Duration: 15 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 56-year-old male presenting with heaviness in right lower extremity that is worse at the end of the day.
This is an interactive clinical case in a patient with non-sainous and saphenous vein reflux. He's a 56-year-old male who presented with complaints of pain, edema heaviness in his right lower extremity, which worse at the end of the day. From his history, had mycaian infarction three years ago. No allergies and he's an ex-smoker. His family history is unknown. During physical exam, he had prominent varicosis extending from the groin to the calf, as you can see in the images, and had normal arterial exam with palpable pulses. So this patient with varicose veins in the right lower extremity from the groin all the way to the ankle. We start the exam from the groin, and here you can see immediately the varicosis near the junction. Here we see there's a femoral junction. And we're going to evaluate first the common femoral vein. His normal flow. We place the Doppler in the center of the lumen. And as we see with the compression, there is no reflex. Next we go to the saofemoral junction. We see the first valve there. And there is a reflux in the terminal valve. Now we see the two veins, the anterior saphenous vein, which is the largest one. And the saphenous vein and clearly the reflex in the dilated anterior safurous vein. Extending from the junction to the accessory. Here is the motion of the valve. And I want to measure the diameter at the junction. It's dilated, measuring 11 millimeters. Now we will be the example with the Valsawa maneuver. There is a lot of reflex. And we look at the duration. And it's quiet for long. Next, we look at both veins. You see the tortuosity and the dilatation, the anterior accessory. The syphus is medial. Now with the diameter of these veins, it's the great typhus vein. And measures 7.4 millimeters. And here is the anterior accessory, siphon his vein. Measuring 10 millimeters. This is the great A vein in the long view. And you can see here on color and that the vein appears to be normal. And we're going to test it with a Doppler. And here we see the proximal great vein below the junction is normal. Now we're moving a bit further down with the diameter of the saf vein. And it measures 5.2 millimeters. Now focus on the varicos of the area is very big veins emerging from the arterial accessory going all the way the skin. Here are all the varios you see going up and down in the area. dilated tributaries coming from the canal of the accessory. Andy here, all these varicosis have reflux. Now we're moving on the safurist vein a bit lower down. You see the great saffist vein is dilated. And we're moving a bit more proximal, the proximal part of the sainus is a smaller diameter. You remember was normal below the junction. The diameter of the normal segment is 5.4. Millimeter and the dilated segment below. Images Just over 10 millimeters. I'm going to examine the area now with a color. And I see reflex is only on the dilated segment, so the very proximal GSV is actually normal. Very clear of the color box, the abnormality in the dilated area. And now we're going to take this area a bit farther down and the safron has reflex at the mid side. We're going to test with a Doppler. And here you see A prolonged reflux. In the middle of the thigh. The suffering is the cross-sectional view. It joins multiple varicosities in the mid distal thigh. There's a huge perforator there, and it goes in the area of the sartorius and under the sartorius. This looks like subsartorial varicosities. And you see on the top, the siphonous vein, the perforator underneath, and all these big varicose veins under the perforator. The siphonous vein at this level. Measures 7.7 millimeters. And a bit distal below the perforator. It measures 4.3 millimeters. Now we're looking The reflux in the vein and the vein clearly has reflux to the level of perforator, and the distal segment looks normal. So the reflex stops where the perfredo comes from. But the distal segment was not dilated is normal. I'm going to check now for reflex in this area and the dilated segment. And clearly Before the connections to subtoial veins, there is a lot of reflex. You can see now the big perforator right in there connecting the great Safni vein and then it goes down to the Deeper veins and clearly there is a big reflex here on this perforator. I'm going to test the perforator now with a Doppler and you see. There is a significant reflex. Here is a bidirectional flow basically, but there is a lot of reflex on this vein. You see the connection again nicely. And you can see now again with the color box. That the veins in the area of sartori muscle through the sartori and underneath. As multiple dilated tributaries. And As you see with the color box here, all of them have reflex, it's very prolonged. I hit the perforator