Peripheral Venous Imaging

Module details

Title

Peripheral Venous Imaging

Type

Specialist

Module code

SPS130

Credits

10

Requirement

Compulsory

Aim of this module

This module provides trainees with the knowledge that underpins this third year specialist module in Vascular Science. It will provide trainees with the knowledge, understanding and practical skills to safely contribute to the diagnosis of acute lower limb deep venous thrombosis and superficial thrombophlebitis.

Competencies

#	Learning outcome	Competency	Action
# 1	Learning outcome 1	Competency Triage request for investigation of a patient with suspected DVT.	Action View
# 2	Learning outcome 1	Competency Set up equipment and room ready for a DVT investigation.	Action View
# 3	Learning outcome 2	Competency Control infection risks associated with DVT investigations in accordance with departmental protocols.	Action View
# 4	Learning outcome 2	Competency Minimise risks and hazards during the DVT investigation in compliance with health and safety policies.	Action View
# 5	Learning outcome 2	Competency Explain the procedure to the patient, address any procedure related questions they may have and provide information on how the patient will be informed of the results.	Action View
# 6	Learning outcome 2	Competency Obtain clinical history from the patient pertinent to a DVT investigation.	Action View
# 7	Learning outcome 3	Competency Gain informed consent for the DVT investigation.	Action View
# 8	Learning outcome 3	Competency Perform an ultrasound scan using B Mode to identify normal venous anatomy in the leg (above and below knee).	Action View
# 9	Learning outcome 3	Competency Perform an ultrasound scan using colour Doppler and spectral Doppler to demonstrate the haemodynamics of normal leg veins (above and below knee).	Action View
# 10	Learning outcome 3	Competency Perform an ultrasound scan to identify an above- knee DVT.	Action View
# 11	Learning outcome 3	Competency Perform an ultrasound scan to identify a calf DVT.	Action View
# 12	Learning outcome 3	Competency Perform an ultrasound scan to identify an incidental finding, e.g. Baker’s cyst, superficial thrombophlebitis.	Action View
# 13	Learning outcome 4	Competency Produce an interpretive report of investigations.	Action View
# 14	Learning outcome 4	Competency Recognise the pitfalls and limitations of the investigation.	Action View
# 15	Learning outcome 4	Competency Ensure results are given in a timely manner with appropriate action for urgent findings.	Action View

Assessments

You must complete:

• 2 case-based discussion(s)
• 2 of the following DOPS/ OCEs:

Perfom and analyse an above knee DVT scan groin to popliteal	DOPS
Perform and analyse a below knee DVT scan calf vessels	DOPS
Perform and analyse a proximal DVT scan Iliac veins vena cava	DOPS
Perform and analyse a superficial venous scan to assess for thrombophlebitis	DOPS
Perform and interpret a complete diagnostic scan on a new patient with suspected DVT.	DOPS
Perform and interpret a complete diagnostic scan on a patient with previous history of DVT.	DOPS
Perform and interpret a complete diagnostic scan on a follow up patient to assess for clot propagagtion of either superficial thromboplebitis or DVT.	DOPS
Perform and interpret a complete diagnostic scan on a morbidly obese patient.	DOPS
Perform and interpret a complete diagnostic scan on an immobile patient in a wheelchair	DOPS
Perform and interpret a complete diagnostic scan on an immobile patient on a trolley bed	DOPS
Introduce yourself to the patient and confirm their identity	OCE
Explain the DVT scan procedure and purpose to the patient	OCE
Obtain patient consent for the DVT scan	OCE
Obtain the relavant clinic history and symptoms pertinent to the DVT scan.	OCE
Prepare and position a mobile patient for the DVT scan	OCE
Prepare and position a patient with mobility difficulties for the DVT scan	OCE
Communicate with the patient during the scan to explain the practical aspects of the procedure e.g. compression	OCE
Explain exhalation inhalation or valsalva technique to DVT patient.	OCE
Explain the DVT scan findings to the patient	OCE
Explain what happens with the DVT scan results	OCE

Learning outcomes

1. Triage request for investigation of a patient with suspected DVT and prepare the room and equipment.
2. Prepare the patient and take a clinical history.
3. Perform scans on patients with suspected DVT.
4. Interpret, explain and report results.

Learning outcomes

1. Recognise and identify normal and atypical peripheral venous anatomy and pathology.
2. Explain the normal haemodynamics and physiology of the peripheral venous system and evaluate the numerous effects of pathology on blood flow.
3. Discuss and justify the clinical use of ultrasound in the diagnosis of acute peripheral venous disease, the linkages with other imaging techniques and the clinical importance in selecting the appropriate technique for the best management of the patient.
4. Discuss and justify the diversity and urgency of presenting signs and symptoms, and critically evaluate expected underlying haemodynamics and pathology.
5. Describe the expected co-morbidity associated with venous disease and evaluate the health and safety risks during the investigation and how they are managed.
6. Explain the infection risks associated with venous ultrasound and patients with suspected deep venous thrombosis.
7. Describe the principles of the deep venous thrombosis pathway and appraise the impact and consequences this has on diagnostic vascular services.
8. Interpret acute peripheral venous ultrasound images, associated spectral data and measurements
9. Critically evaluate the need to evaluate the age of thrombus and proximal extent.
10. Critically evaluate the need to convey complex scientific information to inform multidisciplinary teams of the diagnostic results, conclusions and consequences, in clear reports, in a clinically appropriate time frame.

