In this case study, Dr. Nicos Labropoulos and Dr. Adriano Souza provide instruction on how to conduct a duplex ultrasound on a 46-year-old male patient with history of iliofemoral deep venous thrombosis. The patient presented with pain, edema, varicose veins, and skin discoloration of bilateral lower extremities.
I'm Doctor Nicos Larolos from Stony Brook University Medical Center. Together with Doctor Adriana Souza, I have repaired a post thrombotic case of obstruction in the right femoral veins. This is a male patient, 46 years old, who presented with pain, edema, varicose veins, skin discoloration in the right lower limb. He had surgery for rap orchidism when he was 7 years old. Phlebectomies in his right calf for varicose veins were performed at the age of 16 years. 9 years ago, he had a superficial vent thrombosis in the right calf after a 3-hour flight. 3 years ago underwent bilateral phlebectomies and creates been stripping in the right lower limb. In March of 2020, started working at home due to the pandemic being less physically active. During the first week of August, he developed edema, extending into his thigh, and he was diagnosed with ileofemoral DVT. The arterial system was normal and no other risk factor was present. From his family history, two of his sisters had DVT, one of whom had 2 episodes, while his mother had varicose veins. He had bilateral edema, right, worse than the left, pain, varicose veins in the calf, and skin discoloration. We start by measuring the circumference in the two lower calves. On the left side, we see now that the circumference measures around 39 centimeters. And in the right limb, which is the affected one. Images 42 centimeters. It's about 3 centimeters larger. The ultrasound exam begins with a common femoral vein on the right side, and here we see the artery in the vein. Here is the common femo at verification in the long view. And now with the color we're able to see the continuous flow pattern in the common femoral vein. There some irregularity due to previous post robotic disease. And now we're placing the Doppler to see the waveform pattern in this area. And as you see here, for most part, the waveform is non-phasic, heavy, minimal variation during respiration and small augmentation. Here we see the vein on long and short view. And we're going to try to compress the vein, and as you see here, the vein is not fully compressible. The common femoral vein diameter before compression measures 10 millimeters and during compression is reduced to 4.5 millimeters. The common femoral vein has clear post robotic luminal changes. You see the white line in the center of the lumen, which is collagen to all thrombosis. The color we're able to see the two different lumens and the collagen in the center, and this extends all the way down to the proximal femoral vein. Now, we see with the color box in the proximal femoral vein, the multiple lumens. And with a Doppler we can appreciate the flow. pattern which is nonphasic like the commafemoral vein having low augmentation. In the profunda, there is no possible changes and the waveform is still the same, meaning mostly non-fay. The augmentation, the profunda is very good. And now we move to the left side for comparison. Here, the common femoral vein as a femoral junction compressed very well. The lumen is clean without any post robotic changes. And when we use the dual screen, we're able to see the compression that's complete with no lumen remaining. And now we measure the diameter, seeing the domain measuring 14 millimeters. And when we compress, there's basically no lumen left, you see, only the near and the far wall being together. And this measurement of 2 millimeters represents the wall thickness of the vessel. Now we go on the long view and we see the common femoral vein without any irregularities feeling wall to wall. And now we see that the flow pattern is basic and asymmetric compared to the other side. There is significant respiratory variation. And now we're going to check again with the Doppler and you see the augmentation is much better compared to the other side. Now we're looking at the Safela junction and also the deep external to the vein of the opposite side and are all normal. We see that the inferior gastric vein has a red color as it drains the abdomen to the scia femoral junction. Go a bit further down, we see the femoral vein union. With the femoral and the femoral veins. And both are normal without any post-robotic damage, feeling nicely and having phasic flow that changes with the expression. Going back at the femoral reduction, you can see very nicely the spontaneous phasic flow in the common femoral femoral reduction. And I was seeing the beam mode how clean up the veins and it's neck here. And the the gas main measuring 3.8 millimeters. Using again the color, we're able to see that the inferioriatic vein is nice flow which is not reversed indicating a lack of the femoral suction. And we'll put a Doppler. We're able to see that the efe epigastric vein has phasic wave form above the baseline draining into a femoral reduction. And we look at the confemoral day has flowed opposite to the big atrik, which is also phasic. Now we're going to examine the iliac veins on the affected side. And we start the exam from the proximal common femoral vein, seeing the femoral head with the acoustic shadow on the bottom. And the color now we see the distal confemoral vein in red color. And the proximal confemoral vein in blue color extending into the external iliac vein. So the vein has opposite color of the artery. Yeah, the flow of the iliac vein is also non-phasic. And has low augmentation. As you can see, the vein is somewhat smaller than the artery, indicating the previous thrombosis and the effect of thrombotic events on the luminal vessel. Now continue the proximal external iliac vein, you see, filling defects in color. Due to the previous thrombosis, the post thrombotic effects with collagen seen in the proximal external iliac vein, also we see here, irregular flow tunnels which are often seen after siliconization of the veins. On the mode, we see the external iliac artery and vein and you can see that the diameters of the vessels are similar. Typically, the vein is bigger than the artery, but here it measures about 10 millimeters And in the area where there is some irregularity, it measures 8.4 millimeters. Now we're looking at more detail in this area. You see the regular flow tunnels due to the previous thrombosis. And you see the iliac vessels more approximately. And here the bit more you can appreciate how the artery is compressing the vein. This is uncommon because now we're seeing here compression of the right conc vein by the right conilliac artery. The vein at this area, it measures only 5 millimeters and typically this veins have been more than 12 millimeters. And you see the