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2.3 · Atlas: Extremity Arteries
163
2
a
c
. Fig. 2.106a–d (Atlas) Thoracic outlet syndrome with poststenotic dilatation.
a 45-year-old patient with recurrent pain of the right hand during work (painter). With the transducer in the supraclavicular position, the transverse image (right) and the longitudinal image (left) show aneurysmal dilatation of the subclavian artery. No mural thrombi are depicted. The
aneurysm has a maximum diameter of 14mm; eddy currents in the aneurysm give rise to blue and red ow signals.
b The Doppler waveform recorded with the patient lying in a relaxed position (without provocative maneuver) shows disturbed ow but a triphasic prole without signs of hemodynamically signicant stenosis.
c Examination during Adson’s test reveals compression of the subclavian artery with color aliasing and a peak systolic velocity (PSV)>400cm/s in
the Doppler waveform (consistent with stenosis). The test is positive for a compression syndrome with poststenotic dilatation.
d Specic anatomic conditions (obesity and short neck) may prohibit proper placement of the transducer during Adson’s test. In these patients,
compression during provocation can be demonstrated by the presence of the typical poststenotic changes in the Doppler waveform sampled in
the axillary artery with the transducer placed in the infraclavicular fossa
b
d
. Fig. 2.107a–c (Atlas) Pectoralis minor syndrome.
a Ultrasound imaging of the axillary artery during hyperabduction with the transducer in the armpit reveals compression-induced stenosis as well
as complications of long-standing compression syndrome: extensive, though circumscribed, wall damage with thickening and local thrombus formation. Aliasing in the color duplex mode enables dierentiation of the perfused lumen from mural thrombus. The outer white line in the transverse view (left) indicates the normal vessel diameter. A low echogenicity and concentric wall thickening as in this case may also occur in vasculitis
(which must be considered in the dierential diagnosis when patients present with elevated inammatory markers).
b Doppler waveform showing high-grade stenosis with a ow velocity of over 3m/s, monophasic ow, and turbulence.
c Diagram of compression of the axillary artery between the pectoralis minor muscle and the coracoid process during hyperabduction (from
Heberer and van Dongen 1993)
Pectoralis
minor
muscle
164
ab
Chapter 2 · Extremity Arteries
. Fig. 2.108a–c (Atlas)
Takayasu’s arteritis with
subclavian artery occlusion.
a Long occlusion of the axillary
2
artery and distal subclavian
artery. There is conspicuous
circumferential wall thickening of
low echogenicity.
b Resupply of the axillary artery
through dilated collaterals (right)
and inammatory wall thickening
of the axillary artery (left).
c Angiogram showing occlusion
of the subclavian and axillary
arteries with good collateralization (indicating a chronic
process). The circle indicates the
site of entry of the collateral into
the artery and corresponds to the
detail shown in b. The dotted red
line corresponds to the occluded
arterial segment visualized in a
(courtesy of K.Amendt)
a
b c
. Fig. 2.109a, b (Atlas) Aneurysm of the ulnar artery (hypothenar syndrome).
a Patient with ischemia of the pads of ngers 4 and 5 due to arterial emboli from an aneurysm of the distal ulnar artery proximal to the palmar
arch. The extent of the aneurysm is outlined in the color duplex images (longitudinal on the left, transverse on the right) to illustrate the relationship between the overall size of the partially thrombosed aneurysm (20×18mm) and the patent lumen.
b Angiogram: Aneurysmal dilatation with a rather small caliber of the distal ulnar artery at the junction with the palmar arch and peripheral occlusions of the digital arteries of ngers 4 and 5. The largely thrombosed aneurysm of the ulnar artery was conrmed intraoperatively
abc
fg
de
2.3 · Atlas: Extremity Arteries
165
2
a
c
. Fig. 2.110a–e (Atlas) Interdigital artery occlusion– Raynaud’s disease.
a Interdigital arteries to the right and left of the metacarpal bones scanned from the palm show pulsatile ow (pulsatility varies with sympathetic
tone).
b In interdigital artery occlusion, the small collateral vessels show monophasic ow due to peripheral dilatation. The occluded interdigital artery
with the origin of a collateral is depicted in transverse orientation in the left section and in a longitudinal plane in the middle section. It has a
diameter of 2mm and a plaque (P) is depicted.
