In this case study, Dr. Nicos Labropoulos and Dr. Adriano Souza provide instruction on how to conduct an abdominal and pelvic ultrasound examination on a 45-year-old female patient presenting with dyspareunia and feeling of heaviness in the abdomen.
I'm Doctor Nicos Labros from Stony Brook Medical Center, together with my friend, Doctor Adriano Sousa from Belarus in Brazil have prepared a clinical case on pelvic vein disorders. A female patient, 45 years old presented with spun and a feeling of heaviness in the abdomen. Since she was younger, she had a lot of menstrual cramps that were relieved after starting the use of oral contraceptives. She had two pregnancies the first in 2008 with normal delivery. After the first birth, she continued using oral contraceptive for five years. The second pregnancy was in 2013 where she had placet abruption and undergone a cesarean section. She used oral contraceptive for two more years. After the second delivery. Since 2019, she has been experiencing lower abdominal pain, feeling of heaviness in the abdomen, dys peria and fatigue. She does not have varicose veins in the lower limbs and has no hematuria. Pelvic viruses were found during endo vaginal ultrasound. Her BM I was 19.7 and she has no other medical issues. In a previous work of our 2018, we demonstrated that patients with pelvic vein disorders have a BM I usually of less than 25 and our ongoing study on left rear vein obstruction. We've demonstrated that most people with compression of V have a BM I of less than 23. She underwent a diagnostic li gray demonstrating pelvic viruses and signs of compression of the left comac vein by the right common iliac artery. The examination starts with the left renal vein with a transducer cross sectional view and see the vena cava and the aorta and the renal vein going across here, we can see that the left vein is compressed and with a color, we see mostly the flow is going towards the ovarian vein. Now we see on the blue color, the left renal artery and next to it, the left renal vein but not much blood going across to the cover he received again with the B mode view on magnification, the dilated distal left in a vein and the small size of the vein under the S MA, we measure the diameter at the compression site which is as you see very narrow, measuring only 1.5 millimeters. And then compared to the distal diameter where the vein is distant it, that measures nearly nine millimeters. And there are four who have a tight stenosis, the color on. Now we see the aorta and the renal arteries gonna take away from from the left renal artery. And you see the flow on the ladder being versatile and then go to the left final vein which the flow is slow to use as the standard velocity at the prismatic area, which is nine centimeters per second. And to compare it with the proximal renal vein in the post area where the velocity is more elevated, measuring 38 centimeters per second. Here we look at magnification that most of the flow on the left vein does not cross as a little bit of flow. Now, after we push a little bit distantly in the renal vein, and you can clearly see the small diameter of the renal vein as it crosses between the S MA and the aorta. The diameter here measures just over one millimeter. Now we continue the exam with the inner cover going a little bit lower down. Is it next to the aorta is the Vilna cover by the long view. And it's a beautiful basic flow and go towards the liver with the proximal vena cava. And this nice physic flow, the diameter opening and closing the respiration. And here we see the waveform of the vena cava. And since we are really close to the heart, the flow velocity is very phasic. We continue the examination with the left adrenal vein at the mid and distal level. Here we see the renal artery in blue adrenal vein in red and there are not any major collaterals and the flow is in the correct direction right after we tell the patient in the right, the cupid position and we check the arenal high loom paying attention to the renal veins and any potential collateral veins developing due to obstruction. Here, we see two renal veins and we make velocities from both. And as we can see the waveform in both in veins is normal without any collateral vein seen in the renal highland. Then we turn the patient in the left lateral could be this position to examine the renal vein for potential position compression. Here we see the top of the inferior vena cava with art below. And next to it, you see the left vein which in this position is much larger. The diameter here measures 4.4 millimeters and we continue by looking again the vein making sure it's wide open and taking away for. And here we see a phasic waveform without elevated velocities indicating that this patient has positional stenosis which is apparent with the patient in the spine position. Here, we see the vena cava moving spontaneously and resuming in to see more clearly the left final vein between the S MA and the AORTA. And it's very clear that there is no any significant aliasing and there is flow throughout the cardiac cycle. After that, we used the linear probe and examine the patient super position. You see the S ma, the aorta and the renal vein. This position being compressed and with a color box, we tried to find out the area of the high velocity. And you see the renal vein is tiny under the S MA and above the order. And the zoom view here you see the small diameter which measures only 1.7 millimeters. Then with the patient in the sudden position here, we see