area of Stenos is a bit further down, the steno is fairly long. Because the artery is accompanying the vein for a few centimeters. I see further down the diameter is only 1.8 millimeters. And you can see now with the zoom magnification, the small vein lumen with some wall thickening. And here, when we play the frame slowly, you see the narrow lumen of the vein just above the bone. Right there That measures 1.9 millimeters. So having significant stenosis of the right commoliac vein is is compressed by the right commoliac artery, and in the Valsalva maneuver, the vein opens up a little bit but this seems to be what we call a fixed compression that does not change much with the Valsalva maneuver. I see here, take the diameter during Go Salva, the diameter is doubled, but still it's very small, with only 3 millimeters. Looking again in the area, you see most of the altern at the top. And the vein on the bottom, now we see only the vein lumen in color and clearly this is reduced, measuring about 2.8 millimeters indicating significant stenosis due to the compression from the epsilateral artery. Now, quickly we look at the Coratra site which is widely open. So the artist is on top of the vein. And now we're going back to the right side from a different angle, seeing again the compression of the artery. Over the vein. You see the aliasing, the bright red color on the vein and the normal contralateral iliac vein on blue. The artery on top appears blue as well. Here it's very clear that the vein has stenosis is the compression of the artery. And the measures 4.7 millimeters in this view. It is interesting because using the multiple views, the vein diameter does not get much larger, indicating that has significant stenosis. The contralateral iliac vein as you see here, it measures 1.7 centimeters. And here we see again. The artery on the top on the left side. And then on the right side a significant decrease on the diameter. In a maneuver here in the thigh, I see you're pushing a lot of blood, but were unable to change the diameter as the stenosis on this area is actually fixed. I see a significant compression. Here we're using the Doppler before the stenosis. And you can see the velocity is fairly low. And opposite to that of the artery. And the velocity before the stenosis which is about 27 centimeters per second. And now we're going to find the area of the aliasing. Which is the highest velocity. And you can see here is non-phasic flow which is much higher. Measuring 76 centimeters, indicating an increased V2VN ratio which is compatible with stenosis in this vein. I to make another measurement using The color Looking at the highest aliasing. And also an augmentation maneuver. You see the Doppler is in the highest area of aging and the fragmentation. We're able to increase the velocity. And it's interesting because with the compression, the velocity is really high, but there's no change in the diameter of the vein. You see here they've lost this 155 70s per second. Now we look on the other side, you see the iliac vein is wide open. This is the proximal femoral vein over the femoral head, and below you see in the blue color the external vein. We look at the waveform now in the distal exa iliac vein here and you see the velocity phasic here. That changes nicely with the expiration has a very good augmentation. Then it will continue in the approximate external iliac vein. And you see here the vein is. Wide open and much bigger than the Cotala side. You remember on the other side, the artery has a similar diameter of the vein, but here the vein is much bigger than the artery. And the diameter of this vein here is 13 millimeters in contrast to the other side was 8.6. And as you go higher up, you see very nicely that the vein fills with color wall to wall. I see the iliac vessels coming right now, which is the inter iliac vein in a red color, and also spontaneous flow. And then I go a bit higher up to look at the common iliac vein which is wide open. I see the right common iliac artery on the top. And the Kilac Bay is measuring 15 millimeters, which is much larger than the other side which is only 3 millimeters. Like you said, the long view that on the left is wide open. It was a really good flow. Filling the entire vessel. And then is the decision of the Iliad of Vinaava. And now you see here the contralateral side the stenosis. Look how small the vessels on the right. And how much bigger is on the left side. So here with two color images, it's very nice to see the reduced diameter on the right side and the normal diameter on the left side. Now, we'll do the examination in the starting position, starting from the right side. I see the vein diameter is really big and it's very clear to see the post robotic luminal changes with a white line in the bottom part being the collagen. And now you see the person flow or standing position without any recommendation. And you're going to use the Doppler to see the flow pattern. And the standing position, we see the flow in the vein being more phasic. You see here nicely in here with a linear probe. And they're going to the distal moral vein. Seeing again the snakey extending in the distal part of the confemoral. And with the color we're able to see the two different lumens. And again uses the Doppler in this area see there is some acicity. Here you see very clearly the luminal changes are a bit more distal towards the femoral vein union. And here you see the sinia, the post robotic damage extends into the Dalofemoral vein. Going all the way to the proximal femoral vein. You see the lumen of the congo femoral vein measures 15 millimeters. Now we're checking on the side with the Doppler. And as you see, the person is a reflex to the Bassava maneuver. So clearly the previous thrombosis has damaged the valleys in the area. Producing significant reflux in the common femoral vein. Now we're looking at the common femoral vein on the left side here there is no snake here. The vein is big, feeling wall to wall. And using the Doppler now, which is a very nice phasic waveform with the acicity being more than the right side. Here you see very nicely the fasicity or the proximal common femoral vein. And now we look at the vein in the middle. And its diameter in the static position is almost 17 millimeters. And a bit more proximal, you see, it's over 2 centimeters. Looking a bit more distally now, so the vein is very clean. Compared to the other side, it's only one channel. And the vein fills wall to wall, and with a Doppler, you see a very nice phasic waveform changing with the respiration. This patient had compression of the right commeliac vein by the right commeliac artery. Accurate diagnosis of the different types of abstraction is important for managing these patients. Thank you very much.
Content on this site is intended for United States Healthcare Professionals Only
