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Ann Phlebology 2023; 21(2): 63-65

Published online December 31, 2023

https://doi.org/10.37923/phle.2023.21.2.63

© Annals of phlebology

Ultrasonographic Image Acquisitions of Varicose Veins of the lower Extremities - The 2023 Korean Society for Phlebology Clinical Practice Guidelines

HeangJin Ohe, M.D.1, Tae Sik Kim, M.D.2, Wooshik Kim, M.D.3, Sangchul Yun, M.D.4, Seung Chul Lee, M.D.5, Sung Ho Lee, M.D.6 and Sang Seob Yun, M.D.7

1Division of Vascular and Transplant, Department of Surgery, Inje University Haeundae Paik Hospital, Busan, 2Department of Thoracic and Cardiovascular Surgery, Korea University Guro Hospital, Seoul, 3Department of Thoracic and Cardiovascular Surgery, National Medical Center, Seoul, 4Department of Surgery, Soonchunhyang University Seoul Hospital, Seoul, 5Easyleg Clinic, Seoul, 6Department of Thoracic and Cardiovascular Surgery, Korea University anam hospital, Seoul, 7Division of Vascular and Transplant Surgery, The Catholic University of Korea, Seoul St. Mary’s Hospital, Seoul, Korea

Correspondence to : Tae Sik Kim
Department of Thoracic and Cardiovascular Surgery, Korea University Guro Hospital
Tel: 82-2-2626-1180, Fax: 82-2-2626-1188
E-mail: kmdphd@gmail.com

Received: November 28, 2023; Revised: December 15, 2023; Accepted: December 15, 2023

Venous flow normally circulates from the skin to superficial veins, which drain into the deep veins and the heart. Venous reflux refers to blood flow that flows in the opposite direction. Venous reflux is caused by gravity and valvular insufficiency. Diagnosing venous reflux is important to determine treatment for lower extremity venous disease. Unlike arteries, venous reflux is greatly affected by the relative position of the probe and the vessel. Standardized ultrasound images are required to verify venous reflux using ultrasound. It is important to perform the reflux provocation test using the standardized posture and method.

Keywords Ultrasound, Reflux, Guideline, Varicose vein

Doppler ultrasound is the first diagnostic test for chronic venous disease. Doppler ultrasound provides information about venous anatomy and blood flow. Unlike arterial testing, veins are affected by gravity and valve insufficiency; therefore, the posture of the patient, the method of inducing reflux, and the location of the ultrasound probe and test vessel are important. Generally, the reflux diagnosis for saphenous veins is based on 0.5 seconds, and the reflux standard for deep veins is based on 1 second (1). Throughout this article, we refer to standardized reflux testing methods.

The characteristic change in blood flow direction in venous insufficiency can be assessed by measuring the augmentation waveform caused by calf compression and the reflux waveform due to retrograde flow. These waveforms are positioned in opposite directions along the baseline of pulse wave analysis, allowing for a clear indication of the directionality of blood flow. It is preferable to measure and record the augmentation waveform below the baseline and the reverse flow waveform above the baseline (1-7).

A longitudinal view allows for a more accurate assessment of the length and curvature of blood vessels compared to a transverse view. Therefore, it enables a more precise evaluation of issues, such as stenosis or occlusion, caused by venous thrombosis, providing a higher resolution of the vascular structure. This high resolution aids the examiner in easily identifying and interpreting subtle changes within the blood vessels. Additionally, when measuring in a longitudinal view in duplex or triplex ultrasound, the likelihood of mistaking temporary turbulence or pulsatile flow as reflux is reduced (6-14). Turbulence around valves may be misinterpreted as reflux when measuring in a transverse view (15).

Color Doppler allows for the visualization of blood flow direction by using two colors. Additionally, pulsed-wave Doppler provides information such as flow direction, velocity, and cycle that cannot be solely analyzed using color Doppler. Therefore, to effectively demonstrate the persistence of reflux over a specific period, it is recommended to primarily base it on pulsed-wave Doppler examination and supplement it with color Doppler (6,7,9,10,12).

