Fellows Course: Live Ultrasound Cases in Venous Disease

Recurrent Venous Ulcer With Proximal Iliac Obstruction

A man with a venous ulcer, previously treated with saphenous ablation, returned with recurrence and new swelling. Prior IVUS had shown iliac vein narrowing, and faculty agreed to treat both the proximal obstruction and peri-ulcer varicosities rather than the ulcer area alone.

Ultrasound Clues to Proximal Obstruction

Faculty highlighted retrograde flow in the superficial epigastric vein, normally draining toward the junction, as a sign of proximal iliac obstruction, and noted continuous rather than phasic common femoral flow can indicate obstruction with collaterals even when phasic flow persists.

Rouleau Formation and Varicose Vein Family Risk

A second case showed Rouleau formation, red cells clumping like schooling fish under sluggish flow, at a fourteen millimeter saphenofemoral junction. Faculty cited roughly 35 percent risk of varicose veins with one affected parent, over 90 percent with both.

Choosing Ablation Access and Staging Treatment

Faculty agreed access site should follow the lowest point of reflux rather than a fixed distance, avoiding ablating nonrefluxing segments. Most staged phlebectomy after ablation, since about 60 percent of varicosities resolve without further treatment within a few months.