In this case study, Dr. Nicos Labropoulos and Dr. Adriano Souza provide instruction on how to perform an ultrasound exam for iliac vein compression on a 27-year-old female with dyspareunia, pelvic fullness, pelvic discomfort, varicose veins, and lower extremity and pelvic symptoms.
I'm Nicas Leopoulos from Stony Brook University Medical Center, together with my friend, Doctor Adriano Sousa from Belarus and Brazil have prepared an interactive clinical case of fac vein compression. A female patient, 27 years old, presented with pelvic and left lower limb symptoms in the pelvis. She had dysuria, pelvic fullness, pelvic discomfort and her symptoms were more intense during her period. In the left lower limb, she had varicose veins, swelling, tiredness and heaviness. She had one child with Cesarean section and family history of the vein thrombosis until the exam was normal and there was no other pregnant history. We place the patient in the supine position and we use the curved linear transducer. We start the examination from the left renal vein. The transistor is placed in the traverse view and we're seeing the vinna cover on cross sectional view next in a cava and over the aorta in a long view, the little vein is seen in black and white. We see the diameter of the vein opening and closing with the respiration without having significant stenosis. Now, we see that in a vein with a color and we see the vein extending from the infer in a cava. Although it past the order having normal diameter and being patent without significant stenosis. Next, we move in the imaging of the field in a cover the vena cava seen in the sort in the long view. In the long view, we see the vena cava filling fully with color, having no stenosis and having a normal wafer. Here, we would like to check in general if there is obstruction in the cover, hyperplasia, duplicated cover or even aplasia. Next, we move in the diesel cover until we go to the iliac vein union. It appears that the left common iliac vein has reduced the diameter compressed by the right comac artery over the fifth labor vertebra. Then we move to the right comac vein for comparison and we see that the vein is much bigger and the inter iliac has a red color and the exterra iliac has a normal diameter with a normal physic waveform. Subsequently, we moved to the left distal common iliac vein on the left, the left internal iliac artery is seen having normal wafer. The lateral internal iliac vein has reversed flow and a similar color as the artery. When we look distally, we can see clearly that the entire left internal iliac vein has reversed flow because the patient is le we are using the linear transducer to better evaluate the area of compression. Now, we're using the Zoom magnification to better evaluate the area of the compression we can see clearly that the posterior wall is thick, measuring three times the normal iliac vein wall. After that, we observe the vein and we look at the diameter is significantly reduced. Subsequently, we turn the color on and we see the aliasing and we measure the velocity right under the right common cart and the velocity is clearly elevated measuring 69 centimeters per second. Then we observe the scalar the entire approximately a vein. And we see that s narrow. Then we move to the distal iliac vein and putting the box parallel. And we see that the bay now is wider and we measure the velocity at the distal portion. And we see here that the velocity is much lower than the area of stenosis with a ratio of more than three. Now we move to examine the left ovarian vein, we place the probe left to the UBI likes and we identify the iliou muscle, the vein in parallel on the muscle. And I will put the color box to see any reverse flow. The vein here is normal diameter and is no reflex. We continue to look at the vein of the color. We do also a tapping in the area of the ovarian plexus and we see no reverse flow. Then we miss the diameter, the diameter is normal. After that, we move to the right side taking over the Swass muscle. We see the vein there is a little bit dilated and Now, in the long view, you see the vein is parallel to the muscle, we put the color box on and we clearly see that this vein has blue color towards the inferior vena cover. Now we attempt to image the Perine veins, the linear transducer, but it doesn't seem to be adequate. Therefore, we continue the examination with the external iliac vein. On the left side, the vein is dilated, its normal beautiful color feeling. Then you continue a bit further down on the part of the vein. You see some alien probably indicating stenosis from the guin a ligament. Then we measure the velocity at the end of the stenosis. And we see that the velocity is indeed elevated at the area of a measuring about 68 centimeters per second. Then we look with a color in more detail. And then we see here very nicely, the diameter reduction at the area of the inguinal ligament which is anterior to the vein. After that, we look more carefully to identify the area of the highest narrowing. And see the vein here is significantly reduced, measuring only a few millimeters. Subsequently, we put the Doppler to measure the velocity at the area of the highest stenosis. And here we see that the velocity is 107 centimeters per second, the person flex the hip and automatically the ligament is released and the di the vein is much larger and we measure the velocity in the same area. And here we see the velocity is significantly reduced, measuring 41 centimeter. Then we look in more detail than I am in the area. And from what we see here, the diameter is more than double than the resting position. At the end, we examine the patient in the same area. Use the vasa maneuver. You see the vein now is very dilated. And as we measure it, it's more than triple the size from the resting position. Many patients with non thrombotic iliac vein compression have normal veins in the semi erect or starting position. Therefore, in this patient, we're gonna do the baseline measurements as you see now on the supine. And right after we preparing the patient in the semi exposition to repeat the measurements, the patient is facing the examiner and the probe is placed in the same area. And as you see, the patient has positional stenosis and the iliac vein is wide open. You see the iliac vein between the right comac artery and the fifth lumber vertebra and is so much bigger than the supine position. You see the posibility of the artery over the vein, but the vein has a normal diameter which is very similar. There's zoo magnification here. And now we're gonna check during cysto the diameter of the vein which is over eight millimeters who plays the color on. We're gonna turn the box for better imaging and you see a spontaneous color flow under the artery indicating no stenosis significantly different from the image you had in spinal position. Now place a Doppler to look at the wave form and we're in the area of the previous stenosis. And as you see here, the way from each physic with a significantly reduced velocities measuring 21 centimeters per second. Subsequently, we're gonna put the patient back to the spine position and we're gonna tear them on the left bladder of the cup position because it's another position where the stenosis can be reduced or eliminated. Now, looking at the area of the stenosis, which is very nicely. The vena cava and the iliac vein at the artery, the iliac vein in a red color is wide open. And again, we're demonstrating that the normality of the vein. We continue the examination with a Kline transducer in the investigation of the peru veins, we identify the uterus and then with a color box, we locate the veins on the left side which are dilated and we're going to put the Doppler and typically because the veins are dilated and slow flow is shown on the image. Now, then we look on the right internal iliac vein which I just hear is very dilated and has a very high velocity because it drains both the left and the right lower limb. Now, we're gonna examine the inguinal ligament area on the semi erect position. Using the carline probe, you can see the vein is released having gala flow with no stenosis in this area. Since the patient is slim, we're gonna repeat the examination for the iliac venous stenosis in the semi requisition using the linear transducer. And here having much better resolution, you can see the vein is wide open under the artery and the artery is beating slowly over the vein. The empty is wide open, measuring around eight millimeters. This young female patient had the reflex in the Perine veins. While the leal vein in finna cava and ovarian veins were normal. She had stenosis of the left common iliac and left external iliac veins in the spinal position. The stenosis in both areas disappear in the sitting position. Therefore, in patients with non thrombotic iliac vein compression, it is important to examine them in different positions before a decision is made to treat the obstruction. Thank you.
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