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P.L. Antignani Palermo 2009 Non invasive diagnostic methods:

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1 P.L. Antignani Palermo 2009 Non invasive diagnostic methods:
how have they modified the therapeutical indications? P.L. Antignani Dept. of Angiology, (Director: C. Allegra) s.Giovanni Hospital, Rome, Italy

2 The non invasive diagnostic methods have modified our therapeutical decision in several vascular diseases. Particularly, many forms of surgical treatment, both endovascular and open, are performed based exclusively on evaluation with duplex scanning.

3 We discuss the main conditions in which this change is more evident:
Carotid stenosis Abdominal aortic aneurysm Deep venous thrombosis Superficial venous thrombosis Chronic venous insufficiency

4 Definition of carotid lesion
Investigation techniques High-resolution B-mode imaging Color Doppler flow imaging Power Doppler imaging Compounded imaging Four-Dimensional ColorDoppler flow imaging Contrast ultrasonic agents Transcranial Doppler IVUS Spiral CT scan Contrast-enhanced MR angiography Diffusion weighted MR imaging (DWI) 4

5 A carotid color flow duplex scanning allows:
to quantify the stenosis to assess its morphological characteristics 5

6 Evaluation of stenosis
Degree of stenosis in diameter Degree of stenosis in cross-sectional area Evaluation of velocity

7 Degree of stenosis

8 Color Flow Duplex imaging CAROTID PLAQUE

9 Color flow duplex imaging
Plaque Classification Type I (uniformly echolucent) Type II (predominately echolucent) Type III (predominately echogenic) Type IV (uniformly echogenic) Type V (heavy calcification) 9

10 Carotid plaque and Risk of stroke
Other criterion: PLAQUE MORPHOLOGY Structure Fibrous cap Intraplaque hemorrhage, surface ulceration, rupture

11 Morphology of plaque “The higher the degree of stenosis, the more likely it is associated with ultrasonic heterogeneous and hypoechoic plaque” ( MM Sabetai, J Vasc Surg 2000)

12 Guidelines of ISVI and ACC- AHA-EVES
Diagnosis of presence and grading of carotid stenosis Colour-flow duplex scanning is the investigation of choice for the diagnosis and measurement of carotid stenosis, provided that objective criteria are used, by experienced operators. The velocities detected should be mentioned in the report as well as whether the percent stenosis reported refers to the angiographic ECST or NASCET method. 12

13 Guidelines of ISVI and ACC- AHA-EVES Plaque characteristics
Surface ulceration, low GSM (<25), heterogeneous appearance of the plaque and the juxta-luminal location of the echolucent area after image normalisation are ultrasonographic indicators of plaque vulnerability and should be considered in the selection of appropriate therapy and the frequency of follow up. Carotid Stenosis 50% GSM 17 13

14 A carotid color flow duplex scanning allows to evaluate in the follow up:
surgical results the restenosis the efficacy of medical treatment 14

15 Angio CT/MR allow to evaluate:
Cohexisting aortic arch lesions Intracranial vessels anatomy Avoiding angiography 15

16 Diffusion-weighted magnetic resonance imaging (DWI) allows a fast evaluation of ISCHEMIC LESIONS
before after 16

17 Transcranial color Doppler can be used before CE/CAS to evaluate:
Cohexisting lesions of intracranial vessels Circle of Willis efficiency Intracranial haemodynamic effects of extracranial carotid lesions Cerebrovascular reserve Microembolic events due to ulcerated plaques Crossclamping risk and indication for shunting INDICATION FOR SURGERY IN ASYMPTOMATIC SUBJECTS OR IN PATIENTS WITH BILATERAL CAROTID LESIONS 17

18 CE could be better in patients with:
Surgical indications CE could be better in patients with: Long multifocal lesions Echolucent plaque Severe ulceration Heavy circumferential calcifications of carotid bifurcation Severe tortuosities Extensive aortic or brachiocephalic trunk lesions If a clot is suspected 18

19 Carotid surgery without angiography
Experience of Dept. of Vascular Surgery – La Sapienza University (prof. F. Benedetti Valentini – B. Gossetti) Angiography Without angiography 100 80 60 40 20 % 100 ‘91-’ ’ ’ ’ ’ ’ ’99 ’00 -’04 ’05-’07 ys 19

