Duration: 11 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 61-year-old female patient with complaints of burning in bilateral lower extremities.
This is a clinical case with recurrent reflux in the great softness vein in the left lower extremity and small softous vein reflex on the right side. A 61 year old female presenting complaints of pain, swelling, and burning in her lower extremities. So the previous ainectomy on the left side. CS hypertension, which controls one medication. And no allergies and never a smoke. has a positive family history of corona vious disease. On physical exam, she is obese as bilateral pitting or edema. And varicosis from the upper thigh to the foot on the left side. Palpable pulses and normal arterial exam. We start the exam from the groin on the left side, we have the recurring varicosities. Here we see the common femoral vein on the mode. Now with the color we see. Nice feeling with basic flow. And now with the Doppler we're going to check the vein for reflex. And here the valve is competent. Next, we look at the groin area where multiple small varicosis. There is no suchofemoral junction that's been previously disconnected. And you see here multiple varios in the growing area connecting with the common femoral vein. Which is typical image of recurrences in this area. And you see the varicosis reflux. And continue up in the closer to the sub kind of space you see a multiple questions. Now you see a leaf node with by request inside is the typically of Venus network. The No, this fibrotic and it's big varicosis, not having reflex as you see here with the color. Then we continue further down, see the varicotis continue the Safnos canal. This is not the syphenous vein. The syn vein has been removed, but there are multiple vari cause in this area. They have also prolonged reflex, as you can see with the color. Then some of the requests go outside the canal, close the skin that were visible on the previous pictures. They are very tortuous and dilated. And as you go up and down, you see the entry and the exit of these varicosis from the canal. These are pretty big veins continuing all the way down to the knee area. And here we can see that having a large diameter. And really slow flow as the person is in standing position is not moving. And you can see the saffron is vein, so this is the arrow. So the varicose is reentering the safus canal and have the saffronous vein with reflex at this point. So the safurous vein is missing from the knee to the groin. It's being removed the previous apinectomy, but the recurring varicose is a tributaries reconnects the sainus and the safous reflex from this point below. Here is the sainous vein, and you see the varicose connect on this point. It's a large vatices as you see here, measures the diameter. And this one measures 6.5 millimeters. At the point with the reconnection of the Great Afnes vein, this is the great Afous vein inside the canal now here. At the cross sectional view, you're going to miss the diameter. And the GSV measures almost 5 millimeters at the knee area. I got a long view, see the sluggish flow. And we're going to test with the Doppler for reflex. And here you can see the patient's spontaneous reflex when you squeeze and then release there is high velocity prolonged reflex in the knee area. of the color, the prolonged reflex. So now we can continue the exam. We see the soften his vein just below the knee. Now it becomes hypoplastic there. It gives a big tributary on the top. And you see that the two veins that change the diameter from the Great Sainus to the tributary and also the below knee area, the hypoplastic vein has reflex as well as you see the color. In fact, the sainous vein above and below the tributary and the tributary all have a reflex. You can test again, you can see very nicely the prolonged reflex in all three segments. Going a bit further down, you see now the saf vein there has a smaller diameter. I'm going to test the Doppler if it is a reflex or not, and here you see, despite the smaller diameter, the sainous vein has reflex below the knee. And we repeat the exactly the same. So it's confirmed this vein has reflex a bit farther down the Loriay, a big perforator from the tributor of the Great Ainuss. And we're going to test this vein here. The vers is really dilated. It's a little artery next to it, squeezed, and there is, there is no backflow, so this entry perforator is taking the reflexing blood from the softness and the tributaries back to the system. So you take the doppler for sure, squeeze, and when you release, there is no any backflow. So this perforator is copient, is a dilated reentry perforator. Next you see a pulsating artery. You're going to see the. pattern flow there. This is the pulsar flow of the artery. It's very important when we inject veins in this area, not inject the artery to avoid any skin damage. Now you go a bit further down, you see the safous vein near the medial malleolus. And squeeze and release it looks like a little bit of reflex on higher up, but towards the bottom of the vein looks to be normal. Just to check for sure I put the Doppler on. We check the synous vein now at the distal part, and as you see here, the distal part of the syphus is normal, it's competent. So now we're going to look at some veins that come anteriorly in the lower calf. They are visible during the physical exam. The veins are really dilated as you can see here. And There are more tributaries going up and down. Tortoise dilated in a spontaneous reflex as you can see here. I put the Doppler. And it's going to squeeze the food from this location and clearly this tributa has significant reflex. Now you go a bit further down in the foot area you see multiple varicoses very tortuous pushing the skin upwards. We saw them during the physical exam, and there is a lot of reflex in this area in the foot. So basically if you have varicose veins from the groin to the foot, all of the reflux involving also the main tract of the syphus from the knee to the ankle. Here you see the varicose again in a close view, very tortuous dilate all those reflex. Now go to the small sy from his vein, some slightest flow, some thicken the wall. And so there is some, you know, hypertension here from the long standing disease. But we going to test now with the color and on color there is not any backflow, so the vein is sticking well but it's actually normal. Just to make sure with a Doppler now. Taking the vein, squeeze, release. No back flow, so the vein is really competent. And we take now the Safinoopil junction. You see how the syphus connects the pop and the fossa. And you can see the flow now in color, and there is no any backflow after the release of the compression. Both the great, the small saurs in the public are normal. The small sa is a small vein between the two heads of the gastrous muscle as you can see here in the upper calf. It measures like 3.5 millimeters. Now we go to the other side. You see the contraramsa is a big vein is dilated. It connects the popliteal vein a bit higher up, and you see here the popliteal, the gastrocrimous vein, and the small saps on the top squeeze and release is clearly reflex in the small syphus with the popliteal and the gasocrimia being normal. Take with the Doppler and here you see the high velocity prolonged reflex. Of the saphenous vein in the popliteal fossa area. And here the color is very clear as well. We go a bit farther, you know, up, you see the connection, the junction right in here. And we're going to measure the diameter at this level. So this is the near wall, the far wall, and the small syphus which is almost 7 millimeters, pretty dilated. Go farther down you see multiple buters around coming from the saffronus canal and go towards the skin, but the saurus vein now, so it's a little bit dilated. But at this level with the color at least it doesn't seem to be reflex. If there's not any red flow. We test the Doppler to make sure. And I see here there's a little bit backflow, but there is not really reflex, maybe borderline reflex. And be further down is a big tributary reentering the small Sainuss just below the normal segment, so the venice is bigger now here as you can see. And we're going to test again in this area. So this is a lot of reflex, so the vein is normal on the top. It's a smaller area of, you know, with borderline reflex, but a significant reflex on the mid calf, as you can see with the Doppler here. Go a bit further down, the vein is dilated again, has a tributary that goes to the perforator in the lower calf, and as you can see here, the tributary and the cipherism have reflex, but is not reflexing below in the deep system. And after the ultrasound exam, we produced the vein map. Here you see the CF classification. The patient is varicose veins and edema, it's primary disease. The anatomy is superficial and physiologists reflex. Now we see multiple tributaries from the accessory vein which are extremely varicose and goes through a lymph node, and then it connects with the great safronous vein in the lower thigh and knee area. And as you can see, the black area indicates the previous sectomy and the absence of the great syphus vein and you can see it reflects in multiple tributaries both in the thigh and in the calf extending all the way in the foot. The small sarus vein here was normal. I will see the map on the next leg. Where we're having a reflux in the small syphonous vein from the junction all the way to the ankle, and the great syphonous vein is normal. And this concludes our exam. Thank you very much.
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