[Music] uh hello my name is an Marie kinsky I'm from Albany New York and we are going to demonstrate the basics of a lower extremity Venus Ultras Examination for DVT we start with the patient's leg positioned as you see it here um slightly bent at the knee and externally rotate it at the hip uh one thing to note some folks with arthritic uh issues uh find this position slightly uncomfortable so we'll put a small roll of towel or pillow behind their knee it gives their knee a little bit of support so it takes pressure off of their hip here um I usually begin with a transverse orientation and we start um at the top of the leg um just about uh at the uh groin crease and what I try to do is just sort of get oriented first to see uh what's what and at this level here what we're seeing is the common femoral vein and common femoral artery there's the common femoral vein common femal artery we position this always of course So the patient's right is on the left side of the screen here if I come down slowly you can start to see some changing taking place um both with the artery as well as over here we see the Terminus of the great sainis vein and we see the super the common femoral artery Branch Into The Superficial femoral and deep femoral or profund Emeral so basically we begin at this point and I'm going to sort of take take us through um really evaluating this just on grayscale image um that is the important part of Venus ultrasound is being able to look for thrombus and uh make sure that um there's nothing going on uh in that vein anything subtle so at this point basically I'll just do a slight compression and it won't take much pressure with your patient Seine like this the pressure at the femoral vein at this point at the top of the leg is probably between 5 and 10 mm of mercury so it doesn't take much to compress in terms of documentation um we can use a split screen feature where we have the non-compressed image on the left and then we'll switch to the right and then just compress and freeze and then we can label that as a common femoral uh you can do add in more uh compressed and non-compressed but most Physicians realize the the proper documentation is non-compressed over here and compressed here so just come back to the full screen here and we would probably document at this level here where it's just common femoral and then come down and also document right here to show the Terminus of the gsv and you can actually see his terminal valve right here but everything's nice and fully compressable we don't have any pathology and we would again either record this as a loop or as a still image now and other than taking a look at those last couple of centimeters of the gsv we pretty much done at that point unless a patient's presenting with any kind of symptom suggestive of superficial thrombophob bitis so we'll return back to the the Deep system here the artery branches first as I said and here's the vein and we can see that the vein is starting to change it's moved its position a little bit we were basically uh well almost even laterally with the artery and as I've moved down the leg it's come deeper and underneath it and now we can see that it's gone from just a circle to an oval to now two and we're just going to increase our depth here no other way there we go increase the depth a little bit so we can visualize this is the profund femoral artery or deep femoral artery and profund femoral vein or deep femoral vein and again press and we get everybody to compress we know that there's no thrombus there now because we've got the superficial femoral artery femoral vein and profunda femoral vein to get this vein down here to compress fully may take a little bit more pressure because we're kind of going through the other couple of vessels so we'll want to be able to vary our position a little bit and you can kind of see where I am on the thigh we're down a maybe five or six cenm from the the groin and we're seeing those vessels so we'll document the terminal area of the profunda FAL and we'll also continue now just looking at the femoral vein so here we have The Superficial femoral artery and the companion vein and this is probably a adequate point where we would document again um if we wanted the right and left side by side uh showing good compression and that would be obviously labeled um however you prefer you could say just procs uh femoral vein or whatever kind of uh short uh nomenclature you'd like to use of course all the systems have you know preset labels as well that you can use if you don't like to type so it's press and release press and release every couple of centimeters now interestingly um perhaps you've noticed here I'm just going to come back up a little bit here's the artery there's the vein and down a little bit and we see this other vessel over here and obviously with a little bit of a pressure it's collapsing away often times there are multiple femoral veins um some people uh say half the time a third of the time it's fairly variable just know that they can occur and a look for and you want to just get full pressure and then there's no magic place but somewhere when you're about halfway down the thigh is again where you'd want to document your mid femoral vein again with a a split and then go to the other screen and compress and freeze and label it accordingly so further documentation we did the common femoral we did the great saus we did the termination of the profunda we did the upper thigh femoral mid thigh femoral and we'll continue on down and we'll look at the distal thigh now you can see the vessels are getting deep and they're coming on down and we'll be getting through going through the adductor canal we can see muscle here a muscle here and our model today is a pretty easy subject so it's pretty easy to compress but another thing you can try is with your free hand is to come up behind the leg and you can actually press from behind and do the same thing in terms of collapsing that vein so somewhere again just as far down as you can see we'll document that one more time compressed and non-compressed and remember you know you're by yourself you've got your cine feature you can scroll back to