Duplex ultrasound as first-line imaging for morphology and hemodynamics in the upper limb venous system

Niels BÆKGAARD,1 MD; Charlotte STRANDBERG,2 MD 1Vascular Department, Gentofte Hospital and Rigshospitalet, University of Copenhagen, Denmark; 2Department of Radiology, Gentofte and Herlev Hospital, Copenhagen, Denmark Abstract This review describes venous anatomy and hemodynamic characteristics for venous return in the upper limb, including main differences in comparison with venous drainage in the lower limb. Duplex ultrasound (DUS) is the first-line imaging modality even it seems less standardized than other investigation approaches for veins in the lower limb. This article presents useful instructions to assess veins from the peripheral to the thoracic outlet via the costoscalene hiatus. Without basic understanding, it is…

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Phlebolymphedema: is it a new concept?

Byung-Boong LEE, MD, PhD, FACS Professor of Surgery and Director, Center for the Lymphedema and Vascular Malformations, George Washington University, Washington DC, USA Abstract Venous and lymphatic systems are inseparable “dual” outflow systems with mutually complimentary function so that such mutual interdependence between these two systems causes a new condition to affect both systems simultaneously when one of the two systems should fail to provide sufficient compensation to the other system, known as “phlebolymphedema” (PLE): combined condition of chronic venous insufficiency (CVI)/chronic venous hypertension and chronic lymphatic insufficiency (CLI)/chronic lymphedema. PLE is, therefore, an unavoidable outcome of the joint failure…

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Modeling and 3D printing of veins from CT venograms

Jean-Francois UHL, MD, FacPh of the UNESCO Chair of Digital Anatomy, Paris University Abstract Digital anatomy has more and more applications in medicine and surgery, thanks to the progress in imaging and power of computer software. To evaluate patients with chronic venous disorders, in the case of complex anatomy or recurrent varices after surgery (REVAS), three-dimensional (3D) modeling of the venous system is often a great support. A global 3D depiction of the whole venous morphology will help the hemodynamical mapping achieved by color Duplex ultrasound. In addition to anatomical information, color Duplex ultrasound also provides essential hemodynamic data for…

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What is the best method of imaging in iliofemoral venous obstruction?

Gerard J. O’SULLIVAN MB, BCh, BAO, FRCR National University of Ireland, Galway, Ireland Abstract Iliofemoral venous obstruction is increasingly recognized as a major cause of post-thrombotic syndrome. Patients can be left with significant symptoms after just one episode of iliofemoral deep-vein thrombosis; ranging from milder problems, such as varicose veins, to itching, leg swelling, and even venous ulceration. With the advent of endovascular techniques to reconstruct the iliofemoral segment has come an understanding that accurate recognition and diagnosis form a central part of the puzzle. Clinical evaluation is limited, and imaging has assumed a central role. This article looks at…

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Use of air plethysmography and ambulatory venous pressure measurement in chronic venous disease

Seshadri RAJU, MD, FACS The RANE Center, St Dominic’s Memorial Hospital, Jackson, Mississippi, USA. Abstract Air plethysmography (APG) and ambulatory venous pressure (AMVP) measurement are functional tests used in chronic venous disease (CVD). We review our experience with these tests in 8456 CVD limbs seen over a 20-year period. The venous filling index (VFI90) parameter in the APG test shows progressive significant worsening as reflux and disease severity increase. Venous volume (VV) also increases—a sign of venous pooling—with reflux and disease progression. This is compensated to a large extent by a parallel increase in ejection volume to as much as…

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New diagnostic modalities in lymphedema

Sarah THOMIS University Hospitals Leuven, Belgium Abstract Introduction: Lymphedema is a chronic, progressive, and debilitating disease. An early and accurate diagnosis and treatment is very important to alter the normal progression of the disease. When lymphedema is diagnosed late, the options for treatment are diminished as fibrous tissue is formed. Until recently, lymphoscintigraphy was considered the gold-standard diagnostic technique; however, other new and renewed diagnostic tools have emerged. This article provides an overview of the available diagnostic tools based on the findings from a literature search. Methods: A literature search for each of the diagnostic tools was performed. Results: Diagnostic…

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Instrumental diagnosis of pelvic congestion syndrome

Santiago ZUBICOA EZPELETA1; Javier LEAL MONEDERO1; Assila T. ELKASHISHI2 1 Ruber Internacional Hospital, Angiology and Vascular Surgery Unit, Madrid, Spain 2 Al Salam Hospital, Cairo, Egypt Abstract Pelvic congestion syndrome (PCS) is a multifactorial medical condition that is characterized by the absence of specific symptoms, and therefore, it needs very precise imaging for an accurate diagnosis. Diagnostic techniques can be noninvasive (duplex ultrasound) or minimally invasive (magnetic resonance, CT, and phlebography). Duplex ultrasound is regarded as a first-line investigation for PCS because it is noninvasive, easily accessible, and inexpensive. This procedure provides essential hemodynamic information, and when combining transvaginal and…

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Role of duplex ultrasound investigation in the management of postthrombotic syndrome

Role of duplex ultrasound investigation in the management of postthrombotic syndrome Olivier PICHOT, MD Caroline MENEZ, MD Service de Médecine Vasculaire, CHU de Grenoble, France Abstract Duplex ultrasound is a method for analyzing the anatomy and hemodynamic profile of lower-limb veins; it can also be used for pelvic and abdominal examinations. For postthrombotic syndrome, duplex ultrasound can recognize specific anatomical abnormalities in the venous lumen, wall, and valves. Reflux can be easily diagnosed with duplex ultrasound, although some controversy is present concerning the extent of the reflux detected compared with descending venography. Venous obstruction is more challenging to quantify; nevertheless,…

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Lymphatic system dysfunction in pediatric populations

Christoph M. PAPENDIECK Angiopediatria, Buenos Aires, Argentina SUMMARY Lymphatic system dysfunction in children has many presentations and syndromes and may affect all parts of the body. It can be classified according to the type of abnormality present as dysplasia of the lymphatics (LAD I), dysplasia of the lymph nodes (LAD II), or dysplasia of the lymphatics and lymph nodes (LAAD). Lymphatic dysplasias can be clinically represented by peripheral lymphedema alone or be associated with more and complex dysfunction in different locations, eg, intestinal lymph vessels, thoracic duct, and others. Primary lymphedema has for many years been the least understood form…

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Investigations in postthrombotic syndrome according to clinical status

Michel PERRIN Vascular Surgery, France INTRODUCTION Many angiologists and vascular surgeons consider that postthrombotic syndrome (PTS) should only be managed noninterventional treatment. Unaware of the real possibilities provided by operational treatment, they limit investigation to color duplex scanning (CDS), which in this perspective is logical and reasonable. Compression, drugs, and lifestyle recommendations do not call for level III investigation according to the CEAP classification.1 Conservative treatment as far as etiology is concerned relies mainly on the signs and symptoms, independently of the location, extension of anatomical lesions, and pathophysiological abnormality. Conversely, when surgical or endovenous treatment is considered, the CEAP…

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