Lower Extremity Venous Incompetence Protocol

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 exam may be terminated or completed depending on
the location of the SVT.

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.

This is a basic protocol to determine the presence and severity of valvular insufficiency. It
may need to be altered due to patients anatomy (i.e. duplicated/ accessory veins or SSV
not emptying into Pop V). Additional images may also be needed if pathologies are seen
(i.e. varicosities, large perforators, or suspicion of deep calf vein insufficiency).

Structure Scan Label Images Stored

Plane Identify RT or
LT
Common Sagittal CFV W/ Color & Spectral Doppler with Valsalva
Femoral Vein VALSALVA o If reflux is seen, include
measurement of reflux time on
spectral waveform
Transvers GSV AT SFJ Measure anterior outer wall to posterior
Great
e outer wall
Saphenous Vein
Junction with
Sagittal GSV AT SFJ W/ Color & Spectral Doppler with
Common
AUG augmentation
Femoral Vein
o If reflux is seen, include
(saphenofemoral
measurement of reflux time on
junction)
spectral waveform
Transvers GSV MID THIGH Measure anterior outer wall to posterior
e outer wall
Great
Saphenous Vein Sagittal GSV MID THIGH Color & Spectral Doppler with
Mid Thigh W/AUG augmentation
o If reflux is seen, include
measurement of reflux time on
spectral waveform
Transvers GSV LOWER Measure anterior outer wall to posterior
e THIGH outer wall
Great
Saphenous Vein Sagittal GSV LOWER Color & Spectral Doppler with
Lower Thigh THIGH W/AUG augmentation
o If reflux is seen, include
measurement of reflux time on
spectral waveform
Great Transvers GSV MID CALF Measure anterior outer wall to posterior
Saphenous Vein e outer wall
Mid Calf
Sagittal GSV MID CALF Color & Spectral Doppler with
AK\backup\Vascular I\protocols
 Lower Extremity Venous Incompetence Protocol
W/AUG augmentation
o If reflux is seen, include
measurement of reflux time on
spectral waveform
Transvers GSV LOWER Measure anterior outer wall to posterior
e CALF outer wall
Great
Saphenous Vein Sagittal GSV LOWER Color & Spectral Doppler with
Lower Calf CALF W/AUG augmentation
o If reflux is seen, include
measurement of reflux time on
spectral waveform

AK\backup\Vascular I\protocols
 Lower Extremity Venous Incompetence Protocol
Sagittal FV MID W/AUG Color & Spectral Doppler with
augmentation
Femoral Vein
o If reflux is seen, include
Mid
measurement of reflux time on
spectral waveform
Sagittal POP V W/AUG Color & Spectral Doppler with
augmentation
Popliteal Vein o If reflux is seen, include
measurement of reflux time on
spectral waveform
Transvers SSV AT SPJ Measure anterior outer wall to posterior
Small
e outer wall
Saphenous Vein
Junction with
Sagittal SSV AT SPJ Color & Spectral Doppler with
Popliteal Vein
W/AUG augmentation
(saphenopoplite
o If reflux is seen, include
al junction)
measurement of reflux time on
spectral waveform
Transvers SSV MID CALF Measure anterior outer wall to posterior
e outer wall
Small
Saphenous Vein Sagittal SSV MID CALF Color & Spectral Doppler with
Mid Calf W/AUG augmentation
o If reflux is seen, include
measurement of reflux time on
spectral waveform
Transvers SSV LOWER Measure anterior outer wall to posterior
e CALF outer wall
Small
Saphenous Vein Sagittal SSV LOWER Color & Spectral Doppler with
Lower Calf CALF W/AUG augmentation
o If reflux is seen, include
measurement of reflux time on
spectral waveform

Tips

An 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 patients 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.

AK\backup\Vascular I\protocols
 Lower Extremity Venous Incompetence Protocol
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.

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 may 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

In the transverse plane, measure the Anterior/Posterior (AP) diameter of the saphenous
veins from outer wall to outer wall being careful not to compress the vein at all
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

AK\backup\Vascular I\protocols
 Lower Extremity Venous Incompetence Protocol

Incidental Findings

Incidental findings should be noted as these may explain patients symptoms.

Examples include edema, significant arterial disease (stenosis or aneurysm), and
masses.

AK\backup\Vascular I\protocols