c Color duplex and spectral Doppler show a common digital artery in Raynaud’s disease with a diameter of 0.6mm and very pulsatile ow due to
vasospasm (atypically displayed in blue because the transducer had to be rotated to visualize the artery).
d A “knocking” waveform is recorded from the aected distal interdigital artery due to peripheral spasms associated with Raynaud’s disease.
e Arterial dilatation induced by bathing of the hand in warm water leads to less pulsatile ow with a large diastolic component.
f, g In patients with vasospasm (f), the eect of thermal vasodilation (g) can vary considerably (compare e)
b
. Fig. 2.111a–c (Atlas) Radial artery occlusion with peripheral ischemia.
a Patient presenting with index nger pain after cardiac catheter examination via the radial artery. There is a conspicuously large diastolic component in the brachial artery but with a steep systolic rise (PSV of 107cm/s, EDV of 27cm/s: peripheral widening).
b Long radial artery occlusion.
c Poststenotic Doppler waveform from the digital artery of the index nger; despite a patent ulnar artery, collateralization via the palmar arch is
inadequate (PSV of 12cm/s, EDV of 4cm/s)
167
Extremity Veins
3.1 Pelvic andLeg Veins – 169
3.1.1 Vascular Anatomy – 169
3.1.2 Examination Protocol – 171
3.1.2.1 Thrombosis – 171
3.1.2.1.1 Equipment – 171
3.1.2.1.2 Patient Positioning – 171
3.1.2.1.3 Examination Technique – 172
3.1.2.2 Chronic Venous Insuciency andVaricosis – 174
3.1.3 Normal Findings – 176
3.1.4 Documentation – 177
3.1.4.1 Deep Vein Thrombosis oftheLeg – 177
3.1.4.2 Chronic Venous Insuciency andVaricosis – 178
3.1.5 Clinical Role ofDuplex Ultrasound – 178
3.1.5.1 Thrombosis andPostthrombotic Syndrome – 178
3.1.5.1.1 Leg Vein Thrombosis – 178
3.1.5.1.2 Chronic Venous Insuciency/Postthrombotic Syndrome – 181
3.1.5.2 Varicosis – 182
3.1.6 Duplex Ultrasound: Diagnostic Criteria, Indications, andRole – 184
3.1.6.1 Thrombosis – 184
3.1.6.1.1 Controversy About theUltrasound Strategy in
Suspected Deep Vein Thrombosis – 192
3.1.6.1.2 Additional Examination oftheAsymptomatic Leg – 194
3.1.6.1.3 Pulmonary Embolism – 194
3.1.6.1.4 Diagnostic Tests Supplementing Compression Ultrasound – 195
3.1.6.1.5 Thrombus Age – 198
3.1.6.1.6 Recurrent Thrombosis – 198
3.1.6.2 Chronic Venous Insuciency – 200
3.1.6.3 Varicosis – 204
3.1.6.3.1 Treatment Options – 207
3.1.6.4 Varicophlebitis – 208
3.1.7 Rare Venous Disorders – 210
3.1.7.1 Venous Aneurysm – 210
3.1.7.1.1 Sonographic Workup – 210
3.1.7.1.2 Prevalence ofVenous Aneurysms inUltrasound Studies – 212
3.1.7.1.3 Therapeutic Relevance of Sonographically
Detected Venous Aneurysms – 212
3.1.7.2 Tumors oftheVein Wall – 213
3.1.7.3 Venous Compression – 213
3
© Springer International Publishing AG, part of Springer Nature 2018
W. Schäberle, Ultrasonography in Vascular Diagnosis, https://doi.org/10.1007/978-3-319-64997-9_3
3.1.7.4 Venous Adventitial Cystic Disease – 213
3.1.7.5 Dierential Diagnosis: Lymphedema, Lipedema – 214
3.1.8 Vein Mapping – 215
3.1.9 Diagnostic Role ofUltrasound – 216
3.1.9.1 Deep Vein Thrombosis – 216
3.1.9.1.1 Ultrasound Versus Venography – 217
3.1.9.1.2 Ultrasound forFollow-Up andTherapeutic Decision Making – 218
3.1.9.2 Chronic Venous Insuciency – 219
3.1.9.3 Varicosis – 221
3.2 Arm Veins andJugular Vein – 221
3.2.1 Vascular Anatomy – 221
3.2.2 Examination Protocol andTechnique – 221
3.2.3 Normal Findings – 222
3.2.4 Documentation – 222
3.2.5 Clinical Role – 222
3.2.6 Duplex Ultrasound Findings andTheir Diagnostic
Signicance – 223
3.2.7 Diagnostic Role ofDuplex Ultrasound Compared withOther
Modalities – 223
3.3 Atlas: Extremity Veins – 224
Super
3.1 · Pelvic andLeg Veins
3.1 Pelvic andLeg Veins
3.1.1 Vascular Anatomy
ree groups of leg veins that are aected by dierent clinical
conditions can be distinguished:
5 Epifascial (supercial) veins
5 Subfascial (deep) veins
5 Transfascial (perforating) veins
e epifascial veins belong to the supercial venous system
of the leg and the subfascial veins to the deep venous system
with the transfascial or perforating veins establishing connections between these two venous systems. e deep veins
accompany the arteries of the same name (
. Fig. 3.1 Radiographic
anatomy of the large veins of the
leg (Courtesy of Eastman Kodak
Company)
. Figs.3.1 and 3.2).
