteria include a one second reflux for common femoral vein and papa till vein half a second for axial veins or tibial veins. And a pathologic perforate. Er is one that has greater than 5.5 2nd reflux and is greater than 3.5 millimeters measure deep to the fashion and usually around an area of healed ulcer or active ulcer and a little quick word about therapies. Uh There are various therapies for axial veins or lower extremity venous insufficiency and varicose veins stripping is certainly in the algorithm. Um But then there are thermal and non thermal therapies uh that our available and these really drive the uh protocol for surveillance after intervention as they each are associated with a small but not zero a risk of DVt. So post ablation surveillance, it's routine to do this. And my practice is at 3 to 4 days. And and generally it's recommended to do this about 72 hours post procedure. And the reason for this is that the thermal based devices can have an association with endo venus heat induced thrombosis. And this is an extension of the thrombosis from the a bladed axial vein towards the deep vein. And so bottom left, you have the categorization of what's been described for the staff know pop junction bottom screen, right for the greater staff in this vein and the femoral junction. And how this rhombus stump relates to the deep venous system really drives our decision making for management whether it's observation, anti coagulation or any follow up surveillance that may be needed. And so that's the importance of that. Here we just have a couple of images showing some post ablation pictures on the top screen. Right. One that measures six millimeters from the junction. Bottom screen is showing um a small staff in this vein ablation with a flush uh thrombosis extending to the junction at the property of vein. And with that I'll wrap it up. Thank you very much. Mhm. Mhm. Right
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