Perforating veins can be an anatomically intricate and tortuous network, making measurements in a longitudinal view challenging. In a longitudinal view, the primary goal is to follow the vessel length, making it difficult to measure complex vascular branching or transverse sections accurately. In such cases, measurements can be performed more effectively in a transverse view.

Reflux refers to retrograde blood flow opposite to normal venous flow. To verify venous reflux using ultrasound, standardized ultrasound images are required. Unlike the transverse view, the longitudinal view allows for visualization of both the direction of the blood flow and the ultrasound incidence angle, facilitating an objective assessment of the presence or absence of reflux. Furthermore, the probe must measure blood flow in a fixed position to detect the Doppler frequency shift accurately. The Doppler effect is sensitive to the relative movement between the probe and blood flow. Therefore, performing the reflux provocation test using the standardized position and method provided here is of great significance.

  1. Gloviczki P, Lawrence PF, Wasan SM, Meissner MH, Almeida J, Brown KR, Bush RL, Di Iorio M, Fish J, Fukaya E, Gloviczki ML, Hingorani A, Jayaraj A, Kolluri R, Murad MH, Obi AT, Ozsvath KJ, Singh MJ, Vayuvegula S, Welch HJ. The 2022 Society for Vascular Surgery, American Venous Forum, and American Vein and Lymphatic Society clinical practice guidelines for the management of varicose veins of the lower extremities. Part I. Duplex Scanning and Treatment of Superficial Truncal Reflux: Endorsed by the Society for Vascular Medicine and the International Union of Phlebology. J Vasc Surg Venous Lymphat Disord 2023;11:231-61.
  2. Labropoulos N, Tiongson J, Pryor L, Tassiopoulos AK, Kang SS, Ashraf Mansour M, et al. Definition of venous reflux in lower-extremity veins. J Vasc Surg 2003;38:793-8.
  3. Labropoulos N, Leon LR Jr. Duplex evaluation of venous insufficiency. Semin Vasc Surg 2005;18:5-9.
  4. Markel A, et al. A comparison of the cuff deflation method with limb compression in detecting venous valvular reflux. Arch Surg 1994;129:701-5.
  5. Marianne G. De Maeseneer European Society for Vascular Surgery (ESVS) 2022 Clinical Practice Guidelines on the Management of Chronic Venous Disease of the Lower Limbs Clinical Practice Guideline Document Vol 63. P184-267, February 01, 2022.
  6. AIUM Practice Parameter for the Performance of a Peripheral Venous Ultrasound Examination. J Ultrasound Med 2020;39:E49-E56.
  7. Vascular technology professional performance guidelines: Lower extremity venous insufficiency evaluation. Society of Vascular Ultrasound. 2019.
  8. Frank R. Miele. Essentials of Ultrasound Physics 2008;148-152.
  9. ARC(American College of Radiology) Exam Requirements: Vascular Ultrasound (Revised 3-10-2023).
  10. Intersocietal Accreditation Commission. IAC Standards and Guidelines for Vascular Testing Accreditation (Published June 1, 2023).
  11. Malgor R. Duplex ultrasound scanning for chronic venous obstruction and valvular incompetence. Handbook of Venous and Lymphatic Disorders: Guidelines of the American Venous Forum (4th ed.). CRC Press (2017);151-64.
  12. Joseph A, Zygmunt JR. Venous Ultrasound Second edition 66-67.
  13. Edelman SK. Understanding Ultrasound Physics. 4th ed. Woodlands, TX: ESP Ultrasound; 2012. 309-310.
  14. Ultrasound Practice Guidelines. The Korean Society of Radiology 2014;199-202.
  15. Boisseau MR. Mechanisms of onset of chronic venous insufficiency (CVI). Phlebology 2003;41:161-7.

Review Article

Ann Phlebology 2023; 21(2): 63-65

Published online December 31, 2023 https://doi.org/10.37923/phle.2023.21.2.63

Copyright © Annals of phlebology.

