0:00

Okay, so let me start with this case.

0:02

So this is a, uh, patient who came in

0:06

to the emergency department some years ago, uh,

0:10

and for left leg swelling.

0:12

So here I'm showing you, uh, still images

0:15

of the left common femoral vein.

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So yes, the artery is the vein,

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and with, when we do the compression, you can see

0:24

that the vein is not compressing

0:25

and there's internal echoes.

0:27

So this is a, excuse me,

0:32

quite straightforward case of deep vein thrombosis.

0:37

However, we always look at the darker spectrum as well.

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And even though, uh, it's a unilateral, um,

0:47

study, we always do both iliac veins,

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external iliac veins.

0:52

For comparison, we want

0:53

to compare the doppler spectrum in the, in the iliac veins.

0:58

And so, uh,

0:59

and I really don't wanna take any credit for this case,

1:02

a sonographer, you know, had looked at everything

1:04

and based on what, what she saw, she did additional images.

1:09

But let's see what we see.

1:11

So remember the left side is a swollen leg,

1:13

and we know there is a deep vein thrombosis,

1:16

but when we looked at the iliac veins, we can see,

1:21

and this is the external react vein.

1:23

You can see that there is a lot of ity

1:27

on the right side,

1:29

but the left side is much more monophasic.

1:32

So the first question you have to answer is,

1:34

which side is abnormal?

1:35

So in this case, maybe there's a little bit more ity than

1:38

would expect, but this is clearly abnormal.

1:41

We should not have this monophasic, uh, wave form in the,

1:45

in the, in the legs, in the veins of the lower extremity.

1:49

You could have a, a,

1:50

this could be normal in a portal vein in the liver,

1:52

but it's not normal in the, in the leg.

1:56

And this is, uh, it's mislabeled.

1:58

It's clearly the left iliac vein.

2:01

So based on what is going on,

2:04

we know the patient has a clot more distally,

2:07

but the, this portion of Dana appears open.

2:10

But if you see lack of ity, what you have

2:14

to think about is

2:15

that there may be an obstruction more centrally.

2:18

So we have to look in the pelvis, basically.

2:21

And so she went and looked around

2:25

and this is what we saw.

2:26

So she, she looked in the pelvis, didn't see too much

2:30

and went up the aortic bifurcation.

2:33

And here you have the four vessels

2:35

of the aortic bifurcation, which are patent.

2:38

However, there is a big hypoechoic mass

2:43

just adjacent to the bi, the aortic bifurcation.

2:47

And you can very nicely then show it on the coronal images.

2:50

There's a bunch of masses which are basically

2:53

abnormally enlarge lymph nodes.

2:56

And that is what was

2:58

Causing the leg lack of ity in the left

3:02

external iliac vein.

3:04

So yes, the patient had a DeepEnd thrombosis,

3:06

but by thinking about the DARPA spectrum

3:09

and looking around, we said, okay, you have DVT.

3:12

But there is also something perhaps as serious

3:16

or more serious going on, you have

3:18

what looks like either metastatic troper, lymphadenopathy,

3:22

or lymphoma, one or the other.

3:24

And so this is why just looking at every detail,

3:28

looking at the spectrum is so important

3:30

because if we hadn't done that, we would've sent a patient,

3:33

it would've been treated for DVT, but they would've missed.

3:36

So what is probably the underlying cause

3:38

of the deep faint hobos?

3:40

This patient, uh, ended up having metastatic prostate

3:44

cancer, but that, you know, that doesn't matter.

3:45

Once you find this, then you'll do a full workup,

3:48

you'll do CT scan or MRI, et cetera.