These educational videos are intended to instruct the learner how to locate the distal great saphenous vein, the posterior accessory saphenous vein, perforator veins, and other veins in the lower extremity utilizing ultrasounds. Locating these veins, obtaining their measurements, and understanding their characteristics is vital to assessing a patient with lipodermatosclerosis, a condition associated with venous insufficiency. Understanding each patient’s individual situation is a key step in determining treatment options.
The evaluation of perforator disease with severe lipodermatosclerosis should begin with scanning the distal deep veins below the knee. The anterior tibules are on the lateral side of the tibia, and for the posterior tibial veins and perineal veins, you look for landmarks of the tibia and fibula on the medial side of the tibia. The arrow points to the ecogenic shadow of the tibia. The arrows point to the anterior tibial veins are located on the anterior side of the tibia down to the ankle. Comression maneuvers to rule out thrombus in the deep anterior tibial veins all the way down to the ankle. It is easy to compress the tibial veins in this location on top of the ankle. When scanning the deep veins of the distal extremity, a hand should be placed at the back of the leg to make it more comfortable for the patient. When applying pressure to collapse the top post tibial veins and the bottom perineal veins on the medial side of the tibia, as demonstrated, only leaves the arteries visible. Both sets look like barbells. The compressibility rules out thrombus in the deep veins. During the compression, the veins completely collapse. What is visible are just the arteries that are paired with the post tibial veins and perineal veins. Posterior tibial perforator noted breaking from the posterior accessory sainous vein through both the superficial and deep fascia to the posterior tibial veins. Scanning the posterior tibial veins. Post tibial perforating vein originating from the posterior accessory saffinous vein noted. A perittibial perforator originating from the distal great sainous vein to the posterior tibial veins. Additional perforating vein. Measuring the perforator. Perforator measures 0.61 centimeters, which is significant with the lepidermatosclerosis present, demonstrating advanced chronic venous insufficiency disease. This perforator can be contributing to much of the varicose vein process seen. Perittibial perforator originating from the distal GSV to the posterior tibial vein measuring 0.5 centimeters in width across the fascial plane. Posterior tibial veins compressible. Color box is steered to obtain reflux. Disal and proximal augmentation did not demonstrate reflux. Normal valve closure was noted. Measurement of location of perforator from the bottom of the foot and tibia over is marked with a straw. Flex the foot and remove gel. Measure from the bottom of the foot and tibial over. Measured 10 centimeters up from bottom of foot and back 11 centimeters from the tibia. Another posterior tibial perforator vein is noted above the last perforator. Measuring across the fascial plane 0.47 centimeters. Applying pulsed wave doppler to measure reflux. Augmentation with reflux noted. Measuring the reflux from the upstroke is 1.53 seconds. This posterior tibial perforator connects to the posterior accessory sainous vein. Perforator within the area of lipodermatosclerosis. Color flow and pulsed wave doppler identified 1.21 seconds of reflex demonstrated with augmentation. Measure from midpoint of the perforating vein, compress with a straw to make indentation on the skin. Measure from the bottom of the foot and tibia over. Measuring 19 centimeters up from the floor and 10 centimeters over from the tibia. Now scanning the SSV with the patient standing to observe the veins under hydrostatic pressure. SSV measures 0.26 centimeters in size, which is within normal limits. At this level, there are 2 perforators noted. One is medial of the SSV and one is lateral of the SSV. The medial posterior leg perforator measures 0.45 centimeters. The lateral posterior leg perforator measures 0.44 centimeters. Now the SSV measures 0.50 centimeters with the influx of the perforator veins. Measuring with a straw, the medial posterior leg perforator is 31 centimeters up from the floor. The lateral posterior perforator measures 0.36 centimeters up from the floor.
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