Duration: 14 minutes
In this case study, Dr. Nicos Labropoulos and Dr. Adriano Souza provide step-by-step instruction on how to conduct a lower extremity ultrasound examination on a 60-year-old female presenting with complaints of mild leg discomfort that is worse at the end of the day.
We're going to present a clinical case with anterior sulfurous vein reflex. A female patient, 60 years old presents complaints of mild leg discomfort being worse at the end of the day. She had 3 children and hysterectomy 4 years ago. She has high blood pressure, controlled for medication. No diabetes, no no allergies, and she never smoked. She had a positive family history for being sufficient in hypertension, and during the physical exam, she had varicose veins in the middle aspect of the thigh, as you see on the picture and Varicosis in both anterior aspects of both legs. There is no edema or skin changes, and the pulses are normal. We start the examination at the femoral junction. The probe is placed obliquely at the junction to demonstrate the common femoral vein and the syphalous vein. Here you see cross section, the artery and the vein and the junction. And going up and down slowly to demonstrate all three structures very clearly the junction. And now we're going to turn the color on and we see here the reflex at the junction. Is the blue color flow forward and the red color reflex. And you can see here the valve very nicely, the flow jetting backwards to the softness vein. Now we're going to put the Doppler to calculate the reflex time. And we started a common femoral vein. And then squeeze the cuff and as you see there's a little backflow indicating that the vein is normal. And then it continue with the junction, the same thing, and here clearly this prolonged reflux, more than 5 seconds. And you can see very nicely we try to put the Doppler in the area of the highest color. I go to the black and white, take a nice view, see the image very well, and I'm going to estimate the diameter starting from the near wall or anterior wall to the posterior wall. You see here it measures 11.3 millimeters. It's very dilated at the area of the valve. I'm going to continue a bit further down cross sections of the two lymph nodes there, and the vein is parallel to the deep veins. So basically this is the anterior saurous vein, not the great syphus, and characteristically this vein at this level is accompanied by lymph nodes that we saw back and forth on this image. A bit further down, you see the vein is still parallel to the deep system, so clearly is the anterior sainous vein. We'll continue the exam now a bit further down. I see the vein is really dilated in the Saus canal. Now it goes a little bit more medially. And we're going to look at the diameter again. And here it measures 5.8 millimeters. And continue the exam a bit further down, but from the lower side to the mid side, you see very nicely as you go a bit higher up, the vein is part of the system. Which characteristic of the anterior accessory vein. And now the long view, I see the the artery and the vein, and I see the vein at the top with a spontaneous contrast. And it's nice to see all three vessels together so you know for sure that this is the anterior soft vein. And we go up, you see the lymph nodes again and the inferior gastric vein on the top and the junction. And then going further down again on the long view, you see the spontaneous contrast. And going to test the venues for reflex, put the color and the Doppler. And squeeze And release and you see here a lot of reflexes, more than 5 seconds. And if we put the entire reflex, it goes beyond one screen as you saw just now. Then continue the exam a bit further down, you see very nicely a big tributary emerging from the safous vein here. And the tributer is larger than the vein itself. And it goes close to the skin. And because these varicose veins that go across the skin, this we saw on the initial picture of the patient, right, the varicosis at this level below the skin and visible. And clearly there's a lot of reflex and we saw the color picture. You see here a valve, the valve is immobilized and now we measure the tributary on the top and the varicose, you see, they measure 4.8 millimeters. The same thing on the long view and you see all the varicosis, you know, it's the same vein going in and out in the hypodermis. And the spontane contrast. And when you put the color, it's easy to see the person has a lot of reflex. So this reflexes in continuity with the accessory vein, and these are the exact particles saw on the skin earlier. Now we look further down Gui area. And you see the vein is dilated at the knee right there. And we're gonna take with color box again. And it's clearly reflex. You see the typical pattern of reflex in the valve area, the small dilatation of the vein there. You see the knee below, I see the bone. I'm gonna examine the diameter of the vein at the knee level. Always start from the near wall or anterior. The far wall is called posterior and the measures here 5.8 millimeters. Go I go down to below the area I see the vein there. Continue to have reflux. And with a Doppler, that's the duration, and you see really high velocity and very prolonged reflex, more than one screen, it's usually more than 5 seconds. And then going even further down I see multiple tributaries, some perforating veins below the sainus. And you see back and forth the tributaries and the varios it is in the middle aspect of the lake and now in the long view, you see now in the vein in there and also there is reflex. And farther down The ve got a bit more superficial. And again it reflux as a tributary bringing blood into the vein where the blue color is. So the bi has normal flow and it's feeding