0:00

I'm gonna spend the rest of the time talking about

0:02

the vasculature.

0:04

Uh, so the vessels here.

0:06

I'm just gonna focus on the large vessels.

0:09

We're gonna focus in on the artery, uh, and the vein.

0:12

These travel together,

0:14

I think if there's one thing you just wanna remember,

0:15

they should be together, but right next to each other.

0:20

And, uh, they generally live posterior

0:25

or just slightly lateral to posterior

0:27

with the artery located ant medial, uh, to the vein,

0:32

I always like to do a quick look, uh, at these, uh, areas

0:35

because it's embarrassing to miss, uh, pathology,

0:39

uh, involving them.

0:41

Now, in terms of the popliteal vein, really the only thing

0:44

that I look at the popliteal vein for is

0:47

to see if I can identify thrombosis.

0:50

And this is not a good test for popliteal vein thrombosis.

0:54

Uh, ultrasound is much more accurate

0:58

'cause there are a lot of pitfalls in the vein here.

1:01

You get flow effects.

1:02

So the signal in the vein is highly variable due

1:05

to flow effects, and it can look bright without there

1:08

being any clot.

1:09

So I'm looking more

1:10

for per venous inflammation rather than the signal

1:15

inside the vein, uh, itself.

1:18

So you get a lot of flow issues

1:20

and it can be collapsed, so you don't even see it.

1:23

So in this patient, we can see the artery notice the phase

1:26

ghosting from the pulsations in the artery,

1:29

but I can't even find the vein.

1:31

Sometimes patients that have sluggish flow

1:35

or deep varicosities will show fluid,

1:38

fluid levels in the veins.

1:39

Again, this is not a sign of a clot.

1:42

So these are just some pitfalls that you don't want

1:45

to call a clot just because it's bright, invisible,

1:49

or has levels within it.

1:51

I think the main thing that lets me know that I'm dealing

1:53

with clot is the perivascular inflammation.

1:57

Now, this is a patient with a huge clot,

1:59

with a large bright filling defect, which, uh, corresponded

2:04

to thrombus on the ultrasound,

2:06

but notice all of this inflammation around it

2:10

and that when you see a lot of per venous inflammation,

2:14

at least think of this entity

2:16

and certainly, uh, consider ordering, uh, an ultrasound

2:20

because you're probably not going to be able

2:23

to make the diagnosis accurately, uh, from mr.

2:26

Now, that's, that's my opinion.

2:28

Uh, there are articles describing, um, MR of DVT

2:33

that actually say that it's very sensitive.

2:36

And in this paper by Wester beak, uh, they said

2:40

that they were able to diagnose Frank Clot

2:43

and the majority of patients with acute DVT

2:47

and that they persisted for weeks.

2:49

And in fact, they said they could continue to see clot

2:52

after it had resolved, uh, with ultrasound.

2:55

So, I, I don't know about that,

2:56

but that hasn't been my experience,

2:58

Uh, so far.

3:00

So this is, again, from their article, is that you can see

3:04

abnormalities on Mr

3:06

after the col clot had resorbed on ultrasound.

3:09

I think the inflammation can certainly persist,

3:12

but I'm not sure you're gonna see the bright filling

3:14

defects, uh, in there.

3:15

But this is really, this is what I look for.

3:19

If I see a lot of per venous inflammation, uh, then,

3:23

you know, I think that patient, uh,

3:25

especially in the right clinical setting

3:26

should get an ultrasound.

3:28

This is another example of a patient with clot.

3:32

Again, this case you can see it looks very irregular.

3:35

This doesn't look like a flow artifact.

3:38

There's filling defects.

3:39

And this patient had much more extensive, uh,

3:42

inflammatory change, uh, in their leg related

3:46

to a deep venous thrombosis.

3:48

And Brady Huang has written a really nice article about

3:52

clots in the medial, uh, gastroc anemia,

3:55

which show similar, uh, findings.

3:58

And so this inflammatory reaction is really

4:01

what we wanna look for.