Lower Extremity Venous Incompetence Protocol
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First part of study would be a complete venous study to rule out thrombus. If DVT is present, inform the ordering physician before proceeding with examination. With acute DVT, the exam should be terminated. With chronic DVT, the exam may be completed. If thrombus is noted in the superficial system, inform the ordering physician before proceeding with examination. The location may be terminated or completed depending on the location of the SVT.
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The optimal exam is performed with the patient standing. Have the patient shift their weight to one side and evaluate the non-weight bearing leg. If the patient cannot safely stand, perform exam with the patient in reverse Trendelenburg position (head and body elevated above legs) or sitting with leg hanging off the side of bed.
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This is a basic protocol to determine the presence and severity of valvular insufficiency. It may need to be altered due to patient’s anatomy (ie duplicated/ accessory veins or SSV not emptying into Pop V.
Additional images may also be needed if pathologies are seen (ie varicosities, large perforators, or suspicion of deep calf vein insufficiency).
Structure
Common Femoral Vein
Great Saphenous Vein
Junction with Common
Femoral Vein
(saphenofemoral junction)
Scan Plane
Sagittal
Sagittal
Label
Identify RT or LT
Images Stored
CFV W/ VALSALVA Color & Spectral Doppler with Valsalva o If reflux is seen, include measurement of reflux time on spectral waveform
GSV AT SFJ W/ AUG Color & Spectral Doppler with augmentation o If reflux is seen, include measurement of reflux time on spectral waveform
Great Saphenous Mid
Thigh
Great Saphenous
Lower Thigh
Great Saphenous Vein
Mid Calf
Great Saphenous Vein
Lower Calf
Femoral Vein Central
Sagittal
Sagittal
Sagittal
Sagittal
AK\backup\Vascular I\protocols
GSV MID THIGH
W/AUG
GSV LOWER THIGH
W/AUG
GSV MID CALF
W/AUG
GSV LOWER CALF
W/AUG
Color & Spectral Doppler with augmentation o If reflux is seen, include measurement of reflux time on spectral waveform
Color & Spectral Doppler with augmentation o If reflux is seen, include measurement of reflux time on spectral waveform
Color & Spectral Doppler with augmentation o If reflux is seen, include measurement of reflux time on spectral waveform
Color & Spectral Doppler with augmentation o If reflux is seen, include measurement of reflux time on spectral waveform
Sagittal FV CENTRAL W/AUG Color & Spectral Doppler with augmentation o If reflux is seen, include measurement of reflux time on spectral waveform

Femoral Vein Mid
Femoral Vein
Peripheral
Popliteal Vein
Lower Extremity Venous Incompetence Protocol
Sagittal
Sagittal
Sagittal
Sagittal
FV MID W/AUG Color & Spectral Doppler with augmentation o If reflux is seen, include measurement of reflux time on spectral waveform
FV PERIPH W/AUG Color & Spectral Doppler with augmentation o If reflux is seen, include measurement of reflux time on spectral waveform
POP V W/AUG Color & Spectral Doppler with augmentation o If reflux is seen, include measurement of reflux time on spectral waveform
SSV AT SPJ W/AUG Color & Spectral Doppler with augmentation o If reflux is seen, include measurement of reflux time on spectral waveform
Small Saphenous Vein
Junction with Popliteal
Vein (saphenopopliteal junction)
Small Saphenous Vein
Mid Calf
Small Saphenous Vein
Lower Calf
Sagittal
Sagittal
SSV MID CALF
W/AUG
SSV LOWER CALF
W/AUG
Color & Spectral Doppler with augmentation o If reflux is seen, include measurement of reflux time on spectral waveform
Color & Spectral Doppler with augmentation o If reflux is seen, include measurement of reflux time on spectral waveform
Tips

A LEV exam is recommended first to clear the leg of thrombus. This may have been done prior to the insufficiency study being ordered.

This exam should NOT be done with patient supine. Standing, sitting, or reverse Trendelenburg is required. Standing is recommended if patient’s condition allows.

Use something for the patient to stand on and something to help them stay balanced. Patient safety must always be considered.

Have patient turn and rotate during exam to make the veins more accessible.

Work in pairs for this study if possible. One person can work the machine, one can scan.

Augmentation may be necessary in the small vessels to verify location with color Doppler.

Take breaks during this exam as needed. The patient will tire quickly and so will you.

If an automated cuff system with foot pedal is available, use it!! This will free up a hand.

After augmenting for one image, you must wait a minimum of 30 seconds before evaluating the next segment of vessel to allow flow to normalize.

Keep in mind that the strength and duration of compression will affect the amount of blood that is augmented and therefore the amount of reflux if valves are insufficient/ incompetent.
AK\backup\Vascular I\protocols

Lower Extremity Venous Incompetence Protocol
Spectral Doppler

No angle correct is needed

Gate should be placed in center of vessel. Use reflux seen on color Doppler to aid in placement of the spectral gate.

Make sure PRF and filters are set low for slow flow evaluation

To ensure that the entire amount of retrograde flow is measured, you must show the return to normal, antegrade flow in your waveform. (There should be a visible beginning and end to the reflux).

Sweep speeds need to be adjusted so that each waveform shows:

Normal flow

Valsalva or augmentation with or without reflux

Return of flow or end of reflux

You will need to decrease the sweep speed in cases of severe reflux.

Retrograde flow is measured to determine reflux time
Abnormal Reflux Times

> 1.0 seconds in a deep vein

> 0.5 seconds in a superficial vein (> 2.0 seconds is severe)

> 0.35 seconds in a perforating vein
Venous Diameter Measurements

Usually only done if veins appear enlarged or if clinically indicated

Some physicians may want you to measure saphenous diameters on all patients – clarify before exam

Measure the Anterior/Posterior (AP) diameter from inner wall to inner wall being careful not to compress

Keep in mind that vein diameter will vary from patient to patient

Established abnormal diameter measurements which are highly predictive of reflux include:

GSV at SFJ exceeding 9 mm

GSV mid thigh exceeding 7.5 mm

GSV calf exceeding 5 mm

Perforator vein exceeding 3-4 mm
Incidental Findings

Incidental findings should be noted as these may explain patient’s symptoms.

Examples include edema, significant arterial disease (stenosis or aneurysm), and masses.
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