again, the renal vein come uniting the vena cava and like we saw on the left la the coitus, the vein is wider. And as you see in the spinal position, there's a significant difference in the diameter and the velocity. But in the latter, the cup, this position, the vein is much larger. Now with the patient in the superposition, we'll continue the examination over the left side to identify the left ovarian vein. Here, we see the leftover and went over the source muscle. It appears the red color in the middle of the box. And we the proximal area here where the left ovarian unites the renal vein. Right. In here, we can see very nicely or in black and white, the connection between ovarian vein and less in the vein. And at the proximate level, the left ovarian vein is dilated. And we're gonna see now here by looking at the diameter, it measures over 10 millimeters and just below that, it measures 6.4 millimeters. Then we see this zoom unification. The ovarian vein is spontaneous flow. Basically because in this position, the kidney empties the left ovarian vein and there is spontaneous high volume flow. As you can see here with the color. Now we're gonna put the Doppler to see the pattern of the wafer. And I said earlier, this is spontaneous high volume reflux because the kidney empties into the left ovarian vein. I will look at the section of you and a bit lower than the aorta over the sus muscle. We see the left of arient vein where at this level, we are part of the mid segment images 7.8 millimeters and clearly dilated. Then you use the zoom magnification a little bit more distally. This is the variant vein and you see the flow now again, this is spontaneous and is the same color as the external iliac artery thing on the bottom. Therefore, the flow in the ovarian vein goes in the wrong direction, the doctor to confirm and I'll take it away from from the exter iliac artery. And then I go to the left ovarian vein distally and both are below the baseline showing that the blood goes in the same direction. Then we turn back on the linear probe and see the ovarian vein with a linear transducer. And here you can see because we can angle correct and you can see better with the scalar box. Now the orientation of the direction of the flow and spontaneous high volume reflux in the less ovarian vein by the Doppler. And as you see here, a high velocity reflex, a bit phasic with the respiration and then it go a bit more distally and you see the high flow on the ovarian vein directly above the general a Carter, you see the variant vein and the iliac card have the same color indicating that the flow direction in the variant vein is the wrong way. Here. You see with the linear reducer, the waveform on the extra cat being above the baseline and in the variant vein above the base line as well, the normal of ovarian vein, the flow below the baseline is going towards the heart. Now we're going a bit lower down and we examine the part of the ovarian vein goes the variant plexus and this is multiple big veins in the ovary. So this is how the ovarian plexus forms the ovarian veins. And then a bit further down is the Perine veins and there's a big Perine veins that having reflux. And here we see nicely that the flow is actually faster because the kidney empties into the pelvis. So it's not like typical sluggish flow of the ovarian veins we see in people with adrenal issues. And here we go to the right of Arian vein and we are on the right side. Now, over the first muscle, see beautifully the inferior in a cover the vein here is normal diameter and it measures 3.7 millimeters and the color is blue going in the correct direction. Subsequently, we have the patient in the starting position and we look again at the ovarian vein. In this position, the vent vein is again dilated and a spontaneous reflex. But here, the reflex is a bit less than the supine because the renal vein is less compromised. And even the flow now is much less as the left vein is not as compressed in this position. Then with the patient in the spine position, with torso elevation, we can examine the per uterine veins. Here you see the uterus and the left side see a lot of big dilated veins. And again, you observe fast flow like being an outflow for the kidney rather than the slightest flow within the varicosities when there is no renal vein obstruction. Here, you see the veins are above five millimeters and are pathological. Some of them measuring eight and nine millimeters and the one at the bottom is actually almost 12 millimeters. We take the veins down on the right side. It's also dilated but not as much as on the left side. And this is the Perine veins on the right side which again above five millimeters here measuring eight millimeters. Again, pathological. So this presents dilate Perine veins on both sides which are worse on the left with the most typical pathology to see. Then we look at the color and you see the spontaneous high flow on the left and the right side of the uterus indicating this is outflow for the kidney and the vein is being dilated and tortuous because of the high flow, the result of the renal vein compression and the pregnancies. In this lady, you hear the flow is very fast. There's no slight use and spontaneous. Then we look at the iliac veins here, you see very nicely on the right side, the external iliac, the internal iliac and the common iliac, they see the artery on the top and these veins are normal and you see again the color, the normal flow on the iliac cartridge, the internal and the external and then higher