ficial veins Deep veins
169
iliac vein runs through the true pelvis posterior
e
to the iliac artery, pierces the inguinal ligament, and then
immediately passes to the medial side of the artery, where it
continues as the common femoral vein. Just below the inguinal ligament, the great saphenous vein enters the common
femoral vein on its anteromedial aspect. e common femoral vein receives the deep femoral vein just aer the division
of the common femoral artery into the deep and supercial
branches. e deep femoral vein runs between the arterial
branches of the femoral bifurcation. Distally, the supercial
femoral vein courses along the posterior aspect of the artery
of the same name. In most individuals, a second, large branch
of the deep femoral vein opens into the supercial femoral
vein. Dierent variants exist as to where, how, and how many
deep femoral vein branches enter the supercial femoral vein.
3
Femoral vein
(common)
Lateral accessory
saphenous vein
Medial accessory
saphenous vein
Great saphenous vein
Popliteal vein
Small saphenous vein
Great saphenous vein
Femoral vein
(common)
Medial cirumflex
femoral vein
Lateral accessory
saphenous vein
Femoral vein
(superficial)
Popliteal vein
Sural vein
Anterior tibial vein
Accessory saphenous
vein (posterior)
Dorsal venous arch
Normal course of veins
Fibular (peroneal) vein
Posterior tibial vein
Plantar arch
170
Chapter 3 · Extremity Veins
Femoral vein
3
Femoropopliteal
vein
Small saphenous
vein
Major anterior
tibial veins
a
Great saphenous vein
Communicating vein
Muscle fascia
Popliteal vein
Gastrocnemius
and soleus veins
Major posterior
tibial veins
Major fibular
veins
External iliac artery
Superficial epigastric
veins
Superficial circumflex
iliac vein
Profunda femoris
artery
Deep femoral
vein
Superficial femoral
artery
b
Perforating vein (superficial)
Perforating vein (deep)
External iliac vein
Common femoral
vein
External
pudendal vein
Great saphenous
vein
Femoropopliteal
vein (Giacomini)
Superficial
femoral vein
Posterior tibial vein
c
. Fig. 3.2 a Anatomic relationship between the small saphenous vein and the gastrocnemius veins entering the popliteal vein in the popliteal
fossa. The major calf veins converge distally. b Diagram of the vessels in the groin. Just below the saphenofemoral junction, the great saphenous
vein receives the lateral accessory pudendal vein and the supercial epigastric veins. Farther down, the deep femoral vein joins the femoral vein.
The arteries of the same name (red) lie anterolateral to the veins. c Perforating veins traverse the muscle fascia to drain blood from the supercial
to the deep venous system. Communicating veins connect veins within the same venous compartment
A single supercial femoral vein is present in 62% of individuals only, 21% have a duplicated vein, and in another 14%,
even three or more branches are present. If there is more than
one vein, these may vary in caliber and course lateral or anterior to the artery rather than posterior to it. While the iliac
vein has no valves, the supercial femoral vein has four or
ve valves (Weber and May 1990). Aer its passage through
the adductor canal, the supercial femoral vein becomes the
popliteal vein, which runs posteriorly along the artery of the
same name (closer to the transducer when scanning from the
popliteal fossa). e small saphenous vein joins the proximal
popliteal vein (. Fig.3.1) on its posterior aspect at a highly
variable level. Just below the saphenopopliteal junction, the
small saphenous vein perforates the deep fascia and descends
along the back of the calf. e distal popliteal vein receives
the calf muscle veins (soleus and gastrocnemius veins) at
various levels around the cle of the knee joint. Just before
owing into the popliteal vein, the proximal small saphenous
Communicating veins
vein gives o a connecting branch to the deep muscle veins of
the thigh, the femoropopliteal vein (. Fig.3.2a).
