Advanced Practice - Venous —
Training activity: 5

Details

Perform optimised ultrasound scans to identify incompetence of the greater saphenous and short saphenous veins and any associated branches including perforators

Type

Entrustable training activity (ETA)

Evidence requirements

Evidence the activity has been undertaken by the trainee repeatedly, consistently, and effectively over time, in a range of situations. This may include occasions where the trainee has not successfully achieved the outcome of the activity themselves. For example, because it was not appropriate to undertake the task in the circumstances or the trainees recognised their own limitations and sought help or advice to ensure the activity reached an appropriate conclusion. ​

Reflection at multiple timepoints on the trainee learning journey for this activity.

Considerations

• Patient centred care and support
• Local SOPs
• National guidance
• Clinical presentation of superficial venous incompetence
• Image optimisation
• Limitations of the scan
• Unusual pathology and differential diagnoses
• Acting on urgent findings
• Scope of personal and professional practice
• Patient safety and communication
• Artifact causes and corrections
• Managing risks associated with venous Duplex imaging

Reflective practice guidance

The guidance below is provided to support reflection at different time points, providing you with questions to aid you to reflect for this training activity. They are provided for guidance and should not be considered as a mandatory checklist. Trainees should not be expected to provide answers to each of the guidance questions listed.

Before action

What does success look like?

• Identify what is expected of you in relation to successfully performing an optimised ultrasound scan to identify incompetence of the greater saphenous, short saphenous veins, and associated perforators.
• Consider how the learning outcomes apply, specifically in relation to assessing venous insufficiency and applying scanning techniques to complex pathophysiology.
• Discuss with your training officer to gain clarity of what is expected of you in relation to expected technical standards for reflux assessment, including patient positioning for provocative manoeuvres and criteria for identifying incompetent perforators.

What is your prior experience of this activity?

• Think about what you already know about venous anatomy (saphenous and perforator veins), venous haemodynamics, and scanning protocols for venous incompetence.
• Consider possible challenges you might face during the activity, such as identifying small or tortuous perforator veins, ensuring patient compliance for reflux manoeuvres (e.g., Valsalva), or dealing with complex anatomy or severe lipodermatosclerosis.
• Recognise the scope of your own practice for this activity i.e. know when you will need to seek advice or help, and from whom. You will need to seek advice from your Training Officer when required, for example for unusual anatomical variations or when equivocal reflux findings challenge the diagnostic conclusion.
• Acknowledge how you feel about embarking on this venous insufficiency scanning activity.

What do you anticipate you will learn from the experience?

• Consider the specific skills you want to develop, such as precise mapping of superficial and perforator veins, accurate reflux assessment techniques, and adapting scanning protocols for complex cases.
• Identify the specific insights you hope to gain into the comprehensive assessment of venous insufficiency and the influence of national guidelines on scanning protocols.

What additional considerations do you need to make?

• Consult actions identified following previous experiences of venous scanning (e.g., improving patient positioning or optimising Doppler settings for low flow).
• Identify important information you need to consider before embarking on the activity, such as current guidelines for venous insufficiency assessment and reviewing anatomical variations of the saphenous system.

In action

Is anything unexpected occurring?

• Are you noticing anything surprising or different from what you anticipate whilst performing optimised ultrasound scans to identify incompetence of the greater saphenous and short saphenous veins and associated branches/perforators?
• Are you encountering situations such as:
  • Patient fails to perform the Valsalva manoeuvre correctly or consistently, compromising the reliability of reflux assessment?
  • Difficulty accurately localising or confirming incompetence in small, tortuous perforator veins, complicating the mapping process?

How are you reacting to the unexpected development?

• How is this impacting your actions? For example, are you responding to the situation appropriately? Are you adapting or changing your approach to induce reflux or optimise small vessel visualisation?
• Consider the steps you are taking in the moment, such as:
  • Immediately switching to alternative provocative manoeuvres (e.g., distal augmentation or upright standing) to induce reflux
  • Adjusting Colour Doppler PRF and gain to maximise detection of low-flow, short-duration reflux in a suspected incompetent perforator
• How are you feeling in that moment? For instance, are you finding it difficult to adapt the scanning protocol to patient compliance issues? Is it affecting your confidence in comprehensively mapping all incompetent segments?

What is the conclusion or outcome?

• Identify how you are working within your scope of practice. For example, are you successfully mapping all required incompetent segments and confirming reflux duration? Or are you needing support because complex anatomical variations or equivocal reflux findings challenge the diagnostic conclusion?
• What are you learning as a result of the unexpected development? For example, are you mastering alternative reflux assessment techniques? Or gaining insight into applying precise scanning protocols for complex pathophysiology?

