Case Study on Venous Insufficiency

By: Mary Means

This case study is a straight forward case of an individual with venous insufficiency. This
is a great example of what reflux in veins are when valves become incompetent. For a lot of
people varicose veins are burden either for cosmetic reasons or because they are causing
problems associated with pain and venous stasis ulcers. By using ultrasound we can map out
incompetent veins for physicians so that they can do procedures like ablations.
This case study is about a 58 year old male that came in with large varicose veins on his
left medial thigh and calf that wrapped around to the anterior/lateral calf. There were also some
webs of varicose veins on the posterior calf. He had these varicose veins for 15 years and they
had gotten larger over time and had became painful His risk factors included family history of
varicose veins and years of standing while working at a job in construction.
We started the patient in a
standing position as to get maximum
results for the exam using a linear
transducer. In this exam we
evaluated the Superficial Veins and
the Common Femoral Vein, Femoral
Vein, and Popliteal Vein. We began
in the left mid thigh to start looking
at the Greater Saphenous Vein. We
took dual screen pictures of the vein
compressed to show no thrombus
with a diameter measurement. As you can
see in Image 1, we have a transverse image
of the GSV in the mid thigh with the dual
screen. We take diameter measurements to
show how large the vein has become and so
that the surgeons know that they will be able
to fit their catheters down the veins lumen.
We also take pulsed wave Doppler samples
at all the locations with a distal
augmentation to show reflux. The reflux
shows severe incompetence in the mid thigh
GSV shown in Image 2.

Image 1
Image 1
Image 2
SEVERE
As we continued down the leg we had the same finding throughout the entire GSV with a
consistent diameter and severe reflux. We also found a drain that was coming into the GSV at the
mid thigh that was leading from varicosities in the proximal calf. When imaging, we need to
include any kind of drains so that the physician can know where the varicosities connect into.
We also look for any kind of perforators that may be causing reflux in deep veins, which can
lead to stasis ulcer and other problems. In Images 3 and 4 we see a major drain that is from the
large varicosities and we see a perforator that is connecting superficial veins to deep veins.







We also image the varicosity webs to show that they are truly incompetent and that there
are multiple of them, seen in image 5. After evaluating the GSV we then go onto the Small
Saphenous Vein in the popliteal fossa. As you can see this vein is very small and is not
incompetent and thus is not causing a problem, image 6. Since we pinpointed where the
incompetency was we then needed to go back up and see the source of the problem and look at
the deep veins to check for incompetency in them also. We then had the patient lay on the bed
and we put them into a reverse trendelenburg position as to get pooling in their veins. Since it is
hard for patients to stand for long periods of time for the images taken in the groin we help the
patient from getting tired and help our arms from getting hurt so we lay them on the bed.

Images 3 & 4
Image 5
Image 6
No Reflux
We started in the Common Femoral Vein in which we got severe reflux which suggested
that it was coming from the saphenous femoral junction shown in following images. We then
took Doppler in the junction and to no surprise got severe reflux. As we continued down the leg
we found no incompetency in the Mid Femoral Vein and Popliteal Vein. These findings prove
that indeed the valves are not working in the superficial vein and that it was also draining into the
deep system at the level of the CFV which is a huge concern.
The patient then went on to get an ablation of the GSV and small stripping of the
varicosities. He had an ultrasound a few days later to show that the clotting from the ablation did
not go into the deep system and that there was no longer insufficiency in the deep veins. He is
now happy and has just minimal bruising.