e popliteal vein may be present as a single or duplicated vessel and arises from the union of the posterior tibial
and the bular veins. It receives the anterior tibial vein as the
rst lower leg vein at a variable level. e main lower leg veins
typically follow the arteries of the same name. e anterior
tibial veins penetrate the interosseous membrane and course
along its anterior aspect. e bular veins run close to the
bula in the deep crural fascia between the supercial and
deep exors, as do the tibial veins, but on the posteromedial
aspect of the tibia.
e supercial (epifascial) venous drainage system
consists of two subsystems, that of the great saphenous vein
and that of the small saphenous vein, which receive the
larger arch veins and side branches. e great saphenous vein
extends from the back of the foot to the medial malleolus
and takes a medial course through the lower and upper leg
3.1 · Pelvic andLeg Veins
171
3
to about 2–3cm below the inguinal ligament, where it joins
the popliteal vein. ere is variation in the tributaries to the
great saphenous vein below the knee, but these are mainly
the following:
5 the posterior arch vein, which is connected to the
major deep veins, in particular the posterior tibial vein,
through the perforating veins (Cockett I, II, and III)
5 the great saphenous branch from the back of the foot
5 the anterior tributary vein.
In the thigh, connections to the deep venous system are
established by Dodd’s perforators. Just before its junction
with the common femoral vein, the great saphenous vein
receives tributary veins from the thigh and lateral branches
(lateral and medial accessory great saphenous vein), which
then establish connections to the abdominal (epigastric)
veins and become important as collaterals in pelvic vein
thrombosis (. Fig.3.2b).
e
small saphenous vein drains the lower leg and arises
at the lateral dorsum of the foot, coursing behind the lateral
malleolus to the posterior side of the lower leg, where it
ascends between the heads of the gastrocnemius and pierces
the fascia to join the popliteal vein above the knee joint cle.
e gastrocnemius veins enter the small saphenous vein just
before its termination or enter the popliteal vein directly.
In over 90% of individuals, there is a connection between
the small saphenous vein (just before its junction with the
popliteal vein) and the supercial thigh veins via the subcutaneous posterior femoral vein. is vein may also run as a
proximal continuation of the small saphenous vein in those
rare cases where the latter does not enter the popliteal vein.
e posterior femoral vein may run in the deep or supercial
compartment. In the deep compartment, it communicates
with the deep femoral veins via muscle veins of the thigh.
In many persons, a side branch of the posterior femoral vein
courses craniomedially. is branch is also known as the
femoropopliteal vein or Giacomini anastomosis. When these
veins run in the supercial compartment, they terminate in
the great saphenous vein via interconnecting veins; in the
deep compartment, they drain into the supercial femoral
vein.
Both the great and small saphenous veins have valves.
Compared with the deep veins, the supercial veins have
thicker walls with a thin muscle layer. e lumen varies with
the intravenous pressure and can be compressed by external
structures. ere is wide variation in the course of individual
veins and the connections they form.
perforating veins are transfascial veins that drain
e
blood from the supercial venous system into the major deep
veins. About 150 such short veins exist between the supercial and deep venous systems, among which the Cockett
groups I–III, the Sherman vein, and the Boyd vein are of
clinical importance in the lower leg, the Dodd group in the
upper leg, and the May perforator between the small saphenous vein and deep lower leg veins. e clinically most relevant perforators are the veins connecting the posterior arch
vein of the great saphenous vein and the posterior tibial veins
(Cockett’s group and 24-cm perforator). Direct perforating
veins connect the great saphenous vein territory with the
major deep veins (posterior tibial vein). Indirect perforators
connect these territories via the soleus and gastrocnemius
muscle veins. Boyd’s perforator courses between the great
saphenous vein and the posterior tibial vein at the level of
the tibial plateau, and a further, more cranial perforator runs
into the popliteal vein. Dodd’s perforators are the connecting
veins at the level of the adductor canal (usually two perforators between the great saphenous vein and the supercial
femoral vein). Under normal conditions, valves ensure blood
ow from the supercial to the deep venous system, while
the blood is propelled toward the heart by muscular contraction with compression of the deep veins. is mechanism
prevents backward ow into the supercial veins.
