Duration: 14:00 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 56-year-old male with complains of pain, edema and heaviness in lower extremity, that is worse at the end of the day.
In this case, we're gonna present a reflex in the GSV and large vacos tributaries, which is the left leg of the previous patient. Our patient is a 56-year-old male who presents complaints of pain, edema, and heaviness in his left lower extremity. Which is worse at the end of the day. In his history, the mycard an infarction 3 years ago. No allergies, and he's an ex-smoker. His family history is unknown. During the physical exam, he had large varicosities extending from his thigh down to the ankle. His arterial exam was normal with palpable pulses. Here we can see the left leg of the patient with many varicosities from the medial aspect of the thigh. And you can see how they're bulging out extending down in the knee area, and you see multiple classes of varicosities going down to the medial aspect and posterior medial aspect of the calf connecting potentially with the small sap vein. Here you see a great detail the different classes of varicosities and down in the ankle area, this varicosis the feeding the skin, putting the patient at risk for bleeding. We start the exam from the groin, and here we see the femoral junction with inferior gastric vein. The vein appears to be dilated. Go a bit higher up to start the exam with the common femoral vein as normal phasic flow in the starting position. We put the Doppler and we squeeze the cuff, and here we see there is a reflex in the common femoral vein. So we can measure. The duration of reflex starting from the beginning here go all the way to the end. And it's almost 3 seconds. Typically, a common femoral vein reflex is more than 1 2nd, and here is almost 3. Now we examine the distal part of the common femoral vein to see there's truly reflex in the deep system. And here we see the commercial venue face the flow, squeeze the release. There is no reflex. I'm going to test this for the Doppler. Who place the doping in the center of the lumen. And squeeze, release, and there is no reflex. So there's a reflex only the proximal common femoral vein which is probably induced from the competence of the great typhanus vein. Now we go back to the duction area here you see very nicely the great typhus vein. We measure the diameter and the vein is very dilated, measuring 11 millimeters. I put the color on And we look at the junction again and you see here this clear reflex which is very prolonged. It's a continuity to the common femoral vein. And I'll put a doppler in the area and squeeze the calf, release, and there is significant reflex. Now we look at the softness vein, the cross sectional view. This is dilated in the groin going towards the thigh. We're going to measure the diameter there from the near wall to the far wall, and the, the vein measures 10 millimeters. And we look a bit farther down, the vein is still dilated inside the canal. I go to the mid-thigh area. It's this huge varicosities emerged from the syphous vein. There's a huge cluster with multiple veins inside and outside the canal, mostly outside the canal. And look here how big is this vein emerging from the side from his vein. We're having stasis in the starting position. We're going to measure the diameter of this area. And the vein 2 millimeters is twice the size that dilates itself in his vein. The saffron is very now just below the varicosities. It is only 5 millimeters, with half the size of what it was approximate. And here we look on the long view, the transition from the dilate itself from his vein it's in here. Right, and measures 12 millimeters and just distal to this, it measures 5.5 millimeters. We're going to see if this area has reflex below there. The See the dilate the segment we see here. Has reflex, but the segment below it is actually normal. It's often we see when sva costs emerging, the distal segment could be normal like this patient. We look now with the Doppler, the duration of the reflex in the distal segment at the mid-thigh, and clearly here there is high velocity prolonged reflex. went a bit further down in a normal segment. And here, as you see, there is no reflex. So the saffron vein below the varicose is normal. Go back in the thigh now we see multiple varicoses above the great safffeus vein. So the siphon his vein is right in there. We look with a Doppler in the distal thigh. Squeeze the cuff and release, and here is the reflex again. So it's smaller duration, but you see the vein that connects to varicosity as you can see here, and the varicose render the sy from his vein incompetent. At this level So you go to any area, you see multiple va courses again, both at the skin and also with the ultrasound. You see the connections here with a great a vein. I see the stasis in these big varicosities. As the person does not move his leg. So the saff is vein at any area here measures 4.7 millimeters. I'm going to take with it again for reflex use the color box first and mostly the reflex is, is on the varicosities. The saf vein appears to be normal with the color. Let's use the Doppler. Squeeze the cuff