capture where the compression is okay before we turn our attention to the lower part of the leg let's look at some Doppler that would be the other thing that we'd want to record you can record the whole thing in color as well I don't think transverse color is all that is all that helpful because it's difficult to get good filling um so if I want to look at color I will use A sagittal view or longitudinal view but we'll come back up here at the groin and we're going to bring up this image again so I'm just going to come up here and get the common femoral vein in View and drop our Doppler in and we'll just sorry turn that volume down a little bit [Music] and we'll want to adjust um Baseline down just a little bit there we go I'm sorry can we just move that Baseline down oh I see it's just a toggle down there we go sorry I like to make sure that I can and I'll just drop that volume of second I like to make sure I can see a little bit on both sides of the Baseline particularly obviously if we're GNA do reflex study we're not going to do reflx study in the Seine position because the results are going to be inaccurate so let's just bring the Doppler back up and I'm just going to come back to my live screen some folks like to be able to have full whole simultaneous duplex where we're seeing the live image and live spectral Doppler and I think that that is helpful particularly if you're following down to make sure that you don't fall out of the vessel and what we're going to have is we're just going to again with your free hand take a little and do a little squeeze and we just augmented the signal here as you can see when I squeezed I augmented the return back up the leg and that was detected with that increase um in the Doppler pattern we'll come back here alive and I'm just going to ask the patient to take a big deep breath in all right and relax and we can see that we stop the flow in fact we actually get a little bit of reversal of flow which is not uncommon in this position it does not mean that he has our patient has reflux it is just actually physiologic flow moving retrograde because we don't have enough pressure to engage the valves so this is why we don't do reflux studies toine but that's another story so we've augmented the flow with Val Salva and uh distal compression and we've documented um our Venus Doppler pattern and usually we get just the the femal uh we will always always get a contralateral femoral vein if we're only doing a unilateral study so we can compare the Symmetry right to left the other thing that we'll do many folks will um also grab a mid thigh portion again just to see we need to do our Doppler Sagel because we need a decent angle of insation so here we are and I'm getting a little bit of the artery in there just cuz I was up a little high and you can adjust your controls here to get a nice clean signal nice normal phasic flow with just uh um quiet respiration is exactly what we want to see there's really no need to document and color if we've shown the image and we've shown the Doppler but we can just go through and show you just to be complete since we do have wonderful color Imaging see you know good color filling on the vessel um although color is still considered complimentary um we'll just steer this back is that right oh sorry there we go um work with the natural angle of the vessel so we can get good color filling and you can see a beautiful picture here I'm just going to drw drop the overall color gain you want to be adjusting your gain and your scales a little bit if you've got you know some artifact and what we see here obviously the artery on top the artery is aliasing the color signal is aliasing um because we have our prf set very low or scale is set low so that we can get good Venus filling and we have the common femoral veins splitting into the femoral vein and the profund femoral vein so that's a very nice uh documentation of the color flow there and you can uh scan all the way down if you prefer uh looking at the color signal and documenting the color signal but the interpretive component to this exam is going to show going to be the the illustration of the full compression of those walls together and we can see vessels coming and going we've got again the companion artery aliasing because of the low scale or prf and we're following this all the way down very nicely one thing to remember most of the equipment nowadays have multiple frequencies for um color Doppler and image and if we were in a little bit of a jam and we weren't getting good filling we we could change our our color frequency um although this is set pretty low already but we have multiple frequencies that are available on all the this most of the systems nowadays so and you can see we're pretty much down to uh where we were when we were doing the image so you can document the color if that's part of your protocol now we're going to move down to the lower part of the leg so one thing when you're scanning you don't want to scan behind the center of your body you're going to move yourself back and move your equipment back maybe that'll be well good enough and from this view we can actually see pretty well um if you needed to you could turn the PTI over but um it works pretty well and we're going to come up where we left off and I'm moving up onto his lower thigh and we're visualizing here the vein in the artery and I'm just going to press a little bit make sure we still got a nice compressible vein okay and we're just going to come down I'm basically even with the knee joint here and we would want to record the same left right compression non-compression of the poal vein while I'm also here I'm just because this is the last point that I routinely uh record a Venus Doppler I'm going to go into A sagittal mode and obviously fix the Doppler angle and grab a Doppler do a little augmentation and record that for our poal vein so at this point I'm done with the amount of Doppler I need to record and the rest is based on image so we come down here and we start to see I'm just going to zoom up for a second here we start to see a lot of vessels if I come back up to the pole we see a lot of branching coming off and