Venous insufficiency- antegrade flow post augmentation release... what is happening

[00:00:00]Hi everyone, my name is Donna Kelly and um I saw a post on Facebook that was asking what this waveform means when performing a lower extremity venous insufficiency or reflux study. Um and I started to type a reply and it's really hard to describe in words um on a reply like that. So I decided to make this quick little video um and I posted the link within the comments. So I suspect that is why you're seeing this if you are. Um so the question was, what does this waveform mean when we perform reflux and we do an augment? So they mentioned that they did a distal augmentation, which that would be represented here. We like to have the flow below the baseline. And then I use a cuff inflation system which has a 3-second timer. So we have this little bit of a delay before my cuff actually releases. And then the question is, what the heck is going on here? Because it is going in the correct direction, it's going up the leg just like um our augmented. It's going in the correct direction, but it's happening kind of spontaneously um after our cuff releases. So I went ahead and put together a couple different slides to explain this. And I do want you to kind of ignore my labels here. Um you know, I'm just using this picture to for a demonstration. So this is what we expect to see when we're looking for reflux.

[00:01:09]And we have to remember that, and this will become very important when we're looking at the next slide, that our ultrasound is capturing just direct what's directly under our probe as far as what we're visualizing on our screen.

[00:01:22]However, um the hemodynamics of it all is affected by a heck of a lot more than what's just under our probe. So if we look at this, this is what we expect to see if with our first image here over here on the left. Say we we have our probe on our great saphenous vein here.

[00:01:37]Um we get our nice distal calf augment our calf augmentation here um distal to the probe. And we get our nice um push of blood flow up the great saphenous.

[00:01:46]There's that augmentation here, right?

[00:01:48]So then um my little delay happens with my cuff inflation system. And then what do we expect to happen if there's reflux? The blood just comes right back down that great saphenous vein and there's our reflux above the baseline.

[00:01:59]If we were look at a cine loop in in color flow, here comes our augment.

[00:02:04]There's our blue going up the leg. And then there's our release and there's the blood coming back down. That's all pretty simple, isn't it? Right? Um that's kind of venous insufficiency 101.

[00:02:14]So let's move on to the question at hand. So if we look at um this this image here, and it's the same one that I had in the opening slide, we have our um antegrade flow with our augment. And then we had that delay like I mentioned because of my cuff inflation system. And then we have this antegrade flow. So what the heck is going on here is the big question. So I want you to remember what I said about the fact that just because we're looking at one thing, you know, we can look at that one spot specifically, but when we start talking about hemodynamics, it's so much more than what we're seeing under our probe.

[00:02:49]And the um the reaction on the pulse wave Doppler and the color flow Doppler is going to tell us a story. Um so if we look at this, and let's just pretend this isn't the PT PTE and this is actually the GSV, okay? Um if we look at this and we have our augment and our probe is right here on the great saphenous vein, the blood goes up like it's supposed to, right? And then what's what we would expect to happen, like we saw in the last slide, is it just comes back down or nothing happens. And that would mean the valves are functioning fine. But in this case, what's actually happening is our probe is on the GSV. We get our good augment for that calf and the blood goes up just like it's supposed to. So there it goes. And then we get this release and now we have this antegrade flow. Well, what I can tell you is that this is an indirect sign that there's reflux somewhere else. And what I mean by that is um once we get that release, what's happening is there's another vein and we're going to say in this case the anterior saphenous that has such a strong pull because don't forget we're not just augmenting our GSV, we're augmenting the whole leg.

[00:03:54]So we're pushing blood up all of these veins, okay? Including the anterior saphenous. And then that augment releases, whether it's a cuff or a manual, and all of a sudden we get this rush of blood flow back down the anterior saphenous vein. It's refluxing, but we're not seeing that because our probe is on the GSV.

[00:04:13]But what we're actually going to see sometimes is that this pull is so strong on the in the anterior saphenous that it actually will pull the blood flow up the GSV and then it comes around and goes back down the ASV. So it is like a siphon. It's actually suctioning it up and um and you know, pulling it along so that in it totally changes the hemodynamics. So this is just a quick video of this. So here comes our augment. We get our nice blue. Um there's our augment and then our cuff releases. And then all of a sudden we get this continuous antegrade flow. And that's exactly what's happening. Now if we were able to quickly switch our probe over to the anterior saphenous, you would see that that anterior saphenous is actually refluxing. So it's just a pulling of that blood flow up into another vein that's refluxing. Um so I hope this helps. Um