3.1.2 Examination Protocol
3.1.2.1 Thrombosis
3.1.2.1.1 Equipment
e ultrasound examination of the peripheral veins depends
on the clinical question to be answered. If the clinical symptoms suggest thrombosis, compression ultrasound of the
upper and lower leg veins of the aected side is indicated.
In patients with suspected chronic venous insuciency, the
ultrasound examination includes assessment of valve competence by spectral Doppler interrogation during compression
and release to elicit reux. e deep leg veins are scanned
using a transducer operating at 5–7.5MHz, while the pelvic
veins and the vena cava are examined at 3.5–5MHz (depending on the depth of the target vein). e supercial veins
and particularly the perforating veins should be imaged at
7.5–10MHz.
A linear or curved array transducer can be used. To
achieve full compression of muscle veins and major lower
leg veins in transverse orientation, however, the footprint for
compression ultrasound should not be too small. To depict
the slow venous ow, scanning is performed with a low wall
lter and a low pulse repetition frequency (PRF). Most manufacturers provide a slow ow preset package optimized for
imaging the veins.
3.1.2.1.2 Patient Positioning
e inferior vena cava and iliac vein are examined with
the patient in the supine position. If there is overlying air,
improvement may be achieved by repositioning the patient
on the right or le side; bowel gas can be pushed aside by
applying pressure with the transducer. e femoral vein is
scanned in the supine patient with the knee slightly bent and
a slight outward rotation of the leg. An experienced examiner can scan the popliteal vein and lower leg veins with the
patient in the supine or semilateral position and the knee
slightly bent. Alternatively, the popliteal vein can be examined with the patient in the prone position. However, to avoid
collapse of the veins due to hyperextension of the knee, the
172
Chapter 3 · Extremity Veins
3
. Fig. 3.3 Sonographic anatomy of the junction of the supercial (V.F.S) and deep (V.P.F) femoral veins. There are usually two main branches
of deep thigh veins that join with the supercial femoral vein to form the common femoral vein. One passes under the supercial femoral artery
just below the femoral bifurcation, and the second (the one seen in the image) enters the femoral vein slightly more distally. Thrombosis of this
vein is rare and nearly always involves this more distal branch. The Doppler waveform from the deep femoral vein shows respiratory phasicity and
sometimes also cardiac pulsatility (as seen here)
ankle should be slightly elevated by placing a cushion underneath. When the patient is sitting or standing, venous ow is
increased and the veins below the knee are easier to identify.
However, muscle tone is also increased, making it more difcult to assess vein compressibility. Valve competence in the
popliteal vein, the supercial lower leg veins (varicosis), and
the perforating veins is best evaluated in the sitting patient.
e proximal great saphenous vein and the femoral vein
are examined with the patient supine and performing the
Valsalva maneuver (like the femoral artery; . Figs.3.3 and
3.69 (Atlas)).
3.1.2.1.3 Examination Technique
In the diagnostic evaluation of thrombosis, the deep veins
are continuously scanned from the groin to the ankle and
checked for the presence of intraluminal thrombi by intermittent compression (. Figs.3.4 and 3.17). First, the common femoral vein is identied on the medial side of the
common femoral artery below the inguinal ligament and
followed in transverse orientation down to its junction with
the supercial femoral vein. Along the course of the common
femoral vein, the terminations of the great saphenous vein
and of the deep femoral veins from the upper leg muscles are
tested for compressibility as well (
. Table3.1 and . Fig.3.2).
At the pelvic level, compression ultrasound does not yield
valid results because a continuous structure against which to
compress the veins is not available, and the abdominal organs
and fatty tissue preclude reliable compression, in particular
in obese patients. Nevertheless, compression ultrasound can
be performed, especially in slender patients. e arched iliac
veins in the true pelvis are tested with the transducer in transverse orientation with additional longitudinal scanning as
required. If adequate evaluation of compressibility is not possible in this way, patency must be evaluated by color duplex
imaging.
