Duration: 15 minutes
In this case study, Dr. Nicos Labropoulos and Dr. Adriano Souza provide step-by-step instruction on how to conduct a duplex ultrasound examination on a 55-year-old female with varicose veins and complaint of burning and claudication.
This is a bilateral GSV and SSV reflux case in a patient that has mixed arterial and venous disease. A 55 year old female patient with varicose veins and complained of burning and claudication presented to our clinic. It's history of diabetes, hypertension, taking enalapril and insulin. It's a carotid disease with 4 to 50% stenosis bilaterally. Peripheral arterial disease with more than 50% stenosis of the left SFA and occlusion of the left arteriotibial artery, and eradication distance of 200 m. So no allergies, and she never smoked, and her family history for venous disease is unknown. On physical exam, just bilateral skin discoloration, no edema, and bilateral varicose veins, more prominent in the calf. Now we start the exam in the right politeia fossa. We see the small vein on the top and the gastromal and popliteal vein below. So you going up and down the skin crease, and now we see in the long view the small side finish on the top which has a reflex. You can see the vein valve there in the puppy on the small saphenous vein. And it's a lot of reflex through the valve. We take a little bit higher up on the thigh extension, and this seems to have reflex as well. I'll put the Doppler to measure the duration. And here we see a prolonged reflex in the thigh extension of the small saf vein. The vein there is close to the skin, so it means the distance. From the epidermis to the near wall and it's 2.3 millimeters. We're a bit higher up, so the veins still close to the skin is dilated, goes towards the posteror medial thigh, and there's a lot of reflex, as you can see here. Then it continue and now the vein connects the great saphenous vein. So this is the thigh extension of the small sainus moving posterior or posterior medially to connect to the saphenous vein near the junction. The vein here is the saphenous vein connects to the thigh extension, dilated. This is the syphus vein itself, and as you see here, there is a lot of reflex. In the growing area. So the measure the diameter now there is over 5 millimeters. Go now further down. She there The area of the fossa, the teal vein is normal below the sap vein. That's what we got in again. A bit more distally. I see a small saf on his vein on the top has reflex. The smaller diameter. I take with a Doppler. And here we see both systolic and diastolic reflex. In the small siphon vein in the upper calf. Go a bit lower down. You see the y is vein there now at the mid calf. And you can see there's a reflex here all the way down. Despite the small diameter of the vein. And here we see a reflex. Higher up On the siphon his vein These are on the medial aspects of the leg. Now we see the great sty from his vein in the lower thigh. Now we move up in the groin. And you see here a very nice femoral junction. I see the inferior epigastric vein and the reflex just below the inferior epigastric with a terminal valve being normal. So here nicely you see how the inferior epigastric. Is feeding The area below the terminal valve having a lot of reflux in the great sainous vein. You can hear very clearly the terminal valve is intact. No flow is seen above the inferior gastric vein. Going a bit further down now you see the stasis. So the connection nicely with the common femoral vein. Look at the vein in the transverse view, the valve there is moving, but it's not closing back. So the vein is dilated in the upper thigh. Gum is the diameter. And here is over 10 millimeters. When further down is the stasis of blood on the syphonous vein. It's a tributary in this area. And here is basically the, the connection of the thigh extension to the great toughness. And they get often is dilated and there's a reflex in the thigh extension as well. So she reflects both in the thigh extension and the sainus here a little bit farther down in the tributary who actually brings flow into the sainus. In the knee area of multiple varicositis and clearly all reflex below is the great vein. Nice. is now in the lower part of the calf. The vein is a small diameter. Now we move to the other leg and you see here nicely. The saphenous vein here. This is the inferior gastric vein which is a bit dilated. The sing this vein is dilated itself. There are multiple varico in the groin. This is some. I live on Venus networks. And clearly there's a lot of reflex. We see he's a valve not here, the terminal valve and the terminal valve. And here is a reflex On The siphon his vein, it's prolonged. You see, the terminal valve is not moving. You test the Doppler in the preternal valve area. And here we see a lot of reflex. In that great tough in his vein. In a growing area. You're a bit lower down, you see the saf vein there, and the Saffron canal. The dam draws the vein at this level. Measures 5.7 millimeters. And a bit more distal on the long view, is the stasis. And prolonged reflex see with a color Dopplers, the duration. And here have high velocity prolonged reflex in the apron vein in the thigh. Now we move a bit farther down the lower side 2 it is even more dilated