In the 1990’s it was discovered that a medical innovation of the 70’s, ultrasonic imaging, could provide more precise diagnostic information about veins than had ever been available before. What’s more, this information could be obtained rapidly and with virtually no patient complications, discomfort or inconvenience. The examination can easily be done in an exam room with equipment no larger than a laptop computer.
The ultrasound examination provides precise structural information about the veins in the leg, such as the size of the veins and their exact location. It can also reveal whether there is a thrombosis (clot) in the vein. This information alone has revolutionized the manner in which deep vein thrombosis is diagnosed. There are a staggering number (over a million per year) of patients who develop deep vein thromboses that break loose and go to the lungs. In the United States alone, somewhere between 100,000 and 200,000 people die each year from this condition. It is the second leading cause of sudden death, trailing only myocardial infarctions.
Besides providing structural information, the ultrasound examination also provides dynamic information about the veins. Specifically, it can tell which direction the blood is flowing, and the rate of blood flow. This information is vitally important in the evaluation of varicose vein disease, since in this disease blood flow in the veins goes in the wrong direction. The ultrasound examination can also determine if there is a condition known as continuous antegrade flow in veins, which is important to know when considering treatment for superficial venous insufficiency.
Beyond the invaluable diagnostic information that is available from an ultrasound examination, advances in ultrasound imaging have brought about the procedure known as ultrasound guided sclerotherapy. With this technique it is possible to precisely inject diseased veins that cannot be seen.There is one disadvantage with an ultrasound examination—it is very, very operator dependent. This means that the person doing the ultrasound examination has to understand the anatomy of the structure they are examining. What further complicates the examination is the ultrasound image bears little resemblance to an actual picture or x-ray of the structure.
The ultrasound image to the right is a good example of this. It is probably not obvious to the casual observer that this image is from a portion of the leg demonstrating a vein in longitudinal view, two veins in cross-section, a truncal vein fascial compartment, subcutaneous tissue, two muscles, and a hypodermic needle!
Ironically, most ultrasound examination operators are ultrasound technicians who have minimal medical training––certainly much less training than physicians, physician assistants, or nurse practitioners. It is possible to obtain ultrasound technician certification in only two years. However, the field of ultrasound diagnosis is ever expanding, and there are a number of areas that require ultrasound technicians to have further training and testing, such as the areas of breast exam, abdominal exam, neurological examination, adult echocardiography, pediatric echocardiography, fetal echocardiography, OB/GYN examination, and vascular examination.
Having said that, it should also be noted that the vast majority of ultrasonic technicians become quite adept at ultrasound examinations. Unfortunately, they tend to become better at ultrasound examinations than many physicians who order the examinations.
Consider the typical ultrasound training for vascular diagnosis. The emphasis is primarily on arterial disease and deep vein disorders. There is scant attention paid to the topic of superficial venous insufficiency––varicose vein disease. While the technicians may be trained to be able to diagnose simple reflux of the great saphenous vein, they probably will not have training in recognizing more advanced concepts such as alternative reflux routes, venous perforator incompetence, and continuous antegrade flow.Because of this, we have physicians (including radiologists) and ultrasound technicians come to the Willamette Vein Centré from all over the nation for training. A part of that training is to learn how to perform a complete ultrasound examination of the superficial venous system. To the left is an example of one of the slides we use in our training course.
Wherever you seek care for venous problems, you should see a physician who is able to do an ultrasound examination without sending you to some other facility. If you want the very best care, your physician should be more knowledgeable about performing the venous ultrasound examination than an ultrasound technician with two years of college training.