. Fig. 3.4 Compression ultrasound applying pressure with the trans-
ducer alone is inadequate at the level of the adductor canal. Instead,
the examiner must additionally push the vein against the transducer
from below with the at hand
If the scanning conditions are poor, occlusive thrombosis of a pelvic vein can be ruled out by spectral Doppler
imaging of the junction of the common femoral and external
iliac veins, where the insonation window is good. When an
obstruction is present, respiratory phasicity of ow is eliminated or reduced compared to the unaected side. Doppler
measurement is performed in the external iliac vein (posterior to the artery) somewhat above the inguinal ligament in
the longitudinal plane and with a low PRF.With the patient
stretched in the supine position, the common femoral vein
segment passing under the inguinal ligament may be compressed, especially in slender patients. In such cases, visualization can be improved by slight outward rotation of the hip
joint.
3.1 · Pelvic andLeg Veins
. Table 3.1 Ultrasound examination of the leg veins
173
3
Ultrasound
mode
B-mode Scan
(Color)
duplex
Parameter Scan orientation and
diagnostic information
obtained and documented
Transverse (except for external
orientation
Criteria Compressibility
Note Reversed compression
Documentation
Scan
orientation
Criteria Spontaneous ow, augmented
Note Spectral Doppler always in
Documentation
and internal iliac veins)
Lumen width
Wall morphology
Internal structures
maneuver in adductor canal
Split image: without/with
compression
Normal ndings as outlined in
the text, abnormal ndings
according to the situation
Longitudinal plane, overview
in transverse plane
ow (Valsalva, compressionand- release maneuver)
Color lling of lumen (gaps?)
Wall contour abnormalities,
perivascular structures
longitudinal orientation
B-mode image with corresponding waveform, color ow
image as needed
Next, with the patient in the supine position, the super-
cial femoral vein
is followed down the leg in transverse orientation and is intermittently compressed (every 1–2cm). e
termination of the deep femoral vein is examined by color
duplex ultrasound in the longitudinal plane (. Fig.3.3). In
the distal segment of the supercial vein, at the level of the
adductor canal, compression is dicult due to the absence
of a bony structure and the interfering connective tissue.
Instead, the examiner must press the muscle and vessels
against the transducer from below with his or her other hand
to achieve adequate compression (. Fig.3.4).
Below the adductor canal, the popliteal vein is scanned
from a posterior approach. is part of the examination is
performed with the patient supine and the knee slightly bent
or in the prone position with a support under the ankles.
e bent knee ensures better lling and hence improved
visualization. With the knee stretched or even overstretched
in the at position, the popliteal vein is oen collapsed or
compressed by the surrounding connective tissue structures,
pushing the vein against the artery and bony structures.
. Fig. 3.5 Compression ultrasound of the lower leg veins (course marked).
The transducer is positioned on the calf such that the ultrasound beam is
perpendicular to the interosseous membrane between the tibia and bula
Following evaluation of the popliteal vein for compressibility in transverse orientation, it is followed downward to
the conuence of the bular and posterior tibial veins. e
anterior tibial vein entering at a higher level is oen identied
at its point of entry by means of color duplex only. e anterior tibial artery can serve as a landmark for identication
of the accompanying anterior tibial veins. Compressibility is
then evaluated intermittently while following their course to
the ankle from an anterior approach.
For scanning of the
posterior tibial vein, the transducer
is placed on the extensors and then moved so as to achieve
a beam direction roughly perpendicular to the interosseous
membrane between the tibia and bula. e procedure for
evaluation of the bular and posterior tibial veins including
intermittent testing for compressibility is the same as for
the anterior tibial vein, except that the transducer is in a
posterior position on the gastrocnemius muscle (. Fig.3.5).
While the popliteal and femoral veins are reliably identied by B-mode ultrasound, the veins below the knee may have
to be localized using the arteries of the same name as landmarks, which are visualized by color duplex. e hyperechoic
interosseous membrane is an anatomic landmark for identifying the anterior tibial artery and vein coursing in it,
whereas the deep crural fascia between the deep exors and
the soleus and gastrocnemius muscles is not always depicted
well enough to serve as a landmark for identifying the posterior tibial and bular veins coursing in it (
. Fig.3.6). e
bular vein is easier to identify from the posterior approach,
as it courses close to the bula (and the proximal anterior
tibial vein from the anterior approach). Sonographic evaluation for thrombosis can be performed with the patient in the
supine or prone position, but better lling facilitates visualization of the veins in the sitting patient.
In addition to the major veins of the calf, evaluation of
patients with suspected thrombosis also includes testing the
compressibility of the muscle veins (the gastrocnemius veins
joining the popliteal vein) and of the soleus veins joining the