again, coming back, it's a very dilated vein. I'm going to take the perforator better now and with the color is the prolonged reflex of the perforator vein. So it's a truly incompetent perforator it's very dilated. And here you see the prolonged reflex in the perforator vein. Now we look at the deep system to see if there are any prominent connections to the subsotoal plexus. This is the femoral vein which is dilated as the patient is on the standing position. And we look now with the color. The vein looks normal with the Doppler, and with the Doppler, the vein is normal as well. There's a little backflow, but that's normal. Now we see at the of the knee, multiple varicosities that emerging from the subsartorial plexus in the middle of the knee, and here you see there is reflex in this varicosities. multiple varicosities. But the extended for the subsartorial plexus. Down in the knee area. Now going up to make a panoramic view. And as you see now healorus muscle and these big veins. In the Sas Canal And as we're going down, You see extensive a request from the perforator in the sartorial area. And this feature is very good because you can appreciate the extent of the viricosities. Now we're looking at this tributary down in the knee area. You see the vein under the tributary, the saffron vein is hypoplastic, which only 1.6 millimeters. Where the tributary which is incompetent there. is measuring 5.5 millimeters. I see the very coast of this tributary very extensive in the Gulf. This tributaries is connected with the sub subtoa plexus. A reflex on the tributary, but the syphron vein is normal. So the vein is tiny. And Hypoplastic and mostly the reflex is on the tributaries. As you go down now, you follow the tributaries. In the cuff, there's another perforator here. It's dilated. This prefers typically a reentry, bringing the reflexing blood. To the system and you see on the color this a reentry perforator, there is no reflex. We tested Dopp a perforator vein just below the fascia. And there is no backflow on the release of the compression. It's clear the peripheral vein. It's dilated. Over 3.5 3.6 millimeters. But there is no reflex. Then we take The suffering is in itself now. Farther down is in Ili. Disclose the skin because the person is so much fat, and here the vein is incompetent. So we tested the doppling now the vein in the mid-calf area and clearly there is a reflex in the great from his vein. Then we look further down, you see multiple varicosities. It is a syphalous vein in the lower calf that means 4.6 millimeters. And then we look at the vein of the media maleus now. And the vein of Malaus appears to be normal. Going her up now again in the fossa area, poster media area is the multiple varicosartorial plexus. There's a lot of reflex in all these varicosities. And I'm going to go a bit more posterior to take the popliteal vein. The popliteal vein is right there and underneath the popliteal artery. We put the box in the right direction. To the left and see. There is no reflex in the vein. It's the pulsation of the artery just below the vein, and with the Doppler we saw very clearly that there is no reflex. In this deep vein. Now we're going higher up. You see some of the gastrocrimal veins. We're identify on top between the two gastrocuous muscles, the small sarinous vein, looks like a small caliper. That's the vein at the very top of the circle there. I'm going to miss the diameter. And the vein here measures 2.5 millimeters. We're going to take if there's any issues with the small side from his vein. See the vein all the way down in the upper calf now it is small as well. So the diameter is 2.2 millimeters. That some tributa is connecting here. So the vein gets a bit larger. Mr. Peter is coming from the great so in his vein. And now the vein has a 4.3 millimeter diameter, but we need to check if there is a reflex on the vein or not. We put the color. And you see very nicely with a Doppler now that there is no really reflex on this vein, so the vein is focally dilated and there is no reflex. After we finished the exam, we produce the color map as you see here. There's a reflex in the junction in the arterial accessory in multiple tributaries in the great saffronus vein. Then this segment of the sciferous vein is also normal, and there is this big perforated in the thigh connecting with the sartorial and subsartorial veins. And as you see here a combination of reflex in the sainous and non-sarronous system which are the subsartorial veins. These events were described first time by Dr. Sherman in 1938, but rarely been found in the clinical practice and reported. The veins can be having reflux together the great aus or on their on their own, giving rise to tributaries in the superficial veins at the knee and calf area. This concludes our exam. Thank you so much.
Content on this site is intended for United States Healthcare Professionals Only