20 Abdominal aortic aneurysm

21 Abdominal aortic aneurysm
Among asymptomatic patients, ultrasound detects the presence of an abdominal aortic aneurysm accurately, riproducibly an at low cost. Sensitivity and specificity approach 100 %. Ultrasound is ideal for screening and in determination of aneurysm growth rate. A growth rate of > 0,7 cm per sex months or 1 cm per years has been suggested as a threshold for proceeding to surgery, irrespective of size. Chaikof EJ et al: The care of patients with abdominal aortic aneurysm: the Society for Vascular Surgery practice guidelines. J. Vasc. Surg. 2009;50 suppl October: 8S

22 Color flow duplex imaging
Morphology: Endovascular wall thrombus Ulceration and calcification “true” vessel lumen Size and longitudinal extension

23 Color flow duplex imaging
Hemodynamics Decrease of flow velocity Color: “mosaic” immaging

24 Color flow duplex imaging
Acute conditions: Wall dissection Wall rupture Rapid growth Acute thrombosis

25 Follow up of endovascular treatment
Position and patency of endograft Diameters and pulsatility of aneurysm Endoleak (sensitivity %, specificity %) Patency of other vessels Infections Fistulas

26 Deep venous thrombosis

27 VTE and symptoms Each of these stages of Venous Thromboembolism (calf DVT, proximal DVT, PE) may or may not be associated with symptoms. The development of symptoms depends on the extent of thrombosis, the adequacy of collateral vessels, and the severity of associated vascular occlusion and inflammation. For the diagnosis and monitoring of VTE the clinical findings are useful but inadequate (accuracy no more than 30 %).

28 Diagnosis and monitoring
DEEP VENOUS THROMBOSIS Diagnosis and monitoring CLINICAL DIAGNOSIS: inadequate VENOGRAPHY: gold standard (?) DUPLEX SCANNING: high accuracy COLOR-FLOW IMAGING: NEW GOLD STANDARD PLETHYSMOGRAPHY: complementary (quantitative evaluation)

29 Colour Flow Duplex Scanning
Colour Flow Duplex Scanning can provide both morphologic and haemodynamic findings and represent now a quick and non-invasive alternative method of diagnosing deep vein thrombosis in the lower limbs.

30 Colour Flow Duplex Scanning
Colour Flow Duplex Scanning represents a valid clinical tool, not only for the initial diagnosis of DVT but also to assess long-term outcome of thrombus. This test can guide initial patient management, providing information about clot attachment to the vein wall and resolution. In addition, it can identify those patients with a potential high risk for post-thrombotic syndrome. Finally, CFDS may be used to compare and evaluate the results of different regimens of anticoagulant and fibrinolytic drug therapy on the long-term outcome of venous thrombi in the lower extremity.


32 Compression manouvre Accuracy 100 %

33 Thrombus “at risk”

(354 patients with DVT -28.5%- out of 1238 cases with suspected DVT) cases PE - free-floating thrombi: (11,2%) (60.2%) (----> 2 cm) - “cutted” thrombi: (22.8%) (100%) - “peduncle” thrombi: ( 1,4%) (100%) (free head in venous confluence) - “moving” thrombi: ( 0.5%) (100%) (only fixed base) - adhered thrombi: (63.8%) 35 (15.4%) WFUMB 2000

AND INCIDENCE OF PULMONARY EMBOLISM (354 patients with DVT -28.5%- out of 1238 cases with suspected DVT) DVT EP % m EP f EP -iliac+inferior cava v % -femoral+ex. iliac v % -popliteal+femoral v % -popliteal v % -gastrocnemious v % -long saphenous v % Antignani PL, WFUMB, 2000

36 Risk of Recurrent VTE Monitoring of coagulative factors
The presence of an antiphospholipid antibody (lupus anticoagulant or anticardiolipin antibody) is associated with a 2-fold increase in risk of recurrent VTE. Deficiencies of antithrombin, protein C, and protein S, homozygous factor V Leiden and elevated levels of homocysteine and coagulation factor VIII (> 234 IU/L) have also been associated with higher recurrence rates. Heterozygous forms of factor V Leiden and the G20210A prothrombin gene mutation confer relatively little increased risk of recurrent VTE. (Kryle P. et al. N Engl J Med 2000; Eichinger S et al. Thromb Haemost.1999; Miles JS et al. J Am Coll Cardiol. 2001; Simioni P et al. Blood 2000) Monitoring of coagulative factors

