Lower Extremity Venous Duplex Protocol PDF

**Protocol: Lower extremity Venous Duplex [ ]** **Purpose: 1. Examination for thrombosis and patency** **2. Examination for venous reflux** **3. Examination for preoperative vein mapping** **Location: All TVE Locations Date: 5/15/2022** **Indications** - Swelling/ Pain / Tenderness - Palp...

**Protocol: Lower extremity Venous Duplex [ ]** **Purpose: 1. Examination for thrombosis and patency** **2. Examination for venous reflux** **3. Examination for preoperative vein mapping** **Location: All TVE Locations Date: 5/15/2022** **Indications** - Swelling/ Pain / Tenderness - Palpable cord - Status post venous interventional procedures - Symptoms of Pulmonary Embolism/ Shortness of breath - New lower extremity pain while on anticoagulation/before terminating anticoagulation therapy - Stasis dermatitis or pigmentation /Venous stasis ulcers - Recurrent swelling of the lower calf and ankle /Pain or feelings of heaviness - Visible varicose veins - Pain and edema of the lower extremities / Venous claudication - Preoperative evaluation for venous insufficiency - Preoperative superficial vein evaluation for vein harvesting **Contraindications and limitations** Contraindications for lower extremity venous duplex imaging are unlikely; however, some limitations exist and may include the following: - Obesity - Casts, dressings, open wounds, etc, can limit visualization - Patients with severe edema/swelling - Limited patient mobility - Patient's inability to cooperate/tolerate the exam **Instrumentation** Use appropriate duplex instrumentation with appropriate frequencies for the vessels being examined. - Linear 5-10 MHz transducer depending on depth of vessel - Deeper structures or edematous tissue may require a lower frequency transducer **Patient Positioning and Exam Techniques** The technologist introduces him/herself and briefly explains the procedure while taking into consideration the age and mental status of the patient and to ensure that the patient understands the necessity for each aspect of the evaluation. Patient's questions and concerns are appropriately addressed about any aspect of the Lower Extremity Venous Evaluation. The patient is positioned supine (reverse Trendelenburg- for venous incompetence evaluation) on the exam table. The leg to be examined is slightly bended, externally rotated and relaxed The examination starts at the groin, imaging the saphenofemoral junction. Compression of the SFJ is performed to document closure of the common femoral vein and the greater saphenous vein. The transducer is than moved along the medial aspect of the thigh compression of the femoral vein is performed every 2-3cm.The entire compression portion of the examination is performed in transverse. The compression maneuvers are performed along the medial aspect of the thigh and medial and posterior aspects of the calf to assess deep and superficial venous systems for wall to wall compressibility At the level of adductor canal the transducer is placed behind knee in the popliteal fossa. The transducer is moved proximally to ensure the entire portion of the femoral vein has been examined. Compression of the popliteal vein is performed throughout. The transduced is moved distally to the level of the tibio-peroneal trunk The transducer is than placed in the medial aspect of the proximal calf. The popliteal vein transition into the tibio-peroneal trunk is imaged in transverse. The calf veins (posterior tibial and peroneal veins) are imaged in transverse. Thea transducer is moved distally to the ankle. The gastrocnemius veins are followed as they bifurcate from the popliteal vein. They are followed through the gastrocnemius muscle and compressed every 2-3cm. The soleal veins are imbedded in the soleal muscle are not always easily recognizable. The soleal muscles are imaged in transverse plane to detect abnormalities. The anterior tibial is scanned only if requested or if symptoms warrant All of the veins are assessed for spontaneity, phasisity and augmentation. Color and pulse Doppler imaging of the femoro-popliteal segment is done in longitudinal plane. The color Doppler is turned on with decreased sensitivity. Spontaneous flow, phasic flow and augmentation with distal compression are demonstrated by color and pulsed Doppler and recorded. For reflux evaluation, the great saphenous, small saphenous, various accessory veins and perforator veins are followed along the anatomical path in reverse Trendelenburg and standing position when needed (see image representation sections). The examiner must note visible varicosities, note the areas of visible stasis changes such as ulcerations, stasis dermatitis and trace the varicosities to the source. **Venous Duplex for Thrombosis and Patency** **Image** **Representation:** [\*Abnormal unilateral exams warrant contralateral extremity evaluation **Compression images obtained -- CFV, FV (prox mid dist) Popliteal** at minimum to exclude contralateral DVT.