Advanced Practice - Venous —
Training activity: 6

Details

Perform optimised ultrasound scans to identify deep venous insufficiency

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 deep 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 deep venous insufficiency.
• Consider how the learning outcomes apply, specifically in relation to assessing venous insufficiency and applying ultrasound physics to correctly optimise the scan.
• Discuss with your training officer to gain clarity of what is expected of you in relation to expected technical and diagnostic standards for accurately assessing deep venous reflux and differentiating it from chronic DVT features (Post-Thrombotic Syndrome).

What is your prior experience of this activity?

• Think about what you already know about deep venous anatomy, haemodynamics of deep venous reflux, and specific scanning protocols for deep venous insufficiency.
• Consider possible challenges you might face during the activity, such as achieving reliable patient cooperation for the Valsalva manoeuvre, accurately measuring reflux duration, or differentiating primary insufficiency from flow changes due to outflow obstruction.
• 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 indeterminate reflux findings or if suspicion of outflow obstruction (e.g., May-Thurner syndrome) arises.
• Acknowledge how you feel about embarking on this deep venous insufficiency scanning activity.

What do you anticipate you will learn from the experience?

• Consider the specific skills you want to develop, such as accurate deep vein compression, optimising the Doppler angle for reflux assessment, and precisely measuring reflux duration.
• Identify the specific insights you hope to gain into the diagnosis and significance of deep venous insufficiency and applying advanced scanning techniques in complex cases.

What additional considerations do you need to make?

• Consult actions identified following previous experiences of venous scanning (e.g., managing breathing artefacts or ensuring thorough vein assessment).
• Identify important information you need to consider before embarking on the activity, such as patient history of DVT, symptoms of chronic venous disease, and current guidelines for deep venous assessment.

In action

Is anything unexpected occurring?

• Are you noticing anything surprising or different from what you anticipate whilst performing optimised ultrasound scans to identify deep venous insufficiency?
• Are you encountering situations such as:
  • Difficulty achieving stable Spectral Doppler tracing or accurately measuring reflux duration in the deep system due to patient movement or subtle respiratory effects?
  • Suspicion of an underlying outflow obstruction (e.g., pelvic compression) that may be influencing the measured deep venous reflux severity?

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 optimise Doppler angle or check for flow-limiting conditions?
• Consider the steps you are taking in the moment, such as:
  • Immediately using a small, focused Spectral Doppler gate to accurately capture the reflux duration in the deep vein
  • Halting the reflux assessment to perform a quick B-mode and Colour Doppler check for signs of outflow compression in proximal segments (e.g., external iliac vein)
• How are you feeling in that moment? For instance, are you finding it difficult to adapt to the technical demands of accurate measurement? Is it affecting your confidence in the resulting diagnosis of deep venous insufficiency?

What is the conclusion or outcome?

• Identify how you are working within your scope of practice. For example, are you successfully completing deep venous reflux assessment using standardised measurement criteria? Or are you needing support because the differentiation between primary insufficiency and flow changes secondary to suspected outflow pathology requires senior review?
• What are you learning as a result of the unexpected development? For example, are you mastering accurate deep vein compression techniques? Or gaining insight into applying advanced scanning techniques in complex venous cases?

On action

What happened?

• Begin by summarising the key steps you took when performing the ultrasound scan to identify deep venous insufficiency, detailing the specific deep veins assessed and the methods used to demonstrate reflux (e.g., Valsalva manoeuvre, distal cuff inflation).
• Consider specific events, actions, or interactions which felt important during the scan, such as challenges with demonstrating deep vein reflux due to abdominal pressure, patient tolerance, or assessing post-thrombotic changes.
• Include any ‘reflect-in-action’ moments where you had to adapt to the situation as it unfolded, for instance, immediately adjusting the Doppler sample gate position or angle to accurately measure reflux duration when encountering turbulence.
• How did you feel during this experience, e.g., did you feel focused on applying augmentation methods or challenged by the ambiguity of the flow dynamics?

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., understanding complex flow dynamics or accurate documentation of reflux duration in milliseconds?
• What skills and/or knowledge gaps were evident, e.g., unfamiliarity with differentiating severe insufficiency from outflow obstruction or difficulty consistently assessing deep venous valves?
• 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 methods for deep veins?
• Identify any challenges you experienced, such as needing to seek advice or clarification on scope of practice regarding a complex post-thrombotic change or escalating a case suggesting proximal outflow obstruction, 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 precision of deep venous reflux assessment.
• What will you do differently next time you approach a scan for deep venous insufficiency, for instance, by proactively using specific breathing instructions for patients to improve the reliability of the Valsalva manoeuvre.
• Do you need to practise any aspect of the activity further, such as refining measurement techniques for reflux duration or key learning outcomes related to assessing deep venous valves?

Beyond action

Have you revisited the experiences?

• How have your subsequent experiences of scanning for deep venous insufficiency 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 scan revealed post-thrombotic changes complicating reflux measurement forced you to re-evaluate the technical rigour of your initial reflux duration assessment technique you applied during your first attempt at this training activity.
• Considering what you understand about deep venous reflux duration criteria, provocation manoeuvres, and the influence of outflow obstruction 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 deep venous insufficiency scanning technique based on further learning and experiences? For example, how you proactively reviewed and integrated protocols for differentiating primary insufficiency from reflux caused by proximal obstruction, demonstrating you have adapted improvements based on further learning.
• Has discussing ambiguous deep venous reflux findings or the impact of inaccurate reflux duration measurement with peers or colleagues changed how you now view your initial experience in this training activity? For example, how professional storytelling with a senior colleague about a case where borderline reflux measurement led to clinical uncertainty refined your understanding of the critical nature of precise haemodynamic documentation in the deep system.

How have these experiences impacted upon current practice?

• How has the learning from this initial training activity, in combination with subsequent deep venous insufficiency 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 accurately measuring reflux duration now enables you to confidently perform reflux assessment of the deep venous system 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 deep venous insufficiency? 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 suspected iliac vein compression (e.g., May-Thurner syndrome) arises, recognising this requires specialist evaluation beyond routine peripheral venous reflux assessment.
• Looking holistically at your training journey, how has this initial deep venous insufficiency scanning experience, revisited with its 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 principles for complex venous cases.

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.