it's simple they either have a blood clot or they don't that's what I love about Venus ultrasound you don't have to worry about a bunch of different types of pathology this is how to perform a lower extremity Venus exam a normal exam however I will be going over how to avoid getting false positive results as well as a few tips for tricky exams now when you have a patient who has a lower extremity Venus ultrasound they should have have indications like pain in the calf or their leg swelling in their lower extremities some tenderness and warmth in their leg not coolness but those are the typical symptoms of a deep Venus thrombosis which is what we're looking for of course during the lower extremity Venus exam I'm going to give you what I believe are the three keys to successfully performing lower extremity Venus exams number one you need a proper understanding of anatomy and physiology that's the foundation you've got to have that if you don't have that um need a study in your book or I do have some information in the circulatory skill set number two you need to perform proper compressions I'll get into that later and number three you can use the arteries as a guide to find the veins as the arteries run alongside the Deep veins but but do not image the arteries as the veins I've seen that happen that's not okay of course every protocol is different definitely share with me what protocols you have experienced and I'm going to share with you a protocol that I personally follow when you perform these exams you want to grab your linear probe I usually use a 9 mahz probe now let's get into this protocol first things first you want to start with the patient in the frog leg position their knees slightly bent and their kneecap pointing outwards so you can get to the inside of the leg want them to be Supine position as flat as possible starting with the common femoral vein first thing you need to do is make sure that you have access to that area by moving any fabric out of the way you want to I usually tuck in a towel or a washcloth make sure I tuck that into their underwear so that's not in the way and at first this was difficult for me because I felt like I was in all up in their business so to speak but I have to remind myself this is medically necessary to ensure the health of the patient so I have to get access to where I can see clearly the anatomy always look for the veins in transverse position don't search for them in longitudinal go transverse first and then if you need to turn on on the vessel then you can turn so you're going to start with the common femoral vein in transverse position you're going to be high up in the gro in the crease of the leg the crease of the leg as you can see in this image this is where your transducer should be and this Arrow coincides to the direction that your Notch of the transducer should be facing so when you start Imaging the common femoral vein you should be superior to the saffo femoral Junction now I'll show you exactly how to do that in just a moment now the common femoral vein is always medial to the common femoral artery that's whether you're in the right leg or the left leg the common femoral vein will be towards the inside of the leg more towards the inside of the leg now what are some other ways that you can tell the difference between the artery in the vein the artery will have thicker walls and it will not press as easily as the veins do the artery will also be pulsatile so it'll be jumping up and down a little bit pulsating whereas the veins shouldn't be pulsating so much not in the lower extremity vein like I said to start your compressions you should be above the saapop feral Junction up here now we're going to see the difference in where you should be beginning your compressions here's the junction here's above the junction junction above the junction junction above the junction above the junction is where you should start your compressions now how do you know your pressing hard enough on the vessel once the arteries walls begin to coap and the vein is still not compressing that might be indicative of a deep Venus thrombosis if you have ruled out the other possibilities that we'll discuss later on we're going to turn our transducer from transverse to longitudinal we're going to take the rest of our images you need to take a 2D image next you want to put on color Doppler and make sure you have good color fill it is important to have an angle a little bit of an angle to the Vel that you are visualizing in in longitudinal so that means you will have to heel toe the probe so that you can make sure that the vessel is slanted on your screen so that you can get the maximum Doppler shift and your color Doppler will be able to fill up the vessel now you have to get a spectral Doppler image to demonstrate quality of the blood flow the blood flow should be spontaneous and phasic so there should be just just random flows of the blood flow as well as it can be dependent on the breathing habits of the patient when the patient exhales as far as the com the lower extremity veins then blood flow should increase back towards the heart so you want to demonstrate that through your images many facilities require you to augment the vessels so that means distal to the vessel you are visualizing you will squeeze the leg and that will increase the blood flow so the common F femoral vein I would squeeze the leg at the mid thigh you have to squeeze on the inside of the leg where the vessels are if you squeeze on the outside of the leg nothing's going to happen there's no deep veins right there have to squeeze on the inside of the leg a lot of times I'll use the back of my hand if it's the inner thigh just lean in and push a little bit um you don't want to hammer into the like some people do now the sopal junction here back and transverse you see here on the image we have the common femoral vein with the little Branch