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Usuário(a):DocElisa/Ecodoppler venoso dos membros inferiores

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Veia acessória anterior da coxa
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DocElisa/Ecodoppler venoso dos membros inferiores
A veia acessória anterior da coxa.
Drena para veia safena magna


A veia safena acessória anterior da coxa (VSAA) é uma veia tributária da veia safena magna (VSM) que drena a face antero-lateral da coxa. É uma tributária muito especial que se torna insuficiente frequentemente e causa importantes dilatações venosas na coxa que se estendem à perna e mesmo ao face posterior do joelho. Numa grande maioria dos casos é a única veia patológica e os eixos safenianos não apresentam anomalia.

Normalmente esta veia drena na crossa da VSM muito próximo da junção safeno-femoral. Mais raramente drena diretamente na veia femoral.No terço superior da coxa situa-se abaixo da fascia superficial como a safena magna, mas torna-se muito superficial nos terços médio e inferior da coxa. Ao contrário das outras tributárias da VSM, A parede da VSAA é semelhante à parede da VSM com uma camada média espessa.[1]

Na ultrassonografia esta veia situa-se no alinhamento dos vasos femorais enquanto que a VSM é muito mais antero-interna.

Veia acessória anterior da coxa








Insuficiência venosa

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A insuficiência venosa acontece quando uma veia se dilata, secundária a uma doença da parede ou quando o normal funcionamento das válvulas, que ajudam na drenagem em direcção ao coração e impedem o refluxo, são lesadas ou não coaptam corretamente (a simples dilatação da veia impede que válvulas sãs coaptem eficazmente). Esta situação levará a uma inversão do fluxo sanguíneo na veia ou veias afetadas com aumento da pressão venosa nas zonas de maior declive, tornozelos e pés. O protocolo necessário para um estudo das alterações hemodinâmicas num paciente com insuficiência venosa é muito diferente do protocolo de investigação de uma suspeita de trombose venosa. O exame efetuado com a intenção de tratar o paciente por stripping ou terapia por laser, por exemplo, é muito diferente do exame executado com a intenção de efetuar uma Cura CHIVA[nb 1][2][3]



Unlike the arterial ultrasound study, when the sonographer studies venous insufficiency, the vein wall itself has no relevance and attention will be focused on the direction of blood flow. The objective of the examination is to see how the veins drain. In this way, venous ultrasonography has at times become a hemodynamic examination which is reserved for experienced sonographers who have completed hemodynamic studies and training and have acquired a deep knowledge of this subject.[4]

Also, unlike the arterial ultrasound examination, blood velocity in veins has no diagnostic meaning. Veins are a draining system similar to a low pressure hydraulic system, with a laminar flow and a low velocity. This low velocity is responsible for the fact that it can only be detected spontaneously with the Doppler effect on the proximal and larger femoral and iliac veins. Here the flow is either modulated by the respiratory rhythm or is continuous in cases where the flow is high. The thinner veins do not have a spontaneous flow. However, in some circumstances the blood flow is so slow that it can be seen as some echogenic material moving within the vein, in "spontaneous contrast". This material can easily be mistaken for a thrombus, but can also easily be discounted by testing the vein's compressibility.[nb 2][5]

Vein valve and spontaneous contrast

To evidence the blood flow velocity there are some techniques that the examiner can use to accelerate blood flow and show valvular function:

Manual squeezing and releasing - the examiner can compress the vein below the probe which will push the blood in its normal anterograde direction. On releasing the pressure if the valves are incompetent the flow will appear as a retrograde flow or reflux, greater than 0.5 sec.[6]

Testing sapheno-popliteal junction with Paraná maneuver
Paraná maneuver: checking perforators

Paraná maneuver,[nb 3] makes use of a proprioceptive reflex to test venous muscle pump induced flow. (Proprioceptive refers to a response to a perceived stimulus especially with regard to movement and position of the body).[7] A slight push to the waist, triggers a muscle contraction in the leg, in order to maintain posture. This maneuver is very useful for studying deep vein flow and detecting valvular incompetence, mainly at the popliteal vein level, (above the back of the knee). It is used when legs are painful or very edematous (swollen with fluid). [8]

Flexing the toes and feet and extending on tiptoes, can all be very useful in detecting perforator vein incompetence. These movements unleash a muscle contraction which compresses deep veins. If a perforator valve is incompetent then a reflux from the deep to the superficial through the perforator vein will be registered.[9]

Valsalva maneuver - when the patient performs this maneuver, he or she, increases intra-abdominal venous pressure. If the great saphenous valve at the sapheno-femoral junction is incompetent, a reflux will appear.

