Transcript LES 60 ANS DE LA SFA ET SFP - international union of angiology

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
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.
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
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)
A carotid color flow duplex scanning
allows:
 to quantify the stenosis
 to assess its morphological
characteristics
Evaluation of stenosis

Degree of stenosis in diameter
 Degree of stenosis in
cross-sectional area

Evaluation of velocity
Degree of stenosis
Color Flow Duplex imaging
CAROTID PLAQUE

THICKNESS
mm
HYPOECHOIC
 ECHOGENICITY
HYPERECHOIC


STRUCTURE
HOMOGENEOUS
HETEROGENEOUS
SURFACE
REGULAR
IRREGULAR
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)
Carotid plaque and Risk of stroke
Other criterion:
PLAQUE MORPHOLOGY

Structure

Fibrous cap

Intraplaque hemorrhage, surface ulceration,
rupture
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)
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.
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
A carotid color flow duplex scanning
allows to evaluate in the follow up:
 surgical results
 the restenosis
 the efficacy of medical treatment
Angio CT/MR allow to evaluate:
Cohexisting aortic arch lesions
Intracranial vessels anatomy
Avoiding angiography
Diffusion-weighted magnetic resonance
imaging (DWI) allows a fast evaluation of
ISCHEMIC LESIONS
before
after
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
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
Carotid surgery without angiography
Experience of Dept. of Vascular Surgery – La Sapienza University
(prof. F. Benedetti Valentini – B. Gossetti) 1991-2007
%
Angiography
Without angiography
100
94.5 5.5
100
19.1 80.9
79.1 20.9
80
8.3 91.7
10.3 89.7
15.0 85.0
64.1 35.9
36.4 63.6
60
40
20
‘91-’93
’94
’95
’96
’97
’98
’99 ’00 -’04 ’05-’07 ys
Abdominal aortic aneurysm
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
Color flow duplex imaging
Morphology:

Endovascular wall thrombus

Ulceration and calcification

“true” vessel lumen

Size and longitudinal extension
Color flow duplex imaging
Hemodynamics

Decrease of flow velocity

Color: “mosaic” immaging
Color flow duplex imaging
Acute conditions:

Wall dissection

Wall rupture

Rapid growth

Acute thrombosis
Follow up of endovascular treatment






Position and patency of endograft
Diameters and pulsatility of aneurysm
Endoleak (sensitivity 81-100 %, specificity
74-99 %)
Patency of other vessels
Infections
Fistulas
Deep venous thrombosis
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 %).
DEEP VENOUS THROMBOSIS
Diagnosis and monitoring
CLINICAL DIAGNOSIS:
inadequate
VENOGRAPHY:
gold standard (?)
DUPLEX SCANNING:
high accuracy
COLOR-FLOW IMAGING:
NEW GOLD STANDARD
PLETHYSMOGRAPHY:
(quantitative evaluation)
complementary
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.
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.
Compression manouvre
Accuracy 100 %
Thrombus “at risk”
CHARACTERISTICS OF THE THROMBI
AND INCIDENCE OF PULMONARY EMBOLISM
(354 patients with DVT -28.5%- out of 1238 cases with suspected DVT)
cases
PE
- free-floating thrombi:
40 (11,2%)
25 (60.2%)
- “cutted” thrombi:
- “peduncle” thrombi:
81 (22.8%)
5 ( 1,4%)
81 (100%)
5 (100%)
- “moving” thrombi:
2 ( 0.5%)
2 (100%)
- adhered thrombi:
226 (63.8%)
35 (15.4%)
(free head in venous confluence)
(only fixed base)
(----> 2 cm)
WFUMB 2000
LOCALIZATION OF THE THROMBI
AND INCIDENCE OF PULMONARY EMBOLISM
(354 patients with DVT -28.5%- out of 1238 cases with suspected DVT)
DVT EP
-iliac+inferior cava v.
%
m
EP
f
EP
35
19
54.2%
24
14
11
5
-femoral+ex. iliac v.
144
52
36.1%
77
32
67
20
-popliteal+femoral v.
107 66
61.6%
65
40
42
26
-popliteal v.
18
6
33.3%
9
5
9
1
-gastrocnemious v.
34 4
11.7%
7
-
32
4
-long saphenous v.
16
31.2%
-
-
16
5
5
Antignani PL, WFUMB, 2000
Risk of Recurrent VTE

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
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
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
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.
Differential diagnosis
Neoplasia in inferior cava vein
Venous popliteal aneurysm
Superficial venous thrombosis
Superficial venous thrombosis
Extension and involvement
Clinical assessment underestimates the thrombus
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 - 2007): Treatment of SVT as DVT.
Murgia AP et al: Int Angiol. 1999 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.
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%).
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.
Endovenous laser therapy and radiofrequency ablation of
the great saphenous vein: analysis of early efficacy and
complications. Puggioni A et al. J Vasc Surg. 2005 Sep;42(3):488-93.
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.
No cases of pulmonary embolism occurred.
…we recommend early duplex scanning in all
patients after endovenous saphenous ablations.
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
results comparable to
surgery and with an acceptably low rate of adverse
events.
accomplished using foam sclerotherapy with
These results, however, must be confirmed by larger experience in other
institutions.
Chronic venous insufficiency
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.
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.

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.
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.
Pattern of great saphenous vein
Engelhorn CA; J Vasc Surg 2005
Pattern of small saphenous vein
Engelhorn CA; J Vasc Surg 2005
Prevalence of patterns
of saphenous vein reflux
Engelhorn CA; J Vasc Surg 2005
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.
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
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”
Conservative surgery
Sapheno-femoral external valvuloplasty
 CHIVA type 1 e 2 hemodynamic
correction
 Crossectomy

Duplex mapping is mandatory
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
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.
Endovascular obliteration



Endovenous Laser - ELVT
Radio frequency - VNUS Closure
Foam ultrasound-guided sclerotherapy
Before Laser
After 1 week
After 6 months
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).
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.
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.
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
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
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
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.
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.
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.
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.
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 !!