37 Risk of recurrent VTE Although not predictive of the location of thrombosis, the risk of recurrence is greater when anticoagulants are stopped while there is still evidence of residual DVT on ultrasound imaging. Recurrent DVT may be caused by a disturbed balance between propagation and thrombus regression. Recurrent DVT was reported in 17% of the patients after 2 years. (Kearon C. Clin Chest Med. 2003; Heit JA et al. Arch Intern Med. 2000) Monitoring with ultrasound

38 Post-thrombotic syndrome after DVT
About 60 % of patients with the history at one episode of proximal deep vein thrombosis develop post-thrombotic syndrome within two years. Compression stockings have reduced this rate by about 50 %. The post-thrombotic syndrome is strongly related to recurrent ipsilateral deep vein thrombosis. monitoring of deep venous system with ultrasound

39 Post thrombotic syndrome Instrumental evaluation
The pathophysiology of PTS is not entirely understood. Factors that are probably important in the development of PTS are venous reflux, deep vein obstruction and calf muscle pump dysfunction. The presence and location of venous reflux and obstruction can be measured with ultrasound with high accuracy.

40 Differential diagnosis
Neoplasia in inferior cava vein Venous popliteal aneurysm

41 Superficial venous thrombosis

42 Clinical assessment underestimates the thrombus
Superficial venous thrombosis Extension and involvement The most frequent use of the ECD in this pathology has shown us first that the clinic underestimate the thrombus . like in this case what clinically seemed a varicoflebite of collateral sapfenic, it is extended over the collateral and runs over the sapfenic upper leg , like is visible the saphena in her eye, whit the occupied lumen by trhombotic material. Clinical assessment underestimates the thrombus

43 Superficial venous thrombosis
…is estimated like a thrombus on risk if its distance from SF-J is 2 cm (guidelines by Italian Society for Vascular Investigation ): Treatment of SVT as DVT.

44 Surgical management of ascending saphenous thrombophlebitis.
Murgia AP et al: Int Angiol Dec;18(4):343-7. Surgical management of ascending saphenous thrombophlebitis. METHODS: We retrospectively reviewed 146 patients referred to our Vascular Laboratory for acute superficial thrombophlebitis from 1987 to 1997. Duplex scanning identified 85 cases of superficial thrombophlebitis involving at least a segment of the saphenous vein localized below the knee (58.2%); 37 of thrombophlebitis extending into both the superficial and deep venous systems (25.3%) and 24 of saphenous thrombosis extending to within 5 cm of the saphenofemoral junction (16.4%). The latter group underwent saphenofemoral disconnection. CONCLUSIONS: Duplex scanning showed 100% accuracy both in determining the presence of thrombosis and its extent. Saphenofemoral disconnection for thrombosis involving the saphenofemoral junction is a safe procedure and can be performed on an outpatient basis. Like in surgery , in the evaluation of the extension of the trombosis and in the identification of the right operation

45 Or like in this evaluation

46 DVT was found in 12 limbs (16%).
Deep venous thrombosis after radiofrequency ablation of greater saphenous vein: a word of caution. Hingorani AP et al. PURPOSE: Radiofrequency ablation (RFA) of the greater saphenous vein (GSV; "closure") ………potentially lethal complication, deep venous thrombosis (DVT). Seventy-three lower extremities were treated…. All patients underwent venous duplex ultrasound scanning 2 to 30 days (mean, 10 +/- 6 days) after the procedure The duplex scanning documented occlusion of the GSV in 70 limbs (96%). In addition, DVT was found in 12 limbs (16%). At the end after the initial alarming data (later proved to be wrong, of the treatment whit radio frequency it’s raccomanded : Early Post …. None of these patients had pulmonary embolism. Early postoperative duplex scanning are essential, and should be mandatory in all patients undergoing RFA of the GSV.