Valsalva maneuver is negative
GSV insufficiency at S–F junction – Valsalva positive
GSV Valsalva false positive – flow coming from an abdominal collateral at S–F junction

Normal blood flow is anterograde (going to the heart), and from superficial to deep veins via perforator veins. However, there are two exceptions: firstly, the great saphenous vein (GSV) collaterals, (the veins that run parallel), drain the abdominal wall and have a flow from top to bottom so that when an examiner tests the sapheno-femoral junction, a false positive diagnosis might be made; secondly, in the flow from the sole of the foot venous network around 10% drains to the dorsal venous arch of the foot, going therefore against the norm, from deep to superficial veins.[10]

Attention will be focused on the direction of the blood flow in both of the venous systems, and in the perforator veins, as well as being focused on shunt detection.[nb 4][11] A shunting of blood from the thigh veins back into the lower leg veins will give a reflux situation. The veins most often found to be incompetent are the saphenous veins and the perforators communicating with the deep veins of the thigh.[12]

Technical difficulties

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Venous ultrasonography of the lower limbs is the most demanding of the medical complementary examinations. It is dependent on the examiner's expertise and training, and the interpretation of the results is subjective and reliant on an understanding of venous hemodynamics. [13][14] (A mapping does help the reproducibility and the inter-observer agreement of this examination).[15][16] The examination is made even more difficult because there can be dilated veins without insufficiency, (by hyper-debit), and non dilated but incompetent veins. Moreover, veins can be discretely incompetent in summer but then be normal in winter. Also, by definition of insufficiency, (insufficient blood flow) blood may be seen to flow freely in both directions, anterograde and retrograde between two valves.[17] Another problem when dealing with the superficial venous system, is that venous anatomy is not constant; the position of veins can vary in different patients; also in the same patient the right lower limb is not identical to the left lower limb. As a further complication to the examination, where venous insufficiency is evidenced, the examination needs to be done with the probe in the transversal position but the mapping must be done showing the veins in their longitudinal aspect. This demands a rapid extrapolation by the physician from the transversal images seen to the longitudinal drawing needed.[18][15] The dynamic maneuvers also need to be well executed. The need of a specialized training is mandatory which is a huge problem for many countries today.[19]

Particular details

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Great saphenous vein

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The "eye sign"

The great saphenous vein,(GSV) a superficial vein, is the longest vein in the body. It has its origin in the dorsal venous arch of the foot, a superficial vein which connects the small saphenous vein with the GSV. It travels up the leg and medial side of the thigh to reach the groin, where it drains into the common femoral vein.[20] Along the length of the GSV, it receives numerous tributaries, (from the subcutaneous layer) and drains into the deep veins via the perforator veins. When seen in a scan, the GSV and the Giacomini vein, together with the accessory saphenous vein (ASV), form an image resembling an eye which is referred to as the "eye sign" or "eye image". .[21] All veins which are between the skin and the superficial fascia are tributaries and all veins which cross the deep fascia to join the deep venous system are perforator veins.[22]

Three anatomic compartments can be described, as networks:

  • NI contains the deep veins, also known as the deep compartment.
  • N2 contains the perforator veins.
  • N3 contains the superficial veins also known as the saphenous compartment.[12]

Some authors describe one more compartment N4, containing collaterals which form a bypass between two distinct points of the same vein.[23] This compartmentalization is useful in an ultrasonographic examination because it makes systematization, mapping execution, and any surgery strategic, easier.