Ultrasonographic Image Acquisitions of Varicose Veins of the lower Extremities - The 2023 Korean Society for Phlebology Clinical Practice Guidelines

HeangJin Ohe, M.D.1, Tae Sik Kim, M.D.2, Wooshik Kim, M.D.3, Sangchul Yun, M.D.4, Seung Chul Lee, M.D.5, Sung Ho Lee, M.D.6 and Sang Seob Yun, M.D.7

1Division of Vascular and Transplant, Department of Surgery, Inje University Haeundae Paik Hospital, Busan, 2Department of Thoracic and Cardiovascular Surgery, Korea University Guro Hospital, Seoul, 3Department of Thoracic and Cardiovascular Surgery, National Medical Center, Seoul, 4Department of Surgery, Soonchunhyang University Seoul Hospital, Seoul, 5Easyleg Clinic, Seoul, 6Department of Thoracic and Cardiovascular Surgery, Korea University anam hospital, Seoul, 7Division of Vascular and Transplant Surgery, The Catholic University of Korea, Seoul St. Mary’s Hospital, Seoul, Korea

Correspondence to:Tae Sik Kim
Department of Thoracic and Cardiovascular Surgery, Korea University Guro Hospital
Tel: 82-2-2626-1180, Fax: 82-2-2626-1188
E-mail: kmdphd@gmail.com

Received: November 28, 2023; Revised: December 15, 2023; Accepted: December 15, 2023

Abstract

Venous flow normally circulates from the skin to superficial veins, which drain into the deep veins and the heart. Venous reflux refers to blood flow that flows in the opposite direction. Venous reflux is caused by gravity and valvular insufficiency. Diagnosing venous reflux is important to determine treatment for lower extremity venous disease. Unlike arteries, venous reflux is greatly affected by the relative position of the probe and the vessel. Standardized ultrasound images are required to verify venous reflux using ultrasound. It is important to perform the reflux provocation test using the standardized posture and method.

Keywords: Ultrasound, Reflux, Guideline, Varicose vein

Introduction

Doppler ultrasound is the first diagnostic test for chronic venous disease. Doppler ultrasound provides information about venous anatomy and blood flow. Unlike arterial testing, veins are affected by gravity and valve insufficiency; therefore, the posture of the patient, the method of inducing reflux, and the location of the ultrasound probe and test vessel are important. Generally, the reflux diagnosis for saphenous veins is based on 0.5 seconds, and the reflux standard for deep veins is based on 1 second (1). Throughout this article, we refer to standardized reflux testing methods.

Key Question 4-1. The method involves applying pressure with the hand or a compression band (distal augmentation) or using the valsalva maneuver to induce reverse flow in the leg veins and assessing the presence and degree of venous reflux

The characteristic change in blood flow direction in venous insufficiency can be assessed by measuring the augmentation waveform caused by calf compression and the reflux waveform due to retrograde flow. These waveforms are positioned in opposite directions along the baseline of pulse wave analysis, allowing for a clear indication of the directionality of blood flow. It is preferable to measure and record the augmentation waveform below the baseline and the reverse flow waveform above the baseline (1-7).

Key Question 4-2. During reflux testing, measurements should be taken in a longitudinal view of the blood vessels

A longitudinal view allows for a more accurate assessment of the length and curvature of blood vessels compared to a transverse view. Therefore, it enables a more precise evaluation of issues, such as stenosis or occlusion, caused by venous thrombosis, providing a higher resolution of the vascular structure. This high resolution aids the examiner in easily identifying and interpreting subtle changes within the blood vessels. Additionally, when measuring in a longitudinal view in duplex or triplex ultrasound, the likelihood of mistaking temporary turbulence or pulsatile flow as reflux is reduced (6-14). Turbulence around valves may be misinterpreted as reflux when measuring in a transverse view (15).

Key Question 4-3. Color doppler ultrasound examination alone is not sufficient as a diagnostic criterion for reflux. to objectively demonstrate the presence of reflux findings, a pulsed-wave doppler ultrasound examination should be performed

Color Doppler allows for the visualization of blood flow direction by using two colors. Additionally, pulsed-wave Doppler provides information such as flow direction, velocity, and cycle that cannot be solely analyzed using color Doppler. Therefore, to effectively demonstrate the persistence of reflux over a specific period, it is recommended to primarily base it on pulsed-wave Doppler examination and supplement it with color Doppler (6,7,9,10,12).