On action

What happened?

• Begin by summarising the key steps you took when performing the ultrasound scan for venous incompetence, focusing on the specific techniques used for reflux demonstration (e.g., augmentation manoeuvres) in the saphenous veins and perforators.
• Consider specific events, actions, or interactions which felt important, such as patient difficulty performing the Valsalva manoeuvre, challenges with reflux demonstration, or identification of an unexpected incompetent perforator.
• Include any ‘reflect-in-action’ moments where you had to adapt to the situation as it unfolded, for instance, immediately repositioning the patient or switching to distal augmentation to better demonstrate reflux when the initial manoeuvre was inconclusive.
• How did you feel during this experience, e.g., did you feel focused on systematic tracing or challenged by the technical demands of low flow detection?

How has this experience contributed to your developing practice?

• Identify what learning you can take from performing this scan. What strengths did you demonstrate, e.g., systematic tracing of superficial veins or accurate application of reflux measurement techniques?
• What skills and/or knowledge gaps were evident, e.g., unfamiliarity with the haemodynamic significance of different types of perforators or difficulty optimising Doppler settings for transient reflux?
• Compare this experience against previous engagement with similar activities – were any previously identified actions for development achieved? Has your practice improved in applying appropriate augmentation manoeuvres and systematically tracing vein segments?
• Identify any challenges you experienced, such as needing to seek advice or clarification on scope of practice regarding a borderline reflux measurement or escalating a complex case to ensure diagnostic accuracy, and how you reacted to this.

What will you take from the experience moving forward?

• Identify the actions or ‘next steps’ you will now take to support the assimilation of what you have learnt, including from any feedback you have received, with regards to improving the efficiency and accuracy of reflux assessment.
• What will you do differently next time you approach a scan for venous incompetence, for instance, by proactively reviewing the current guidelines on reflux duration criteria before the scan.
• Do you need to practise any aspect of the activity further, such as refining perforator identification or key learning outcomes related to scanning techniques to assess venous insufficiency?

Beyond action

Have you revisited the experiences?

• How have your subsequent experiences of scanning for saphenous and perforator incompetence since completing this specific training activity led you to revisit your initial approach or decisions during that activity? For example, how an instance where a subsequent patient required meticulous mapping of a complex web of recurrent superficial veins forced you to re-evaluate the rigidity of your initial segment tracing protocol you applied during your first attempt at venous incompetence assessment.
• Considering what you understand about venous insufficiency criteria, reflux assessment techniques, and anatomical mapping now, were the actions or considerations you identified after your initial reflection on this training activity sufficient? How have you since implemented or adapted improvements in your incompetence scanning technique based on further learning and experiences? For example, how you proactively reviewed and integrated the standard criteria for identifying incompetent perforators (e.g., size and flow direction) to ensure accurate mapping, demonstrating you have adapted improvements based on further learning.
• Has discussing challenges in demonstrating reflux or the impact of inaccurate perforator mapping on treatment planning with colleagues changed how you now view your initial experience in this training activity? For example, how professional storytelling with a vascular surgeon about a mis mapped incompetent perforator refined your understanding of the critical nature of precise anatomical and haemodynamic documentation for venous insufficiency.

How have these experiences impacted upon current practice?

• How has the learning from this initial training activity, in combination with subsequent venous incompetence scanning experiences, contributed to your overall confidence and competence in assessing venous insufficiency using ultrasound, particularly in preparing for assessments like DOPS? For example, how your accumulated ability in precise reflux assessment now enables you to confidently perform a primary venous insufficiency scan and identify and assess the thigh and calf perforators for patency and competence during a DOPS assessment.
• How has reflecting back on this specific training activity, combined with everything you’ve learned since, shaped your current approach to scanning for saphenous and perforator incompetence? How does this evolved understanding help you identify when something is beyond your scope of practice or requires escalation? For example, how your evolved approach means you now routinely seek advice immediately when complex anatomical variations or unexpected deep vein involvement complicates the superficial assessment.
• Looking holistically at your training journey, how has this initial superficial incompetence scanning experience, revisited with your current perspective, contributed to your development in meeting the objectives related to assessing venous insufficiency and applying ultrasound scanning techniques to complex pathophysiology? For example, how this foundational experience has supported your development in refining haemodynamic assessment protocols.

Relevant learning outcomes

#	Outcome
# 3	Outcome Assess venous insufficiency using ultrasound.
# 4	Outcome Apply ultrasound physics to correctly optimise an ultrasound scan of the lower limb veins.
# 9	Outcome Appraise the impact of research evidence on national guidelines.
# 10	Outcome Apply ultrasound scanning techniques to assess patients with complex pathophysiology.