 
Carrying out vein mapping

Being protected between two fasciae, the superficial veins belonging to compartment N3 very rarely become sinuous. So that when a sinuous vein is detected, the sonographer will suspect that it is a tributary. The sapheno-femoral junction is tested by the Valsalva maneuver with the use of color Doppler being helpful at this stage.[23]

Accessory saphenous vein

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ASV at sapheno-femoral junction, the "Mickey Mouse sign"

The accessory saphenous vein (ASV), either anterior or posterior, is an important GSV collateral frequently responsible for varicose veins located on the anterior and lateral aspect of the thigh.[24] The anterior ASV is more anterior than the ASV and is outside the femoral vessels plan. The two veins terminate in a common trunk near the groin, the sapheno-femoral junction. Here, the ASV can be located aligned with the femoral vessels at the "alignment sign".[22] Also, at the groin it can be seen at the outside of the great saphenous vein, and together with the common femoral vein (CFV) these three create an image, the so-called "Mickey Mouse sign". Some authors, inspired by this sign (presented for the first time at CHIVA's 2002 meeting in Berlin), described a "Mickey Mouse view" at the groin, an image formed by the common femoral vein, the GSV and the superficial femoral artery. When the ASV is incompetent, its flow becomes retrograde and tries to drain in the superior fibular perforator, at the side of the knee, or sometimes it runs down towards the ankle to drain in the inferior fibular perforator.[25]

Small saphenous vein

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The small saphenous vein (SSV), runs along the posterior aspect of the leg as far as the popliteal region, in the upper calf. Here it enters the popliteal space which is located between the two heads of the gastrocnemius muscle where it usually drains above the knee joint in the popliteal vein or a little less often in the great saphenous vein (GSV) or other deep muscular veins of the thigh.[26] The use of ultrasonography has allowed a number of variations to be shown at this level; when no contact is made with the popliteal vein it might be seen to drain in the GSV, at a variable level; or, it may merge with the Giacomini vein and drain in the GSV at the superior 1/3 of the thigh. It can also but rarely, drain in the vein of the semimembranosus (thigh muscle) (shown below). Usually though, it connects with a perforator vein at its middle 1/3.[27] To check for insufficiency, the Paraná maneuver is very useful.[8]

 
Insufficiency from the SSV at sapheno-popliteal junction
 
Insufficiency from the SSV flooded by the vein of the semimembranosus muscle
 
SSV variant draining in the vein of the semimembranosus muscle

Giacomini vein

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The Giacomini vein mostly acts as a bypass between the GSV and SSV territories. Usually its flow is in the normal anterograde direction, from bottom to top. However it can become retrograde without pathology. For example, after a GSV stripping, laser ablation or after its ligation at the sapheno-femoral junction, the Giacomini vein will drain into the SSV, with a retrograde flow. When there is a GSV thrombosis or other cause of insufficiency, the Giacomini vein can divert the blood flow to the SSV and from there to the popliteal vein. Where surgery, other than stripping or laser ablation is intended, the examiner will make reference to the blood flow direction in this vein, as it will be of importance.[28]

Perforator veins

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Insufficient perforator

Perforator veins play a very special role in the venous system, carrying blood from superficial to deep veins. During the muscular systole their valves close and stop any blood flow coming from the deep to the superficial veins. When their valves become insufficient, they are responsible for a rapid deterioration in existing varicose disease and for the development of venous ulcers. Detection of insufficient perforators is important because they need to be ligatured. However, the detection of competent ones is as important because they may be used strategically in new techniques of conservative surgery, for example a minimally invasive CHIVA. The ultrasonography report will include insufficient and continent perforators, which will also be shown on venous mapping.[29] To test these veins properly, the examiner will need to use some techniques like the Paraná maneuver, toe and foot flexion, and hyper-extension on tip toes.

Examination report

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SVS normal mapping

After performing this examination, the physician writes a report in which some points are crucial:

  • The condition of the deep vein system (DVS), its permeability and compressibility, and whether it is continent or insufficient;
  • The permeability and compressibility of the superficial vein system (SVS), the presence or absence of superficial insufficiency, and in which veins or vein segments;
  • Which perforator veins are continent or insufficient;
  • The presence or absence of shunts;
  • Mapping the insufficient veins, flux direction, shunts, and perforators.[24]

[nb 5]

This enables surgeons to plan interventions, in a stage known as virtual dissection.[nb 6] Drawn on paper, after the examination, it will be drawn over the patient's skin before surgery.