up to the common iliac vein. On the right side, put the Doppler on the Teri iliac vein. The Teri vein has normal flow opposite the artery indicating no obstruction on the flatter vein. Now, with the same exam, the iliac veins on the left side. And here you see beautifully the inter iliac vein, the external and the common. And in between you see, the inter iliac artery has different color, opposite color than the vein. And the vein here has flowed below the baseline opposite of the artery indicating that there is no ipsilateral iliac vein obstruction. Then we continue the exam going towards the a bifurcation. And you see here the two arteries on the Arctic bifurcation. And underneath, you see the common iliac vein on the left side and on this position, it appears that the vein is smaller and we look now without putting any pressure on the producer, the diameter of the vein distally measuring over nine millimeters. And here is the iliac green union, that's a common iliac vein on the top measuring 10 millimeters. Then going further down me the external approximately that measures almost nine millimeters and the inter iliac vein that measures about 7.7 millimeters. This is the same measurements on the contra side. The common iliac measuring 9.7 the external iliac is 7.7. And the eter iliac here is a bit larger, measuring 9.9 exit the flow again, be normal on the ter iliac being opposite of that of the artery. Then we look carefully at the expression of the right commonly advance in a cover and it looks normal. So that's the commonly a vein more proximal and then you see the less common vein now right under the artery. So there is some alias in the air and the velocity somewhat elevated measuring about 68 centimeters per second. Then you go distally to compare the velocity, the two velocities to have the V two VN ratio. And here on the distal common iliac vein, the velocity is much less than the area of the stenosis. And here the velocity is 23 centimeters per second, which is almost three times less than the area of the stenosis. Again, this is the of the sno on B mode image. You see clearly there, there's the noise on the vein. The vein is narrow without putting any transducer pressure and right under the artery at this level. The vein measures only 2.3 millimeters. Here's the color under the artery, the vein is much smaller than the artery and the diameter using the color here is again, 2.3 millimeters like we saw every with a B mode. Here we use the zoom magnification to have a better view of the lumen of the vein. It's the lumen there and the artery compressing more during the cysto, during the cysto, the diameter of the vein is very small and this is the smallest diameter because during cystoid, the athletic is compressing more the vein, we basically less than one millimeter. And is it during diastole? The vein is bigger like we see here. Now measuring 1.3 millimeters. So we have several measurements showing that the vein has small diameter. And here you see, even if during diastole, if the patient completely relaxes 3.2 millimeters, pus would classify as significant stenosis more than 50%. The am the reduction. Now, we perform a BSA maneuver with the low pressure to allow good imaging. And here you see the vein diameter is opening up, measuring 4.7 millimeters. And now we elevate the patient. They see the torso being elevated, take the d of the vein, see the vein is much open than before and it's more physic. Now we're gonna put the patient on the starting position and here see very clearly the area of the compression that we saw earlier in the spine position, we optimize the the image. And here you see very nicely that the vein is much bigger. Now measuring 7.3 millimeters. So basically ba appears a positional stenosis and the floor. Now in this position, it looks fine without any aliasing like in many patients, the positional stenosis is evident like demonstrating these images. Here is the velocity distal to the stenotic area that is about 12 centimeters per second. A V two VN ratio of more than 2.5. When a present is diagnostic for more than 50% diameter stenosis. As we saw in our paper in 2007. In this patient, the velocity ratio was three. The mosaic color in the post area helps to identify the highest velocity. Here we see in the spinal position during the anterior stall, the vein has the smallest diameter. While in the same position during diastole, the vein is somewhat larger. In the standing position. The vein is almost five times bigger than that of the spine. In non thrombotic ive compression, the stenosis is more pronounced in the spinal position. The millibar diameter as we saw is seen usually during the stall in the standing position. The stenosis is often reduced while there is minimal diameter variation throughout the cardiac cycle. Here we see that in the starting position, the left com brain diameter is significantly larger while the velocity is markedly reduced. And here we have the direct comparison between the spine and subposition, seeing a significant change in the diameter of the vein. Therefore, in non thrombotic iliac vein, stenosis, we have to be very careful because often the stenosis is positional. Sometimes the stenosis can be fixed and find in all positions before treatment is decided. Such patients need to be evaluated in different positions to make sure that the patient has stenosis on the iliac vein. And indeed the science symptoms attributed to this pathology. Thank you very much.
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