Key Question 4-4. In the case of perforating veins, measuring in a transverse view may be more practical, as obtaining measurements in a longitudinal view can be physically challenging

Perforating veins can be an anatomically intricate and tortuous network, making measurements in a longitudinal view challenging. In a longitudinal view, the primary goal is to follow the vessel length, making it difficult to measure complex vascular branching or transverse sections accurately. In such cases, measurements can be performed more effectively in a transverse view.

Conclusion

Reflux refers to retrograde blood flow opposite to normal venous flow. To verify venous reflux using ultrasound, standardized ultrasound images are required. Unlike the transverse view, the longitudinal view allows for visualization of both the direction of the blood flow and the ultrasound incidence angle, facilitating an objective assessment of the presence or absence of reflux. Furthermore, the probe must measure blood flow in a fixed position to detect the Doppler frequency shift accurately. The Doppler effect is sensitive to the relative movement between the probe and blood flow. Therefore, performing the reflux provocation test using the standardized position and method provided here is of great significance.

References

  1. Gloviczki P, Lawrence PF, Wasan SM, Meissner MH, Almeida J, Brown KR, Bush RL, Di Iorio M, Fish J, Fukaya E, Gloviczki ML, Hingorani A, Jayaraj A, Kolluri R, Murad MH, Obi AT, Ozsvath KJ, Singh MJ, Vayuvegula S, Welch HJ. The 2022 Society for Vascular Surgery, American Venous Forum, and American Vein and Lymphatic Society clinical practice guidelines for the management of varicose veins of the lower extremities. Part I. Duplex Scanning and Treatment of Superficial Truncal Reflux: Endorsed by the Society for Vascular Medicine and the International Union of Phlebology. J Vasc Surg Venous Lymphat Disord 2023;11:231-61.
  2. Labropoulos N, Tiongson J, Pryor L, Tassiopoulos AK, Kang SS, Ashraf Mansour M, et al. Definition of venous reflux in lower-extremity veins. J Vasc Surg 2003;38:793-8.
  3. Labropoulos N, Leon LR Jr. Duplex evaluation of venous insufficiency. Semin Vasc Surg 2005;18:5-9.
  4. Markel A, et al. A comparison of the cuff deflation method with limb compression in detecting venous valvular reflux. Arch Surg 1994;129:701-5.
  5. Marianne G. De Maeseneer European Society for Vascular Surgery (ESVS) 2022 Clinical Practice Guidelines on the Management of Chronic Venous Disease of the Lower Limbs Clinical Practice Guideline Document Vol 63. P184-267, February 01, 2022.
  6. AIUM Practice Parameter for the Performance of a Peripheral Venous Ultrasound Examination. J Ultrasound Med 2020;39:E49-E56.
  7. Vascular technology professional performance guidelines: Lower extremity venous insufficiency evaluation. Society of Vascular Ultrasound. 2019.
  8. Frank R. Miele. Essentials of Ultrasound Physics 2008;148-152.
  9. ARC(American College of Radiology) Exam Requirements: Vascular Ultrasound (Revised 3-10-2023).
  10. Intersocietal Accreditation Commission. IAC Standards and Guidelines for Vascular Testing Accreditation (Published June 1, 2023).
  11. Malgor R. Duplex ultrasound scanning for chronic venous obstruction and valvular incompetence. Handbook of Venous and Lymphatic Disorders: Guidelines of the American Venous Forum (4th ed.). CRC Press (2017);151-64.
  12. Joseph A, Zygmunt JR. Venous Ultrasound Second edition 66-67.
  13. Edelman SK. Understanding Ultrasound Physics. 4th ed. Woodlands, TX: ESP Ultrasound; 2012. 309-310.
  14. Ultrasound Practice Guidelines. The Korean Society of Radiology 2014;199-202.
  15. Boisseau MR. Mechanisms of onset of chronic venous insufficiency (CVI). Phlebology 2003;41:161-7.
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Vol.21 No.2 Dec 31, 2023, pp. 53~98

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