History

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O efeito Doppler foi descrito pela primeira vez por Christian Doppler em 1843. Cerca de quarenta anos mais tarde, em 1880, o efeito piezoelétrico foi descoberto e confirmado por Pierre e Jacques Curie. Estas descobertas foram usadas no desenvolvimento da ultrassonografia. George Ludwig usou pela primeira vez os ultrassons com fins médicos nos fins dos anos 40. [30][31]

A utilisação da ultrassonografia em medicina se seguiu em diferentes pontos do mundo. Nos meados dos anos 50mais investigação foi feita em Glasgow pelo Professor Ian Donald e colaboradores, que desenvolveram a tecnologia e aplicação dos ultrassons. Em 1963, em França, L. Pourcelot iniciou a sua tese que foi apresentada em 1964, e usou o Doppler pulsado para o estudo da circulação do sangue.[32] Estes estudos foram continuados por Peronneau em 1969. Dr. Gene Strandness e o grupo de bio-engenharia da Universidade de Washington, que conduziam a investigação do Doppler como uma ferramenta de diagnóstico para as doenças vasculares, publicaram o seu primeiro trabalho em 1967.[33][34]

O primeiro trabalho sobre o sistema venoso apareceu nos anos 1967-1968.[35] Os primeiros aparelhos comercialmente disponíveis datam de 1960. Depressa mais avanços na electrónica e nos materiais piezoeléctricos conduziram a uma utilização cada vez mais eficaz dos ultrassons em medicina, com possibilidades de diagnóstico cada vez mais preciso com o subsequente tratamento cada vez mais adequado. Isto teve um enorme impacto em diversas especialidades médicas e cirúrgicas, incluindo radiologia, ginecologia, obstetrícia, cardiologia e angiologia.[36][37] Rápidos avanços técnicos levaram a uma boa sensibilidade-especificidade da técnica.[38]

O estudo hemodinâmico do sistema venoso é descrito pela primeira vez em França, em 1985, com Claude Franceschi que descreve o tratamento conservador da insuficiência venosa, conhecido por técnica CHIVA.[39]

cópia do original: (Os primeiros trabalhos publicados utilizando o efeito Doppler para o estudo do sistema venoso datam de 1967-1968.[35] A evolução da técnica deu-se sobretudo a partir de 1970, sendo os primeiros dez anos marcados pela utilização do Doppler contínuo numa tentativa de estudo hemodinâmico e funcional do sistema venoso. A partir de 1982-1983 o uso da eco-tomografia e o aperfeiçoamento dos aparelhos tornou possível o enriquecimento desta técnica e a obtenção de resultados fiáveis visando um diagnóstico e a solução terapêutica.[38] Os estudos visavam quase sempre a trombose venosa e foi a partir do aparecimento do Doppler pulsado e dos estudos de Claude Franceschi, inventor da Cura CHIVA que a insuficiência venosa crónica começa a ser realmente estudada.[40] A partir de 1990 com a codificação a cores do Doppler este exame triunfa no diagnóstico da patologia venosa e afasta definitivamente o uso da flebografia.[37] No entanto, se a codificação a cores é de grande utilidade no estudo das artérias, já no estudo das veias a sua utilidade é menos importante, com algumas exceções, podendo mesmo levar a falsos positivos ou falsos negativos.)







The Doppler effect was first described by Christian Doppler in 1843. Nearly forty years later in 1880, the piezoelectric effect was discovered and confirmed by Pierre and Jacques Curie. Both of these findings were used in the development of ultrasonography. The first ultrasound was applied to the human body for medical purposes by Dr. George Ludwig, University of Pennsylvania, in the late 1940s.[30][31]

The use of ultrasonography in medicine soon followed in different locations around the world. In the mid-1950s more research was undertaken by Professor Ian Donald et al., in Glasgow, which advanced the practical technology and applications of ultrasound. In 1963, in France, L. Pourcelot started on his thesis, which was presented in 1964, and used pulsed Doppler for blood flow calculation as its subject.[41] This was followed up by Peronneau in 1969. Dr. Gene Strandness and the bio-engineering group at the University of Washington who conducted research on Doppler ultrasound as a diagnostic tool for vascular disease, published their first work in 1967.[42][34] The first report published about the venous system appeared around 1967-1968.[35]