\*] [\*\*In presence of femoro-popliteal DVT, **Deep femoral vein** must be assessed for patency\*\*] [\*\*\*Bilateral examination is considered a complete examination. Unilateral exam can be performed if symptoms are isolated to one extremity. All unilateral exams include contralateral common femoral vein evaluation.\*\*\* ] [Transverse grayscale images in dual screen] without and with transducer compressions (when anatomically possible or not contraindicated) [must be documented and must include at a minimum]: - common femoral vein - saphenofemoral junction; - proximal femoral vein; - mid femoral vein; - distal femoral vein; - popliteal vein; - posterior tibial veins; - peroneal veins; - additional images to document areas of suspected thrombus/ reflux(including deep muscle soleal and gastrocnemius vein and superficial veins when clinically indicated or requested ) - additional images (if required by ordering physician). - symptomatic superficial veins / varicosities (areas of pain and tenderness); [Spectral Doppler] waveforms demonstrating spontaneous venous flow, phasicity and/or flow augmentation must be documented and must include at a minimum: - right and left common femoral veins. - femoral vein - popliteal vein; - additional waveforms if requested by physician and/or abnormality is found **[Diagnostic criteria and Interpretation for thrombosis]** The technologist should observe and analyze sonographic characteristics or normal and abnormal tissues, structures, and blood flow to allow necessary adjustments to optimize exam quality. Ensure that sufficient data is provided to the physician to direct patient management and render a final diagnosis. **Normal:** Veins are fully compressible by applying transducer pressure. Veins do not appear distended. No thrombus visualized. Flow is spontaneous, phasic and augmentable. Color flow fills the entire lumen. **Abnormal:** Thrombus, depending on echogenicity, may or may not be visualized. Intraluminal echoes range from anechoic/hypoechoic (spongy appearance) for acute findings to hyperechoic/ echogenic for chronic findings. Compressibility is absent or incomplete. Color and Doppler flow is absent or incomplete. Luminal encroachment is observed with acute/subacute findings. With non- acute findings echogenic intraluminal material/webbing, decreased vein size, presence of collaterals, poor lumen filling with lumen separation is observed. [Indirect evaluation:] Doppler flow demonstrating diminished continuous signals may indicate obstruction cranial to the interrogated vein. Diminished augmentations may indicate obstruction caudal to interrogated vein. Presence of collateral veins in the region may indicate obstruction of the anatomical vein **Venous Duplex for Reflux** Patient positioned in at least 30 degree reverse Trendelenburg. Valsalva maneuver and/or proximal and distal augmentation techniques should be utilized. Superficial veins to be reevaluated for reflux in [standing position] in the presence of enlarged vein (GSV\>5.4mm, SSV\>4mm) when reflux is not represented with Valsalva or augmentation maneuvers The patient position to be included in the report **Image representation** [Transverse grayscale images in dual screen] without and with transducer compressions (when anatomically possible or not contraindicated) [must be documented and must include at a minimum]: - common femoral vein - saphenofemoral junction; - proximal femoral vein; - mid femoral vein; - distal femoral vein; - great saphenous vein: - popliteal vein; - posterior tibial veins; - peroneal veins; - small saphenous vein - additional images to document areas of suspected reflux(when clinically indicated or requested ) [Spectral Doppler] waveforms with the extremity(s) in a dependent position, demonstrating baseline flow and response to distal augmentation and if reflux is present, duration of retrograde flow measured in calipers and documented and must include at a minimum: - common femoral vein; - saphenofemoral junction; - great saphenous vein proximal thigh and knee; - femoral vein mid thigh; - popliteal vein; - small saphenous vein at saphenopopliteal junction( or in the proximal calf/or where visualized if not visualized at saphenopopliteal junction. and/or if abnormality is suspected or if indicated) - perforator vein waveforms in the setting of active or healed venous ulcers - additional documentation of incompetent accessory veins, and varicosities [Transverse grayscale images of diameter measurement] must be documented as required by the protocol and must include at a minimum: - saphenofemoral junction; - great saphenous vein -- proximal/mid/distal - small saphenous vein at SPJ or at proximal calf if no SPJ identified (additional measurements if reflux present) - additional documentation of incompetent/enlarged accessory veins, perforators and varicosities (straight segment length included for short and tortuous veins) **[Diagnostic criteria and Interpretation for venous incompetence]** **Normal:** Absent or minimal (\