47 …we recommend early duplex scanning in all
Endovenous laser therapy and radiofrequency ablation of the great saphenous vein: analysis of early efficacy and complications. Puggioni A et al. J Vasc Surg Sep;42(3): Between June 1, 2001, and June 25, 2004, endovenous GSV ablation was performed on 130 limbs in 92 patients. RFA was the procedure of choice in 53 limbs over the first 24-month period of the study Routine postoperative duplex scanning was initiated at our institution only after recent publications reported thrombotic complications following RFA Thrombus protruded into the lumen of the CFV in three limbs (2.3%) after EVLT. One received a temporary inferior vena cava filter because of a floating thrombus in the CFV. This is recommended also whit and for the treatment with laser No cases of pulmonary embolism occurred. …we recommend early duplex scanning in all patients after endovenous saphenous ablations.

48 Venous disorders: treatment with foam sclerotherapy. Bergan J at al
This report describes initial experience in treating 332 patients DVT (1.8%) was limited to gastrocnemius veins (3 cases) and posterior tibial veins (3 veins). No pulmonary emboli or lung complications occurred. CONCLUSIONS: Treatment of a variety of venous disorders can be accomplished using foam sclerotherapy with results comparable to surgery and with an acceptably low rate of adverse events. These results, however, must be confirmed by larger experience in other institutions. And also in treatment sceroterapeuics with foam that results comparable too

49 Chronic venous insufficiency

50 Introduction Pre-operative evaluation is best performed by means of duplex scanning and physical examination. Duplex scanning for venous insufficiency is simple and cost-effective. Duplex mapping defines individual patient anatomy with considerable precision and provides valuable information that supplements the physician's clinical impression.

51 Pre surgical Duplex mapping
The superiority of duplex ultrasound scanning over clinical examination for presurgical mapping has been well documented. Although ultrasound determinations of reflux at the junctions and at specific locations above and below the knee may be adequate for diagnosis and epidemiologic studies, pre-operative mapping must include the entire length of the saphenous veins. Such mapping may lead to selective surgical treatment and avoidance of complications related to extensive surgery.

52 Pre-surgical Duplex mapping
Ultrasound mapping provides an opportunity for conservative ligation and perhaps sclerotherapy of tributary and perforating veins acting as the main source of reflux. Such procedures could be performed under ultrasound guidance in an outpatient setting.

53 Examination The examination consists of interrogating specific points of reflux with the patient standing. Forward flow is produced with muscular compression, and reverse flow is then assessed in the crucial areas that are important to operative planning. The patient is placed in an upright position so that the leg veins are maximally dilated.

54 Pattern of great saphenous vein
Engelhorn CA; J Vasc Surg 2005

55 Pattern of small saphenous vein
Engelhorn CA; J Vasc Surg 2005

56 Prevalence of patterns of saphenous vein reflux
Engelhorn CA; J Vasc Surg 2005

57 Goals of treatment Three principal goals must be kept in mind in planning treatment of varicose veins: The varicosities must be permanently removed and the underlying cause of venous hypertension treated. The repair must be done in as cosmetic a fashion as possible. Complications must be minimized.

58 Guidelines of Italian College of Phlebology
The aim of varicose vein surgery is to relieve the symptoms, and prevent or treat any complications while recognising that the varicose disorder is likely to be progressive. “Inadequate” venous surgery is sometimes the main reason for post-surgical recurrences despite a good surgical technique. There are valid medical alternatives and sclerotherapy, for collateral veins, which therefore do not necessarily call for a surgical approach. Int Angiol 2003

59 Ablative surgery Complete and resolutive treatment
Stripping Crossectomy Phlebectomy “Before any decision is taken on which technique is indicated, a detailed color flow duplex study should be done to avoid diagnostic errors”

60 Duplex mapping is mandatory
Conservative surgery Sapheno-femoral external valvuloplasty CHIVA type 1 e 2 hemodynamic correction Crossectomy Duplex mapping is mandatory

61 Conservative surgery External valvuloplasty of the terminal and/or subterminal valve of the great saphenous vein, after thorough preoperative assessment, and with careful intraoperative checks, is a good way to treat saphenous reflux in 5-8% of patients. CHIVA 2 should not be used for saphenous veins with a caliber of more than 10 mm at the thigh, especially if the segment below the origin of the collaterals shows aplasia or hypoplasia, so as to limit the risk of saphenous thrombosis at the open cross. ICP Guidelines. Int Angiol 2003

62 Mini invasive treatment
An increasingly popular alternative to traditional surgical stripping of the GSV for management of saphenous vein reflux is endovenous ablation (EVA) of that vein using laser energy, radiofrequency generated thermal energy or a chemical sclerosant. In all of these treatment the color flow duplex examination represents the basis and it is a “part” of method.