From the 1960s commercially available systems were introduced. Soon, other advances in electronics and piezoelectric materials enabled further improvements which meant that ultrasound was quickly adopted for use in medicine due to its rapid, accurate diagnostic capabilities which offered the possibility of prompt treatment. Alongside the improving imaging technology, acoustic Doppler velocimetry and medical ultrasonography color Doppler were developed, which have had a significant impact on many specialties, including radiology, obstetrics, gynecology, angiology and cardiology, and have provided even greater scope for ultrasound investigations.[43][44] Since 1970, real-time scanners and pulsed Doppler, have enabled the use of ultrasound to study the function of the venous system. The first demonstration of color Doppler was achieved by Geoff Stevenson.[36][37] Further progress in the 1970s was made with the arrival of the microchip, and the ensuing exponential increase in processing power has meant the development of fast and powerful systems. These systems involving digital beamforming and greater signal enhancement, have introduced new methods of interpreting and displaying data.[45]

Rapid technical advancements in transmission tomography made possible the very good specificity and sensitivity capability of this technique, enabling the possibility of properly seeing the superficial tissues.[38] Hemodynamic study began in France in 1985, when C. Franceschi, first described the conservative treatment for venous insufficiency, known as CHIVA.[39]

Footnotes

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  1. ↑ CHIVA means "Venous Insufficiency Conservative, Hemodynamic and Ambulatory treatment" the order of words coming from French because is a procedure invented by the French researcher Claude Franceschi
  2. ↑ Echogenic is the tissue which reflects the ultrasound beam and can be visualized on the screen
  3. ↑ Paraná maneuver has been described for the first time by Claude Franceschi at the Chiva congress 1998 at Paraná Town, Argentina
  4. ↑ In venous circulation, shunt is the situation where blood circulates from one vein (leak point) to another and from this one to the former (re-entry point) creating a pathway in a vicious circle between two veins one with a physiologic flow and the other with a retrograde flow
  5. ↑ Mapping is a schematic depiction of the venous anatomic-functional configuration in an individual
  6. ↑ Virtual dissection is a schema based on venous mapping where the surgeon projects what he will do to treat his patient.