coming off the side this Branch always comes off the the vein medially so that means depending on which leg you are visualizing it will be on a different side of the screen keep that in mind but we'll go over that later so here we can see it coming off the right side of the screen while we are doing the right sapal Junction and then I have compressed the vein here you can no longer see the vein but you can still see the artery next we have the proximal femoral vein and the Deep femoral vein these I usually try to get in the same image possible so here we have The Superficial femoral artery there's the femoral vein here's the Deep femoral vein in the Deep or profunda fous artery so I try to compress these both at the same time and here you see The Superficial femoral artery and profunda fous artery still in the compression picture whereas the veins you should not be able to see the femoral vein ends when the Deep femoral vein joins that vein so do not image once it has joined image inferior to that Confluence I will show you how now now in transverse the common moral vein looks like one Circle once you get to the Deep femoral and femoral vein it looks like two circles so you have common femoral and once you're far enough then you'll have two circles the femoral vein and the Deep femoral vein let's see what I'm talking about in this video clip one Circle two circles one Circle two circles one Circle two circles it's very important to make sure you are at the right location when you're Im doing this Imaging now when you turn into longitudinal on this vessel just use a little bit of imagination here you have to angle a little bit to get both of these vess in the same image we have the femoral vein the proximal femoral vein and the proximal portion of the deep femoral vein then you have color and then pulse weight I failed to mention you do not need this do this angle correct you do not need this angle correct that you see here in this image my facility just requires that why I do not know because Venus flow is not angle dependent like the arteries the moral vein which is more anterior have demonstrating the normal phasic and spontaneous flow we're augmenting I usually would augment at the mid thigh here demonstrate that next we do the Deep femoral vein and augment at the mid thigh you do have to augment a little harder for the Deep femoral vein for the mid femoral vein going to move inferiorly at the mid thigh here in transverse so we see the femoral artery and the femoral vein again if you ever get lost try to F follow the arteries and if you completely lose vein always go up to the common femoral vein and then follow the veins back down that's a good tip if you ever get lost in your Imaging go back to the common femoral vein where you start from where you know and then go try to follow what you don't know turn longitudinal here you see the mid femoral artery in the mid for moral vein in longitudinal remember to try to keep a slight angle on the vessels that you are visualizing take your color Doppler image and then for the pulse wave take that image and augment for the mid by the time I get to the mid for moral vein I will start augment ing in the Cal the medial Cal little squeeze now for the distal for moral vein this is a tricky spot because a lot of times you can stop seeing the vein as it Dives in in through the adductor canal as you can see in this image and also compressions are difficult because it can be painful because of the location so uh what I will do I was performing an exam on a person who worked in my field and he kindly let me know you don't have to press that hard you should press behind the leg so that it doesn't hurt the patient as much I was like okay thank you but the tip works so that's what I started doing I compressed the back of the leg so that I don't have to jam into the patient's leg just to compress the vein so I'll compress with the probe and the back of the leg to close that vein so here's the femoral artery the femoral vein this patient had an extra vein right here and that would be called a bitfit system here we see vein artery vein you're going to take the color Doppler you're going to take your pulse wave image and augment again in the calf the medial calf then for the poal vein here it's de difficult to demonstrate or image exactly where you'll be but you're going to be behind the calf in this area you have to make sure that the per the patient definitely has their knee bent to help you get access to that area here's the the poil artery and the poil vein you're going to compress and you can still see the artery here the vein walls have [Music] coapted and this is the patient positioning that you need for sure for examining the poil FAA so this happens to be the left leg but this is nonetheless position that you need for the longitudinal longitudinal image make sure you keep an angle on the vessel fill the vessel with color Doppler and then you'll take your pulse weight image and augment in the medial calf I fail to mention I do like to image the poal vein superior to the other veins that join to form the poal vein superior to the gastrus veins and saop Junction some facilities require this and some do not Imaging the gastr nemus veins you're going to move inferiorly in the poal FASA until you can see two sets of paired veins it is not easy to see these veins when you're first starting out but with practice you will see them you can see one set vein artery vein and then another small set vein artery and vein it's hard to tell I know lighting change so the posterior tibial and perinal veins you want to use the tibial bone as a guide guide for the posterior tibial veins so you're going to be medial to that tibial bone that's the more anterior bone you're going to be on the inside of that bone I usually will start looking for the vein the calf veins in the mid calf I don't start all the way up here never going to