63 Endovascular obliteration
Endovenous Laser - ELVT Radio frequency - VNUS Closure Foam ultrasound-guided sclerotherapy Before Laser After 1 week After 6 months

64 Endovenous Laser treatment
Pre-operative, a Duplex scanning is performed in the upright standing position to map incompetent sources Of venous reflux and then to mark the skin overlying The incompetent portion of the GSV starting at the SFJ. After venous duplex mapping a percutaneous entry point is chosen. This point may be where reflux is no longer seen or where the GSV becomes too small to access (usually just above or below knee level).

65 Endovenous treatment Potential candidates for EVA include patients with reflux in an incompetent GSV or SSV or in a major tributary branch of the GSV or SSV such as the anterior thigh circumflex vein, posterior thigh circumflex vein, or anterior accessory GSV. Therefore, the presence of reflux in these veins is important to document using duplex ultrasound imaging, as pertaining to the CEAP A5 nonsaphenous category.

66 Endovenous treatment Variations to standard venous anatomy, when observed on the ultrasound examination, should be reported. These include tortuosity of the target vein, duplications, atresia, the presence of anatomic venous variants, or variable termination of the SSV. The diameter of the GSV and SSV, <= 2 cm of the junction with the deep vein (common femoral or popliteal) and target vein (if not the GSV or SSV) should be measured.

67 Endovascular methods Neither of endovascular obliterative procedures is validated as yet for long follow-up in the literature but these methods were proven to be less aggressive and effective at mid-term. They must therefore be considered as still in the clinical validation stage, and as such only used in accredited, qualified phlebology centers, after the necessary learning period. ICP Guidelines. Int Angiol 2003

68 What surgery ? Actually, there are not defined the hemodynamic specific patterns for each conservative surgical treatment. End point: Mini-invasivity Optimal long-term results Evolution of technique and methods

69 Recurrent varicose veins
“These are varicose veins that appear after surgical treatment, not the remains of the treated veins”. The most frequent causes of recurrences are: Errors of diagnostic strategy and treatment Technical errors

70 Recurrent varicose veins
“Radical surgery", defined as physical extraction of the saphenous vein with all its collaterals and all the enlarged varices, which has been the surgical procedure of choice for varicose veins for almost a century, has been replaced by a "radical hemodynamic approach", meaning elimination of the hemodynamic defects at the root of the formation of the varices (the reflux). Among the reasons leading to errors during surgery for varices in the legs, certainly the most important is the wide anatomical variety of the sapheno-femoral junction, and, moreover, of the sapheno-popliteal juncgtion, which can lead to the surgeon sometimes inadvertently leaving collaterals in place.

71 Recurrent varicose veins
A "map" of the varicose veins and circulation defects of the lower limbs is used in CHIVA interventions and "traditional" surgical procedures. Incorrect application of these concepts, especially on an anatomical basis, can leave the way open to recurrences.

72 Conclusion After treatment, we have to control the patient by means of duplex ultrasound at 1st week, at 1st month and every sex months for 1 year. We have to know well the type of treatment for evaluating the results.

73 Conclusion The most important factor in determining a good treatment outcome is making an accurate diagnosis. Recognizing common clinical patterns of venous insufficiency is important, but with duplex US now readily available to many providers, direct visualization and mapping of venous pathways is possible. This will ensure not only complete treatment of all of the abnormal venous segments but preservation of normal veins.

74 Thank you for your attention !!
In the evaluation of chronic venous insufficiency such as in the other reported conditions, the duplex examination have modified the therapeutical approach. Thank you for your attention !!

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