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PART 4 — PERIPHERAL VENOUS
Chronic venous valvular insufficiency (CVVI) is a common disorder of the modern era. The develop- ment of minimally invasive techniques has enhanced the awareness and treatment potential of superficial veins with incompetent valves and reflux. CVVI is a subset of the classical, most commonly used term “chronic venous insufficiency” (CVI). CVI includes venous obstruction and/or valvular insufficiency. This chapter focuses on valvular disorders (and not on venous obstruction), most commonly a conse- quence of deep venous thrombosis. Most patients with CVVI do not have a venous obstruction. The hypothesis is that patients with venous obstruction have characteristics distinct from those with venous valvular insufficiency, and the two groups deserve to be differentiated for appropriate diagnosis and treatment.
One of the philosophies behind the clinical, etio- logic, anatomical, and pathophysiological (CEAP) classification of CVI recommendations is to clearly specify and differentiate types of CVI to improve the understanding of distinct disorders.1–3 This chapter reviews CVVI with summaries of relevant anat- omy, prevalence of disease, signs and symptoms, classes of disorders, quality of life questionnaires, noninvasive examinations, types of treatment, and follow-up.
ANATOMY
The sonographer must have knowledge of the deep and superficial venous anatomy as detected by ul- trasound. The anatomy of the venous system has been discussed in previous chapters. Pertinent sonographic information is provided as follows.
Current knowledge about the superficial venous system has expanded, with a description of ultra- sound landmarks to differentiate veins by location
Figure 17-1 A transverse ultrasound image of the great saphenous vein illustrating the normal position of the vein within the saphenous compartment. Arrows indicate fascia both superficial and deep to the vein.
Figure 17-2 A transverse ultrasound image of the great saphenous vein within the saphenous compartment distally within the leg. Arrows indicate fascia both superficial and deep to the vein.
within the fascia layers of the tissue. Recently ad- opted nomenclature applies specifically to the su- perficial system: the great saphenous vein (GSV), formerly named the greater or long saphenous, and the small saphenous vein (SSV), formerly named the lesser or short saphenous vein.4,5 Saphenous nomenclature follows the anatomical position and includes the anterior accessory saphenous vein (AASV), the posterior accessory saphenous vein (PASV), and the vein of Giacomini (VOG). Saphe- nous veins are within saphenous fascia layers, which are readily identified with ultrasound.6,7 The saphenous “eye” differentiates the saphenous compartment from the superficial and deep com- partments (Figs. 17-1 and 17-2). The GSV courses medial in the thigh and leg within the saphenous compartment. Although the AASV is within a sa- phenous compartment, the “alignment sign” is the anatomical landmark for its location (Fig. 17-3). The AASV is aligned with the femoral artery and vein followingaverticallineperpendiculartothetrans- ducer surface in cross-sectional imaging. The AASV and PASV course anterior and posterior in the thigh, respectively. The PASV may connect to the VOG. Tributaries are veins that drain into another
Figure 17-3 The “alignment sign” with the anterior acces- sory saphenous vein (AASV ) aligned over the deep system artery and vein, whereas the great saphenous vein (GSV ) lies more medially.