find them uh start mid or the distal Cal to find them but you want to make sure in any veins you are looking at compressed all the way down from each from the common feral down to the paranal compress at every few CM here I'm starting at the mid calf to check the posterior tibial which is medial to the tibial bone and then the paranal tip for locating the paranal veins look anterior to the fibula here you see this echogenic area with the shadowing that is the fibula just Anor to that you will usually find the paranal veins So paranal Vein panal artery both of these sets of veins have an artery in the middle of them here's the panal vein perinal artery perinal vein posterior tibial vein posterior tibial artery posterior tibial vein so I usually get those these in the same image and compress them both and here here you see I've compressed the vessels in this image you cannot see the veins anymore tips for viewing the Cal veins a lot of people have a lot of trouble with this of course I always search for the veins and transverse but one thing one thing you can do is put on color flow augment distally here in the distal medial distal calf and then you can see where the veins and Aries line up and you can also just try to search for the artery all spells search for the artery you can see it pulsating and a lot of people will have unfortunately some calcifications on their arteries so you can see where it's more bright in the walls of the arteries look for that and then you'll find the vein so some facilities will require you to visualize these veins in longitud longitudinal of course just turn very slowly to be able to stay on these vessels here's the posterior vein so here's the second vein here's the color impulse wave of these two posterior tibial veins remember you have two veins two posterior tibial veins two paranal veins now here I could get all three vessels in the same image for the paranal so two paranal veins and then the paranal artery in the middle then use a little bit of augment sometimes to help fill the vessels with color and then you get your pulse wave images of each vein now for the left leg the left saffo feral Junction I'm not going to go over the whole protocol for this but you see here gsv the great saff the great saffin vein comes off medially on the left side of the image here as opposed to the right side so keep that in mind it's not always going to come off on the exact same side of the image if it does come off on the same side you have your probe backwards and you need to straighten it so here are the references for a few of the photos that I use such as the diagram very last ultrasound image majority of these images I scanned myself for so thank you guys thank you thank you for my contribution to society here now tips and tricks I got a few I've got a few I mentioned false positives I have seen some sonographers they will see Rulo flow or sluggish flow in a vein and they will say that that patient has a deep Venus thrombosis ruof flow is not the same as deep Venus thromboses rulof flow me means that red blood cells are clumping together they're stacked together and thus you can see the red blood cells in your 2D image you can see them moving through the vessel slowly that is not completely normal but it's not a DBT the ultimate Way the primary way to make sure whether there is or is not a deep Venus thrombosis is through compressions with ruof flow the vein will still compress completely so that means that that patient even though they have ruer flow they do not have DBT that is one way to avoid a false positive another Pitfall of sonographers is that sometimes they are not able ble to compress a vessel and they assume that the patient has a deep Venus thrombosis in that vessel in reality sometimes the patient is holding their breath if the patient is holding their breath the veins will not compress especially in the thigh or the groin some people are ticklish or sensitive in the groin and they will be anticipating pain or anticipating discomfort and they they will tense up and hold the breath this will prevent you from being able to compress the vein you have to sometimes convince the patient to allow you to compress the vein within reason of course sometimes you can just say not able to be compressed due to Patient intolerance however if you are able to coach them I will usually get them to while I'm getting my probe ready imp position to inhale and then I'll ask them to Exhale and then I'll compress the vein before they know what's coming if you are trying to demonstrate color flow Doppler and you're not able to get the vessel to fill with color the patient could be holding their breath or taking very very shallow breaths so what you can do is as the patient to take in a deep breath and let it out once they let it out be ready to freeze that image so you can get your color Doppler image and for larger patients with larger lower limbs sometimes if the limb is so large do not even start with the linear probe go ahead and grab the curved probe you're going to need the curved probe to image certain areas I usually narrow down my sector and decrease the depth significantly so I can get focused on my region of Interest it comes to the femoral vein meaning the mid and the Deep femoral vein I usually will start looking for the vessel with color Doppler if I can't see the vein in 2D or follow it in 2D I will use color Doppler to locate the vein sometimes I can only locate the artery and then I'll augment to get some color flow to know okay that's a vein I'll take my compression images with and without color Doppler if you found this video helpful at all I hope I broke this down simply enough for you please give this video a thumbs up and comment what video you would like to see next if you haven't already check out this stepbystep corate artery tutorial video thanks for watching and I'll see you in the next video [Music]