and release and basically the vein is normal. It's the valve now there. And you can see very nicely that the siphon his vein is kind of normal diameter, but the wall is very thickened. Because the price is chronic venous hypertension and the wall thickness is 1.2 millimeters, which is 3 times its normal size. Here is the varicosi, the upper calf that they emerged from the great Sas vein, and many of them at various levels. Look at the stasis here and this big varicosity. And we see the spontaneous contrast. And you see the valve on the saffron vein and the vein is normal in this area. You see on the long view, look how nicely the valve sources opening and closing. And this is a copient valve we're going to check with the ultrasound on here, the color box it reflects the varicosis, but the saffronous vein is normal because the valve is holding. Now we're going a bit farther down. Well, in the mid-calf area we see multiple varicosities. The siphon has been a small diameter. It's a small perforator there testing the varicosities. The cipher vein is normal, but it's a reflecting the varicose on top. And here another perforator which is typically a reentry perforator. And I see there is no reflex on the perforator despite being dilated. And as you go a bit further down, we are at the area of the medial malleus, see the periosteum of the tibial bone there, you see the syphenous vein over the tibia, and the syphenous vein is even smaller here, measuring only 3.2 millimeters. And now we look at some of the varicosis next to the synous vein. There are multiple both medial and lateral. I see the skin here is all the fibrous tissue. Going a bit further down. Now we see this varicosis pushing the skin and putting the person at risk for bleeding and clearly all these big varicosis in this area have a lot of reflux. Now we're moving higher up, go in the posterior medial and posterior part of the. upper calf in the fossa, see multiple varicosis in the area, go up towards the thigh, go posteriorly. And we can trace the viricosities. Postero immediately Multiple varicosis going across the thigh and then they go all the way back to the varicosis of the great syphronist vein. So despite these veins are found posterior or posterior laterally, they're all coming from the great syphron vein as you see in this picture here, multiple varicosities. wrapping around the lower thigh. Going the fossa. Here again you see very nicely how these veins go back to the great typhus vein. Now we're going to examine the politi al fossa. We look at the political vein and The pot vein is very big. The middle of vein joins right there. The polial artery below and is normal. And it's normal flow which is one of the doppling in the vein. And here there is no reflex. The vial vein is normal. Now we're taking the smallest side from his vein. We're doing the two heads of gastrocnemius. You see the circle on the top there. With the diameter It means 2.8 millimeters. Go further down there's a varicosities from the Great Sainuss connecting with the small Safs right in here. See the varicos is joining. That's a common phenomenon having varicose from the grade joining with the small in the cafe area. See they connect to the perforator in the gastric muscle. And we're going to take the small siphonist vein now, put the vein in the long view. This is the preferred to earlier. And the perforator looks normal. It's dilate. It's a perforator. That's a small sac from his vein which is dilated from the connection of the varicositis. We For the Placing the box in the right position and here as you see, despite the veins being dilated, there is no reflex in the small syphus vein. So this most of his vein in the lamas down now. A normal diameter I'm going to magnify the picture to see this a little bit better. And you can see the small size in his vein. With a tributary there. And next you see the sal nerve as you're pointing out with the arrow. Here we see the vein map after the finish of the ultrasound exam. The patient has a reflex in the groin for the safino femoral junction to the mid thigh. Then there's a small segment of the GSE that's normal. There's a little bit of a reflex in the remaining segment of the knee, and the syn vein is normal enough from the knee all the way down to the ankle. There is big varicos emerging at the mid thigh. Both medial and lateral. And this varicos extending from the anterior part all the way down to the knee. Then they move medial and they go to the medial malleolus. The medial tributary moves posterior in the lower thigh, going posterior lateral on the knee, and extends all the way to the dorsum of the foot. The small siphonist vein was normal. As you remember, this person has the reflex in the common femoral vein. Which was segmental just at the junction. The comma femoral vein was normal below the femoral junction, indicating that this reflex in the deep vein, it was induced by the reflex in the great syphenous vein. Typically in case like that where you operate and treat the reflex in the great syphron's vein, the deep vein reflex disappears. And this concludes our exam. Thank you.
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