we've got the small saffin way up at the top yeah we've got a bunch of veins and arteries right here those are the gastro memas they're staying within the muscle and there are paired lateral and medial gastr and other than taking a look here I don't really follow them much more let me come back and and let up on the leg a little bit and then compress and I like to actually record a little Loop of this data versus a still image but you could do the same thing as we've done before you could do the right left still compress and freeze that and store that but with these small veins I think Loops are pretty helpful so we'll just come down it's important to look at the calf and look at an area if the patient's presenting with a focal pain that's important because a lot of times it is one of the smaller gastro memus veins that are um involved with a partial thrombus so I'm going to come back up to the pole which is in the center of you there and I'm just going to see how well I can follow it without changing my view in terms of my Approach onto our patient's leg here and you can see it's a little deep a little hard to follow but now we're getting into the point where the calf is most muscular and the vessels are starting to Branch So you you're going to try to follow from behind and kind of swing up forward okay and now we're over where we see our tibial vessels and from this point on down then we we can use a much more medial approach and follow all the tibial vessels remember they're not under a lot of pressure so if we push push too much we will get them to collapse away so let's just point out what we're looking at here on the image I'm using a lot of gel here so we can reduce any artifact by any little bits of air that might be trapped in uh under the by the skin as a result of hair on the leg so we we'll get them nice and gooped up we see some vessels here that are kind of deep and we see some vessels up here that are more a little more superficial okay the tibia is over here and actually the fibula is right here these guys right here here vein artery vein sitting right on top of this bone from this medial approach those are the fibular vessels or what we now call more commonly the the um uh paranal vessels or peronal if you're from the UK but we've got the vein artery vein and we can get good compression and we'll follow them up a little bit we lose them a little bit right up and through here and that's when we're we're going to vary our approach and try to come around and this point in through here on the leg is probably the point where you're going to have to press the hardest um you might want to warn your patient or apologize in advance because they're so deep they're deep to the muscle there okay so we kind of follow them right on up getting good compression actually pretty much compressing them away if you have very small veins that are difficult to visualize you can sit the patient up and have them fill more now I'm going to look up here and I'm going to look at these vessels up here here we have a large vein well large by tibial level standards which is probably a solal vein it looks like it's coming right on in let's see if if color will make things any more apparent not too much that's the the hard thing I mean we can see the vessels colorize as I compress but it's not all that helpful I think the better thing is to rely on the ability to compress those vessels and record that either as a loop so these are the posterior tibial vessels that's what we're following up here now and again we're going to do the same thing follow them back up to where they Connect into the paranal now I've zoomed up our depth a little bit but you can see we're coming up and folling up and then in a minute we're going to be back up to where we started at the POA teal level now the posterior tibs are right here they're very easy very nice we're going to continue to follow them basically all the way to the level of the ankle and I don't like to use a ton of Goo although I will use a fair amount of gel um the more gel you put on as that starts to evaporate the cooler your patient will get when they get cold they vasoconstrict which also makes your job harder so keeping them warm wrapping their foot in a blanket uh keeping the rest of them covered is very helpful so you can see I'm all the way down to the ankle and I've got very nice visualization of the posterior tibs and it's the only vessel up here and I'm just working my way back up we see this guy at the top of the screen up here that's the great sainis and uh that was actually a perforator coming down down again topic of another lecture but we can see and we're kind of getting back up to where we started in the midcalf now there's one vessel that we haven't looked at and that's the anterior tibial vein most folks don't image it I'll just show you I'm going to have you just roll your knee for me Mike a little bit this way the anterior tibial vein is going to course along here along the uh anterior lateral aspect they are really small um it might be very hard to see um in this view but actually and I didn't even plan this but this is them right here here's the tibia this is the anterior compartment over here and here's our distal anterior tibial artery which will turn into the dorsalis pedus in a few more centimeters dist but here are the companion veins right here and you see I've kind of taken the image depth up a bit to see them but these are the only vessels that are going to be over here and that's where you'll follow them from the foot from here and back up this way if there was an issue but most Labs uh don't routinely include the anterior tib but that's where I would go to find them they're going to continue on up and then about somewhere in here dive deep to come back up and Connect into the popla heal so we've gone through the B mode Imaging and we've gone through the required Doppler Imaging and how we can use color if we want to help follow um we've talked about requiring Doppler at the poal and femoral or common femoral levels but compression of the veins all the way from the groin to the ankle and that is the basic uh exam for lower extremity DVT thank you very much