References

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  1. ↑ Franceschi, C.; Zamboni, P. (2009). Principles of Venous Hemodynamics. [S.l.]: Nova biomedical Books. pp. 14–15. ISBN 978-1-60692-485-3 
  2. ↑ Mowatt-Larssen, Eric; Shortell, Cynthia K. (2012). «Treatment of Primary Varicose Veins Has Changed with the Introduction of New Techniques». Seminars in Vascular Surgery. 25 (1): 18–24. PMID 22595477. doi:10.1053/j.semvascsurg.2012.02.002 
  3. ↑ Mowatt-Larssen, Eric; Shortell, Cynthia (2010). «CHIVA». Seminars in Vascular Surgery. 23 (2): 118–22. PMID 20685567. doi:10.1053/j.semvascsurg.2010.01.008 
  4. ↑ Cina et al. 2005.
  5. ↑ Franceschi 1988, pp. 84–5.
  6. ↑ Labropoulos et al. 2003.
  7. ↑ O.D.E. 2nd Edition 2005[falta página]
  8. ↑ a b Franceschi & Zamboni 2009, p. 93.
  9. ↑ Franceschi & Zamboni 2009, pp. 92–4.
  10. ↑ Franceschi & Zamboni 2009, p. 19.
  11. ↑ Franceschi & Zamboni 2009, p. 37.
  12. ↑ a b Recek, C (2004). «The venous reflux». Angiology. 55 (5): 541–8. PMID 15378117. doi:10.1177/000331970405500510 
  13. ↑ Franceschi & Zamboni 2009, pp. 9–17.
  14. ↑ Saliba, Giannini & Rollo 2007.
  15. ↑ a b Galeandro et al. 2012.
  16. ↑ Wong, Duncan & Nichols 2003.
  17. ↑ Zamboni 2009, p. 26.
  18. ↑ Franceschi & Zamboni 2009, p. 81.
  19. ↑ WHO 1998, p. 14.
  20. ↑ Caggiati & Ricci 1997.
  21. ↑ Franceschi & Zamboni 2009, p. 14.
  22. ↑ a b Cavezzi et al. 2006.
  23. ↑ a b Franceschi & Zamboni 2009, pp. 11–3.
  24. ↑ a b Ciccone, Marco; Galeandro; Quistelli Giovanni; Scicchitano, Pietro; Gesualdo, Michele; Zito; Caputo; Carbonara; Galgano; Ciciarello; Mandolesi; Franceschi (2012). «Doppler ultrasound venous mapping of the lower limbs». Vascular Health and Risk Management. 8: 59–64. PMC 3282606 . PMID 22371652. doi:10.2147/VHRM.S27552 
  25. ↑ Franceschi & Zamboni 2009, pp. 11–13.
  26. ↑ «Archived copy» (PDF). Consultado em 29 de junho de 2013. Arquivado do original (PDF) em 17 de julho de 2013 [ref. deficiente]
  27. ↑ Coleridge-Smith et al. 2006.
  28. ↑ Escribano et al. 2005.
  29. ↑ Pierik et al. 1997.
  30. ↑ a b «History of the AIUM». Consultado em 24 de fevereiro de 2013. Cópia arquivada em 3 de novembro de 2005 
  31. ↑ a b «The History of Ultrasound: A collection of recollections, articles, interviews and images». www.obgyn.net. Consultado em 24 de fevereiro de 2013. Arquivado do original em 5 de agosto de 2006 
  32. ↑ descotes J., Pourcelot, L. (1965). «Effet Doppler et mesure du débit sanguin». C.R.Acad.Sc.Paris (261): 253–6 
  33. ↑ Zierler, R. Eugene (November 1, 2002). «D. Eugene Strandness, Jr, MD, 1928–2002». Journal of Ultrasound in Medicine. 21 (11): 1323–5  Verifique data em: |data= (ajuda)
  34. ↑ a b Dauzat 1991, pp. 5-6.
  35. ↑ a b c Sigel B, Popky GL, Wagner DK, et al. (1968). «A Doppler Ultrasound method for diagnosing lower extremity venous disease». Surgery, Gynecology & Obstetrics (127): 339–50 
  36. ↑ a b Eyer, M.K.; Brandestini, M.A.; Phillips, D.J.; Baker, D.W. (1981). «Color digital echo/doppler image presentation». Ultrasound in Medicine & Biology. 7. 21 páginas. doi:10.1016/0301-5629(81)90019-3 
  37. ↑ a b c Persson, AV; Jones, C; Zide, R; Jewell, ER (1989). «Use of the triplex scanner in diagnosis of deep venous thrombosis». Archives of surgery. 124 (5): 593–6. PMID 2653279. doi:10.1001/archsurg.1989.01410050083017 
  38. ↑ a b c Dauzat M., Laroche J. P. (1983). «L'echotomographie des veines: proposition d'une méthodologie et illustration des premiers résultats pour le diagnostic des thromboses veineuse profondes». Journal d'Imagerie Médicale. 1: 193–197 
  39. ↑ a b Franceschi.
  40. ↑ Erro de citação: Etiqueta <ref> inválida; não foi fornecido texto para as refs de nome Franceschi
  41. ↑ descotes J., Pourcelot, L. (1965). «Effet Doppler et mesure du débit sanguin». C.R.Acad.Sc.Paris (261): 253–6 
  42. ↑ Zierler, R. Eugene (November 1, 2002). «D. Eugene Strandness, Jr, MD, 1928–2002». Journal of Ultrasound in Medicine. 21 (11): 1323–5  Verifique data em: |data= (ajuda)
  43. ↑ Cobbold 2003, pp. 608-609.
  44. ↑ WHO 1998, pp. 1–2.
  45. ↑ Erro de citação: Etiqueta <ref> inválida; não foi fornecido texto para as refs de nome bmus.org

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Project 1
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