 

Indicative content

Overview of peripheral venous disease

• Anatomy of deep lower limb veins
  • Anterior tibial veins
  • Posterior tibial veins
  • Peroneal veins
  • Gastrocnemius veins
  • Soleal sinuses
  • Popliteal vein
  • Femoral vein
  • Common femoral vein
  • Profunda vein
  • External iliac vein
  • Internal iliac vein
  • Common iliac vein
  • Inferior vena cava
• Anatomy of the superficial lower limb veins
  • Sapheno-femoral junction
  • Long saphenous vein (and branches)
  • Sapheno-popliteal junction
  • Short saphenous vein
  • Giacomini vein
• Anatomy of the perforating and communicating veins
  • Cockett’s perforators
  • Boyd’s perforators
  • Dodd’s perforator
  • Gastrocnemius perforator
• Presence and position of valves and valvular sinuses
• Morphologic variations of the vein anatomy
• Pathology
  • Acute deep vein thrombosis
  • Superficial thrombophlebitis
  • Chronic venous incompetence
  • Varicose veins, reticular veins
  • AV malformations
• Haemodynamics and normal physiology
  • Function of valves
  • Function of the calf pump
  • Effects of respiration on venous flow
  • Effect of pathology on flow
• Presenting signs and symptoms of peripheral venous disease
  • Acute DVT
  • Superficial thrombophlebitis
  • Varicose veins
  • Chronic venous insufficiency
• Associated co-morbidity and risk factors
• Imaging techniques
  • Ultrasound, venography, MRV
  • Correlation with histology
  • Natural history studies
  • Prospective studies
• Treatment
  • Medical management
  • Surgical management
• NICE guidelines

Ultrasound investigation of acute lower limb deep venous thrombosis and superficial thrombophlebitis

• Historical perspectives and criteria developments
• Peripheral venous examination technique
  • Risk assessment and infection control
  • Patient preparation
  • Explanation of test
  • History taking
  • Patient positioning
  • Scanning procedure and protocol
    • Infra-inguinal veins
    • Supra-inguinal veins
  • Interpretation and determination of disease severity
    • B-mode imaging interpretation of thrombosis
      • Luminal diameter and echogenicity
      • Compressibility
• Doppler imaging and spectral interpretation
  • Spontaneity of flow
  • Phasicity of flow
  • Augmentation
  • Pulsatility
• Accuracy of duplex scanning in the detection of acute venous disease
• Limitations, equivocal data, artefacts, conflicts and pitfalls
  • Suboptimal visualisation
  • Diagnosis within the pelvis
  • Bifid femoral venous systems
  • Excessive transducer pressure
  • Acute-on-chronic deep vein thrombosis
• Other findings
  • Baker’s cyst
  • False aneursym
  • Muscle tears
  • Haematoma
  • Abscess
  • Arteriovenous fistula
  • Popliteal aneurysm

Activities

• Identify a patient with a DVT requiring anticoagulation therapy and, with permission, follow the progress of the patient from the initial consultation through investigation, treatment and the follow-up appointment, and reflect on your learning from this process.
• Identify two patients with a DVT requiring anticoagulation therapy and critically reflect on the effect on the lifestyle of the patient and the role of the healthcare scientist in the diagnosis and treatment of patients.
• Observe a series of patients reviewed as new and follow-up patients and critically appraise the process of referral, diagnosis and treatment, including the range of healthcare professionals who contribute to the care of each patient and how the interprofessional team works together.
• Prepare a portfolio of case studies and images from a series of volunteers or patients that demonstrate the normal characteristics of lower limb veins on B Mode, colour Doppler and spectral Doppler, including variations in anatomy.
• Critically appraise the role of B Mode, colour Doppler and spectral Doppler in the assessment of lower limb veins, and reflect on the effect technique (particularly compression and augmentation) and patient positioning have on the images. A portfolio of evidence should include images obtained from a variety of veins (e.g. vena cava, iliac veins, femoral veins, calf veins, superficial veins) and clearly demonstrate the relationship with other structures used as landmarks (e.g. the femoral artery, gastrocnemius muscle, fibula) and the effects of technique and patient positioning.
• Prepare a portfolio of case studies and images from a series of patients that demonstrate occlusive and partial DVT in a variety of veins (e.g. femoral vein, popliteal vein, calf veins).
• Critically appraise the role of B Mode, colour Doppler and spectral Doppler in the diagnosis of DVT and reflect on how these modes are utilised together to establish a diagnosis, particularly in challenging cases (e.g. large legs, drug users). A portfolio of evidence should include images obtained from a variety of veins (e.g. femoral vein, popliteal vein, calf veins) from a series of patients and clearly demonstrate the presence of DVT.
• Reflect on each patient’s response to their diagnosis.
• Prepare a portfolio of case studies and images from a series of patients with incidental findings (e.g. superficial thrombophlebitis, Baker’s cyst, enlarged lymph nodes).
• Critically appraise the relevance of reporting incidental findings and reflect how these affect the patient’s treatment. A portfolio of evidence should include images obtained from a variety of incidental findings (e.g. superficial thrombophlebitis Baker’s cyst, enlarged lymph nodes) from a series of patients.
• Keep a portfolio/logbook of all clinical scans performed/observed noting challenges and risks encountered with reflections on learning achievements.