Duration: 12 minutes
In this case study, Dr. Nicos Labropoulos and Dr. Adriano Souza provide step-by-step instruction on how to conduct a pelvic and lower extremity duplex ultrasound examination on a 67-year-old female patient presenting with complaints of long-standing pelvic pain.
This is a case of pelvic and small sarinous vein thigh extension reflex. A 67-year-old female presented complaints of long studying pelvic pain. She had hypertension, controlled for medication. No recent sexual history. She has no diabetes, no allergies, and non-smoker. Her family history for the disease is unknown. On physical exam, vulva varicosis, reticular veins in muscular extremities, no edema, and palpable pulses with normal arterial exam. We start the exam with the patient in the starting position. The exam will begin at the groin. So we'll see right now the slight knee flexion and the vulva vertices. Coming in the posterior media thigh. And we can see some reticular veins on the left side of the screen in the thigh. That are more visible now. We start this in a femoral junction of the groin. This is a common femoral vein. It looks Payton You put the color on, see nice phasic flow. We test with the Doppler. And here we see normal phasic flow and no reflex after the distal augmentation. We continue with the junction. You see here the sainofemoral junction is very small, and it's normal flow and there is no back flow after the compression. So the saofemoral junction is normal as you can see right here. Now we can test with the Doppler and here it's easily seen. There is no back flow and the suffering is normal. Further down, the vein is really small. It's medial to the vessel inside the femoral canal, the syphus canal. And we're going to measure the diameter at this level in the proximal size. And the saffronist vein is less than 2 millimeters. This hypoplastic saffronist vein. The same thing in the mid thigh, the vein is really small. Magnifying the zoom, so the vein is really tiny. It's a hypoplastic vein in the Cyphrons canal and again here measures less than 2 millimeters. Going further down, the vein is small, going out to the middle malleolus again, the vein is hypoplastic. You see the circle next to. The tibial bone inside the Safron canal. And again we're looking at the diameter here. And it's less than 1.5 millimeters. So we're going to the fossa. You see the area of the valve is a little bit dilated. And the thigh extensively looks a bit smaller. Look at the small vein, the long view right now and the junction. And you can test the color. It is both the popliteal and the small sizes are normal. You can see the red color on the thigh extension, so there's reflex in the thigh extension. The red color is not easily visible on the top. So there is a small high extension of reflex. Put the Doppler now in the sainous vein near the safinopolial junction, and you see here the vein is absolutely normal. And then we're going to test the high extension. And here having reflux which is actually both systolic and diastolic during the compression and relaxation. I'm going to see you with a Direction of para Doppler very nicely. The reflex on the small thigh, the thigh extension of the sous where the popliteal and the sous are normal. And continue the vein cross section go head up. It's a small vein, as you see, go up in the lower thigh to the mid thigh. Gets follow the van again from The lower part of the thigh going up, she continues all the way. Toward the poster media thigh. Well, and now you can see actually the when's a bit dilate, there's a little bit of reflex. So basically we have a reflex in the thigh extension of the small syphenous vein. Now we're going to the groin area where the small suffer vein connects. And there's a lot of varicosis inside the uterus in the peri uterine area. And here is spontaneous reflex, and when you squeeze and the release, you see a lot of reflex in this area. We use the part of it again here you see the vast plexus of uterine and pericuterine veins on the right side. And here is a classic example of, you know, pelvic reflux in the patient presents with pelvic viruses and pelvic pain. Now I got a bit higher up to examine deeper in the pelvis and you see the dilated varicose on black and white. And they're using the color in this area and you see very distended veins. With a lot of reflex. After compression and release. So here you can appreciate the plexus going from deep inside the uterus all over the skin. Now we move to the left of extremity, start again with a common femoral vein. The vein looks normal. Fill it nicely with color. And by using the Doppler, we can appreciate that the valves are copy them. And I go to a femoral junction, you see the terminal valve closing nicely here. And there is no any reflex after the release of the compression. You can see here the vein immediately. The the vessels. Right now and see the stuff in his vein being normal. The vessels look good. There is no any signs of previous DVT. You can appreciate the large lymph node higher up, and here is the syphonous vein a bit farther down. Which is With small Like in the contarata side. And the diameter here is less than 3 millimeters. We look with the color And you can see there is no reflex on the vein, so the vein is normal like in the other side. Now we're going down to the cuff. In the ankle area, the vein is normal as well and it's small in size. Go higher up. The vein it says segmental aplasia and outside the canal. This this this accessory vein in the tributary. There is no vein in the canal and the vein at this level is normal as well. So the great vein is normal in both limbs. Now I'll go back to the popliteal space on the left extremity, the popliteal artery and the vein, we use a Doppler and the pupiliteal vein is normal. Then we examined the thigh extension, and thigh extension spontaneous reflexes as you can see. Boystolic and diastolic, we put the Doppler in the thigh extension. And the high extension is reflex, not as prominent as in the other side, but as reflex as well. The suffering is going further down. It looks normal. A small diameter You can put the zoom box now here to appreciate the vein a bit better. the vein looks a bit larger. Using the zoom And in this area you see the vein looks normal. Following the rain up and down in the cuff. And there are not any apparent varicosities. So in both legs this patient has reflex in the thigh extension. Go now again in the growing area. And you can see here multiple varicosities in the pelvis, and you can see here the big plexus inside the uterus and the pericuterine space. So this patient has a thigh extension that connects with the vulva viruses and The person having pelvic pain with significant varicos. Here we see the vein map on the right lower extremity, and you can appreciate the vulva of varicosities coming down, connecting with the thigh extension of the small syphronous vein, having reflex throughout its its length, while the great the small saffronous vein being normal and you can appreciate some reticular veins coming off the vein in the middle upper groin and extending in the medial and anterior thigh. In the left leg you can appreciate the same scenario where you can see the thigh extension being incompetent. Connecting to vulva varicosis while the small syphonous vein itself and the great syphus are normal, you can appreciate the segmental hypoplasia of the great syphalous vein at the upper calf and knee area. Now we move in the abdominal exam since this patient has pelvic pain and pelvic vitics. We start with the left renal vein. You can see here there's a spireric artery in the aorta below, and in between the blue color is a vein, then it's normal phasic flow has a good diameter, so it's fine. Now we're moving to the left ovarian vein which is really dilated. Now put the color box and now here you see the red color has a lot of reflex. And now we can test the Doppler. And you can see significant reflex. In the ovarian vein that is fairly prolonged. After this, we're going to move a bit further down the varian vein a bit more distally, and you can see now the ovarian vein being dilated there. And you can miss the diameter. And it measures 7.3 millimeters. And that's abnormal. Typically theva is 2 to 4 millimeters in size. I go a bit further down. We see the ovarian vein over the so muscle. We put the color box and you see again reflex on the vein. Over the sources muscle. I'm going to test this With the Doppler And again in the most distant part of the vein we see significant reflux in the left ovarian vein. And this concludes the exam. We examined both her extremities and the pelvic veins. This patient has, you know, pelvic reflex with pelvic viruses and pelvic pain, and unusual connection with the thigh extension of the small sarous vein in both lower extremities. Thank you very much.
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