Evaluasi USG dan Tatalaksana

Pada Varises Vena Tungkai

Ramzi Asrial
• Thrombosis
• Stenosis
• Venous reflux

2
• Venous duplex imaging has become the favored
technique for evaluation of CVI to confirm the
diagnosis and assess its etiology and anatomy.

• A venous duplex reflux examination combines B-

mode and color-flow imaging of the deep and
superficial veins and pulsed Doppler assessment of
the direction of flow.
 Explanation

• Information provided by DS will have significant

impact on the selection of appropriate treatment

• Failure to identify all sources of venous filling is

likely to result in early recurrence
Ultrasonic assessment
A standard modified examination is performed
to rule out:
1. deep vein thrombosis
2. Reflux direction of flow is assessed with
provocative maneuvers, which may involve
the Valsalva maneuver or augmenting flow
with distal limb compression
Images courtesy of Olivier Pichot, MD Images courtesy of Olivier Pichot, MD
 Color
Color
Grey
Grey scale
scale Doppler
Doppler

Power
Power Pulse
Pulse
Doppler
Doppler Doppler
Doppler
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 Probe Selection
• Linear
– 7.5Mhz, Vascular, Soft Tissue, Ocular
• Phased Array
– 5-1Mhz, Echo, Abd, OB, Vascular Access
• Pros and Cons
Poin-poin penting:
1. Posisi ideal adalah berdiri
2. Visualisasi “Mickey Mouse appearance”
3. Cek trombus di vena dalam
4. Cek refluks sf
5. Cek refluks v. safena magna
 Therapy
• Education
• Compression
• Drugs
• Physioterapy
The goals of therapy
are :
- Relieve of the
complaint/discomfort
- Prevent recurrent
varicose veins
- Shorter recovery period
  Conservative management :
- leg elevation
- avoid long period of standing
- avoid crossing your legs sitting
- wear compression stocking
- walking is better for your circulation
- maintain a normal weight
- keep skin clean, dry and soft
• Special Exercise
– Pedal exercise
– Swimming
– No sudden or constant high energy effort
Compression Stocking
  Medication:

• As the phlebotropic drug is effective in the most

severe stage of the CVI
• Diosmin Hesperidin, Diosmin
• Action at the level of the microcirculation,
increases venous tone, lymph drainage >>
• Relieves all signs & symptoms
Sclerotherapy

Direct injection sclerosing agent into varicose vein to

eliminate small to medium size varicose veins by
transforming the wall of varicose vein into a fibrotic cord

 permanent occlusion
Polidocanol (Aethoxysclerol)
Sodium tetradecyl sulfate (STD)
 Surgery
Saphenous vein stripping
• Cryostripping
• High saphenous ligation
• Ambulatory phlebectomy
• Stab/avulsion phlebectomy
• Perforator ligation

Dwerryhouse, S, Davies, B, Harradine, K, Earnshaw, JJ. Stripping the long saphenous vein reduces the rate of reoperation for recurrent varicose veins: five-year re
sults of a randomized trial. J Vasc Surg 1999; 29:589.

Menyhei, G, Gyevnar, Z, Arato, E, et al. Conventional stripping versus cryostripping: a prospective randomised trial to compare improvement in quality of life an
d complications. Eur J Vasc Endovasc Surg 2008; 35:218.
 Skin laser therapy
• Telangiectasias,
reticular veins and
small varicose veins
<5mm
• Not used for larger
varicose veins
Is pre-op duplex
assessment
important for
varicose vein
surgery?
Position of the patient
Greater saphenous
Position of the patient
Lesser saphenous
Anatomy of superficial veins of the lower
limb
Anatomical structures on B-mode
 GSV
 Bound anteriorly by superficial fascia &
posteriorly by deep fascia
 Often called “saphenous eye”
Fascial layers creating “saphenous eye”

Images courtesy of Olivier Pichot, MD

 Small Saphenous Vein (SSV)

• Courses from lateral ankle up

posterior calf
• Terminates in popliteal fossa at
Saphenopopliteal Junction (SPJ)
SPJ
– Variable confluence with Popliteal Vein Pop V
(PV)
SSV
– Proximal portion lies between
superficial & deep fascial layers

Figure adapted from: Weiss RA, et al eds. Vein diagnosis and treatment: A comprehensive approach. McGraw-Hill Companies, Inc.; 2001.
Detection of reflux on Doppler
Pre-op Ultrasound Assessment
• Map and mark
– Maximum diameter
– Tortuous segments
– Aneurysmal segments
– Areas where vein is very
close to skin
– Large branches or perforators
– Potential access sites
Thank
You