basically a reflux into the syphous vein. As you go further down, you can see very nicely the saf this vein here. And you see some valve stations and the tributary have normal flow, but the sufferers having reflux. Then you go a bit further down. You see the vein into the center there. I'm going to look at the diameter again. And start again from the near far wall and the here measures 3.8 millimeters. I see the vein sticking. And put the Doppler to see the duration of reflex here, squeeze, release, and again, there's nonstop reflex more than 5 seconds. Now continue the examiners further down, you see some tributaries emerging from there. And you see the tributary has a normal flow where the sufferings when his reflex. I see the beautiful now, the demonstration of the tributary having normal flow gonna test this Doppler. As the tributary has flow below the line, which is normal. So basically, all these flow goes is the sainous and is reflexing to the lower segment of the saphauss. And then as we move further down now below this tributary, the vein is thickened and sclerotic and there's a lot of reflex past this tributary. Further down, it's more tributaries that go right off the skin area. It's a perforator near the tibia. On the left side of the screen with the color on and the perforator is a normal flow. This is a reentry perforator basically. With the Doppler now? I see there is no reflex. So this tributary perforator reentered the blood from the sainus into the deep system. And going out to the lower part, me to lower calf. I see this happens again. There is a reflex there as well. But it's not as much as it was prior to make sure that there's a true reflex, we're going to put the Doppler. I see the duration. And here actually is a bit of backflow, the pain is normal to be reflexes with more than half a second and here is basically less than 100 milliseconds. So the reflexivity stops at the mid calf. And the vein here, the normal take measures. 2.7 millimeters, which is much smaller than the reflex segments above. I'm going to examine the very last part. You see another perforator here pacing the fascia. The sci is really small on the side. And the perforator is also normal. And then we see multiple veins, and this is the vein of the medial malleolus. So this is the one of the last parts of this happens to do the exam. And the vein here is absolutely normal. And let's see now the last diameter here in the media maleos area and the veen measures 3.2 millimeters. Now we're gonna go to the interior segment because there are some tributaries seen there. See where they come from, where are they going to. This is the, the bone and autopsy the varicosities. And you see they go around and they meet the synous vein. You see that the vein is really dilated. And it goes around over the bone and the tributaries on the patient shin are basically the varicoses that are coming from the syvein down to the anterior part of the calf. It's I know, pretty decent sized varicosities. And I'm going to look again what's the diameter. And this varico here measures 5.7 millimeters. I think another dect Barrios were from the sufferers is probably larger. The diameter here is over 8 millimeters. And here you see in the long view, the multiple varicosis over the bone. And all of them have significant reflexes you see here. I look one last time, the sainous vein there. I see the long view. This is the artery in the vein. This is the femoral vein on the bottom, the artery on the top. Take the femoral vein for reflex. Put the sample volume in the center of the lumen. repositioned the box. And put the Doppler. And squeeze the cuff and basically the vein is normal. There is no reflex. See the artery pulsating on the top and the vein is clearly normal. So there is no deep vein reflex on this patient. Then we're going to tell the patient. Facing away from us and we're going to start looking at the Safino reduction area in the fossa. We still are on the left extremity. You see on the top of the small saurs vein, the gasocrinal veins, the polial, and the poiteal artery.al artery in vein. The vein is the biggest vessel there. You see very nicely It's clean, right? There is no backflow. We're gonna test the steadyflux. And squeeze, hold it to release, and definitely there is no backflow, so the popliteal vein is also normal. And now we're going to look at the area above the popliteal vein, a little bit more proximal, and we see the small sufferings on the top and the gastrocranial veins. The size of the syphus looks normal. We look at the small shove in the long view. Correct the box orientation and the vein is normal. There's nothing wrong. And you go a bit lower down in the calf area and you see here the saphenous vein is sometributers and a perforator vein in the gastrobu muscle. And we're going to test all the vets at the same time with the color. And there was really nothing wrong there. You see the saffron is very now the meat calf, and it's normal as well. So basically this was a Doppler just to make sure. Squeeze, hold it, and release, and there's no backflow during the release. So the small saphous veins as well as the deep veins were normal on this patient. Here is the Venus map demonstrating the pattern of reflex in the left lower extremity. The GSV had aplasia from the groin to the knee. The anterior saphenous vein was the main superficial vein in this area, and it connected to the GSV at the level of the knee. The small softness in the deep veins were normal. It is important to have the vein map constructed accurately so we can plan the treatment and also in the follow-up examinations to know if there is any residual or recurrent disease. Thank you.
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