Q&A Case Study With Joseph Zygmunt Jr., RVT

What type of venous disease did your patient have?

A 48-year-old woman came to my office with leg pain, varicosities and recurrent superficial phlebitis of the medial calf. She had first noticed a bulging vein on her left medial calf about six years ago, which slowly got worse over time as did her symptoms. She came to our facility in August 2004 for a second opinion. She was previously seen in two different “vein clinics” and had duplex ultrasound scans done by “experienced techs.” The woman was disappointed and given poor prognosis. Her original diagnosis included DVI, deep-vein incompetence, and no treatment options [had been] offered aside from lifetime use of compression hose.

What was your patient’s history with the disease?

Records from previous ultrasound studies were obtained which reported the following findings:

Study 1 from Dec. 15, 2003: There is a focal area of superficial thrombus involving a branch of the great saphenous vein. There is deep and superficial venous insufficiency. (Details from the body of the report: Incompetence of the left femoral vein and incompetence of the saphenofemoral junction.)

Study 2 from Jan. 16, 2004: Chronic thrombus of below-knee varicosity, no acute thrombus. (Details from body of the report: Incompetence of the deep-vein system and incompetence of great saphenous vein. Note: Reflux in the deep system ceases with GSV compression at the knee.)

After a history and physical examination, a new ultrasound evaluation was performed in August 2004 at our facility, which revealed the following vein map and impressions:

Our impressions were the following: GSV measures 8.9 to 9.5 millimeters in the thigh; the GSV is located in a more anterior position than normal, along the midline in the upper two-thirds of the thigh. There is a saphenofemoral junction incompetence of 4 to 5 seconds. There is thrombophlebitis of the distal saphenous segment—below-knee varicosity. The deep system shows no evidence of obstruction of insufficiency.

What treatment did you recommend?

Treatment of the incompetent great saphenous vein was performed with a 980-nm laser ablation, with phlebectomy of the below-knee varicosities and extraction of the chronic thrombus.

During post-laser treatment, the patient wore a surgical dressing for three days, followed by 30 to 40 mmHg compression hose for seven days. The patient had an uneventful post-operative course with little to no discomfort and prompt resolution of her preoperative symptoms. On follow-up about 6 weeks after the endovenous ablation, the following ultrasound image was documented:

At 45 days, ultrasound-guided sclerotherapy was performed along the medial calf and lower leg using 5 cubic centimeters of 2 percent Sotradecol foam. Following these injections, 7 to 10 days of compression hose was carried out. The patient was seen again at six and 12 months, at which time the patient reported resolution of symptoms. After one year, there was sonographic absence of the ablated vein. She was discharged from active care and instructed to return to the office only if further pain, swelling or additional varicosities appeared.

What was your final medical opinion on this case?

This woman presented with an anatomic variation in her great saphenous vein distribution which lead to misdiagnosis. Fortunately, the misdiagnosis did not lead to an inappropriate interventional treatment, and, therefore, she was not harmed.

Proper ultrasound diagnosis utilizing both the fascial relationships to correctly identify the saphenous vein and the alignment sign over the deep femoral vessels allowed for proper identification of primary saphenous incompetence, which was easily treated with endovenous thermal ablation.

This case was selected to emphasize the importance of proper ultrasound diagnosis techniques and the value that a “vein map” brings to planning interventional therapy of this type.

Please send questions or comments to Joseph Zygmunt Jr., RVT, at [email protected].