 Hello and welcome to noon conference hosted by MRI online noon conference connects the global radiology community through free live educational webinars that are accessible for all, and is an opportunity to learn alongside top radiologists from around the world. We encourage you to ask questions and share ideas to help the community learn and grow. You can access the recording of today's conference and previous noon conferences by creating a free MRI online account. You can also sign up for a free trial of our premium membership to get access to hundreds of case based micro learning courses across all key radio radiology subspecialties. Today we are honored to welcome Dr Sheila chef for a lecture entitled peripheral vascular ultrasound Venus Doppler and challenging arterial cases. Dr chef completed radiology residency at Sinai hospital in Baltimore and body imaging fellowship at the Johns Hopkins medical institutions. She was on the faculty at Johns Hopkins in the Department of Radiology until 2020. She is currently on faculty in the section of abdominal radiology at NYU Langan in New York City. At the end of the lecture, please join Dr chef in a live q amp a session where she will address questions you may have on today's topic. Please remember to use the q amp a feature to submit your questions so we can get to as many as we can before our time is up. With that, we are ready to begin today's lecture. Dr chef, please take it from here. Okay, good afternoon. This is afternoon in the United States in New York City where I am. And so I hope everybody can see my screen. And so this is going to be like a case based talk. I gave a similar talk to our fellows in the body imaging section yesterday because I think sometimes it's easier to learn that way. So just look at the cases and challenge yourself. So let's get started. Okay, so this is my disclosure. And so what we what I just want to review initially because I'm going to show some Venus cases at least to begin with. So how do we do Venus ultrasound if it's very basic and I apologize but I just think it's important to to review this so when we look at the Venus ultrasound. I think the most important features actually a transverse grayscale image where here we have the common femal vein you have the artery in the vein. And we want to show that with compression from the transducer and you can nicely see on the clip and we ask a technologist to a sonographer studio clips like that the vein should be dark. So internal echoes and should be very easily collapsible for from, you know, just a little bit of pressure from the transducer. It's much easier to do it transverse because that you see the whole vein to make sure you're not rolling off the vein, as if you were doing it So that's the most important question in my opinion of the case to exclude a deep end homeboses. And then of course what we also look at we put color just to make sure the vein is filling the wall is thin. And then we get a Doppler spectrum because we want to make sure that there is Venus type flow which is relatively more the physics, but it just would be some facicity from transmitted respiratory and cardiac facicity to the vein. And that is a very important concept because that means that there is no blockage in between more central vein and what you're examining. And so this is what we do now we do not do augmentation in the oldest we used to augment in the capital we don't do that. First of all, it's increased the length of the examination. It's not really necessary. And, you know, if the patient does have a cloud there's always a small risk that by by doing calf compression, you can throw it from the ambulance so we don't do that anymore. Okay, so let me start with this case so this is a patient who came in to the emergency department, some years ago, and for left leg swelling. So, yeah, I'm showing you still images of the left common femal vein. And here's the arteries the vein, and with when we do the compression you can see that the vein is not compressing and there's internal echoes. So this is a, excuse me, pretty straightforward case of deep vein thrombosis. However, we always look at the Doppler spectrum as well. And even though it's a unilateral study, we always do both iliac veins, external iliac veins for comparison, we want to compare the Doppler spectrum in the in the iliac veins. And so, and I really don't want to take any credit for this case a sonographer, you know had looked at everything and based on what what she saw she did additional images but let's see what we see. So remember the left side is the swollen leg and we know there is a deep vein thrombosis. But when we looked at the iliac veins we can see and this is the external iliac vein. I think that there is a lot of phasicity on the right side, but the left side is much more monophasic. So the first question you have to answer is which side is abnormal. So in this case maybe there's a little bit more phasicity than we'd expect but this is clearly abnormal we should not have this monophasic waveform in the, in the, in the legs in the veins of the lower extremity and you could have us. This could be normal in a portal vein in the liver but it's not normal in the, in the leg and this is it's mislabeled with clearly the left iliac vein. So based on what is going on we know the patient has a clot more distally, but this portion of then appears open but if you see lack of phasicity. What you have to think about is that there may be an obstruction more centrally so we have to look in the pelvis basically. And so she went and looked around. And this is what we saw. So she, she looked in the pelvis, didn't see too much and went up the early bifurcation. And here you have the four vessels of the early bifurcation which are patterned. However, there is a big hypoechoic mass. So just adjacent to the by the early bifurcation and you can very nicely then show it on the coronal images. There's a bunch of masses, which are basically abnormally a large length notes. And that is what was causing the lack of phasicity in the left external iliac vein. So, yes, the patient had a deep pain thrombosis but by thinking about the Doppler spectrum and looking around. Okay, you have DVT but there is also something perhaps as serious or more serious going on, you have what looks like either metastatic retropionyl infatnopathy or lymphoma, one or the other. And so this is why just looking at every detail looking at the spectrum is so important because if we hadn't done that we would have sent the patient it would have been treated for DVT but they would have missed the what is probably the underlying cause of the deep thrombosis. This patient ended up having metastatic prostate cancer but that you know that doesn't matter once you find this then you'll do a full work of your CT scan or MRI etc. So this is a different case, a companion case, because I really want to stress this point so this was a 42 year old woman who presented with abdominal pain and left foot extremity swelling. And about five years prior to her presentation to the emergency department, she had had a radical hysterectomy for cervical cancer. So they requested a duplex venous ultrasound of the lower extremity. And in this particular case, all the vessels were patent. So here is the right side. Again, by now you know what I'm driving it right. This there is normal phasicity. This is an old case so we were doing augmentation at the time we don't do anymore. There is normal phasic flow in the right external aliac vein in the right common femur vein. And on the left side, you can see that there is very normal phasic flow. And if you have both sides to compare that's really so striking. So I think it's important to always look at the control at all side, at least one Doppler spectrum which is a routine. And then when we looked at the vein itself, the right common femur was compressing the left was also compressing was a little hard to compress because the patient had pain but basically the veins completely normal normal size no there was no echo genetic material within it. So again we said there is no dbt but because we saw this lack of phasicity we said okay well we don't see anything but the patient needs a CT scan to see if there is anything more centrally. So, here's the patients. So again just to recap, bilateral common femur veins are compressible there is flow demonstrated in both external aliac veins however there is what's more important the dampen flow in the left external aliac vein with lack of normal phasicity. So let's look at the next step with a CT scan and here you can see on the actual images as well as the corner images that the vein itself is painted maybe a little compressed but what is really important this patient has an aquatic mass in the left pelvic sidewall compressing the external aliac vein and that is the cause of the dampened flow in the left external aliac veins in this particular case, if we hadn't paid attention to this dampened flow we could potentially have send the patient home because we did not see a dbt. And now this patient that turns out was lost to follow up and unfortunately for her what this was was a big metastatic nodal mass from squamous cervical cancer and we know that squamous cell metastasis are often aquatic, such as this node. So this is very, very, very important to pay attention to the doctor's spectrum. And so this is basically what we need is recognize the dampened flow on one side in a vein, you have to think about a more central pathological process. So this is an upper extremity case so upper extremities are even a little bit more challenging.