in here. And the diameter here is larger. And it measures almost 8 millimeters. And we're in the knee area now and you see the distance from the skin. It's again very small. It's 2.8 millimeters. I see the multiple varicosass emerging in this area. You can see Azeni. Just below a You see this great vein out here being dilated to a mobilized valve which are 6 millimeters. A tributary coming in. This is a valve is and there's a lot of reflex at the knee level. So I have a reflex from the groin to the knee so far. And then got a bit lower in the in the calf, the ankle area, the syphalous vein has a smaller diameter. And this area appears to be normal. The diameter is very small. Here is a perforator. The transition from the reflex to non-reflexingainus, and you see the perforator right there. I see the proximal part of the calf. is having reflex and a great toughness. Here is the reentry perforator which flow only towards the deep system. So you see the flexing blood is entering the perforator to go back to the veins. We can test with Doppler to make sure. And When squeeze and release, blood is only in the normal direction, so there is no reflex. This is a reentry dilate the perforator. Now we look at the popliteal fossa. The small saffronous vein is dilated, connecting with the popliteal vein. You see here the connection of the small sainus, the safronnopolial junction, and there's reflex from the popliteal vein to the junction where the gas or cremeous vein in between is normal. You know for the Doppler And I see very clearly the high velocity prolonged retrograde flow in the small sain. Here you see the high extension of the syphus a bit higher up the pot below. I see all three veins together. With the diameter at the Sarona Junction, which is 6.2 millimeters. This is a political way now. Here is the the potial vein having reflex, and it is typical reflex because of the large junction sucking blood into the small sos. If we go distally, this is the potial vein here. Below the junction. And here you see it is normal, so the proximal mobility reflex is related to the reflex of the small sainuss, and when we treat the minus, this reflex will disappear. Here you see the syn vein in the upper calf. It's dilated, having a large diameter, measuring 8.4 millimeters. I see a big tributary coming in and joining the Safe vein right there. You see a lot of stasis in this dilated vein with a reflux, and here you see the clear reflex in the. Small siphonist vein. Megacarchemia veins below it are normal. It's nicely a better view of the tributary join in there. A small sip his vein in the upper calf towards the fossa. Here you see the popliteal vein, the more syphonous vein, the thigh extension above the small syphonous vein. You see the nerve right here with the arrow with the tibia nerve. It's very close to the Mosafius, so it's very important to observe those things to avoid any injury when you do thermal ablation or other techniques. So this is the valve on the on the small sap in his vein. There's clear reflex in the upper calf. We're going to test now with the Doppler. And here we see high velocity prolonged retrograde flow in the small syphonous vein. You're a bit farther down, that's a small it's multiple tributaries that they connect in the upper calf. The saffron is in the canal, the valve right there. The valve is not moving. And you can see some back flow even on black and white. At this area of the immobilized valve here the color is very clear. It's prolonged reflex and the valve is not moving at all. It's a frozen valve. We're going to take this with a high definition zoom real time. And you see here the valve is not moving one way compressing the muscle distal to it. And then you go further down, the vein still looks a bit dilated. And now we're going to test the vein here again. It's getting a bit smaller further down, but still has reflux. I'm going back to the opal fossa to examine the thigh extension. And the thigh extension is a bit dilated but normal. There's no reflex on the thigh extension. And this is the Doppler And you see the thigh extension of the smallest in his vein has no reflex. This is the syn venal vein which is very dilated. This is the junction. You see here nicely. The slag is flow in the poultia and the Msafinus. And like so here at the end, a normal valve, you see the valve is opening and closing, and it's a high definition zoom. When you screeze and release, the valve is closing nicely, not allowing backflow. After the examination, we produced a vein map, and here you see on the right lower extremity. There's reflux in the saphenous vein for the preterminal valve all the way to the upper calf with reflex multiple tributaries and also reflex in the thigh extension of the smaller syphonous vein that connects with a great sarinus near the groin. On the left of the extremity of reflex from the femoral junction all the way to the mid calf. With a reflex in multiple tributaries and the networks in the groin. With big varicosis in the knee area and also reflex in the small syphonous vein from the junction to the mid calf and the intersyphonous tributaries that they connect both veins. Let's conclude our exams. Thank you very much.
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