SVU Open Forum

​​Thanks for all of the good information. I appreciate the tips and help. I know many Sonographers that are not familiar with this condition, hopefully the posts will be helpful to them too.

It is interesting to use the Hamburgo classification.

I've seen a few of them over the years, but one stands out in my mind. A woman in her 70's + or -, presented with what she called her "milk leg". Gradually over the last 30 years or so her left leg had become increasingly more edamatous. Every time she went to a new PCP they ordered a DVT study, which of course was normal. I did the same and found no DVT but it seemed to me someone should look further. I scanned her iliac vein and the vein configuration that Ms. McAdam mentioned was obvious at about the level of the distal common iliac vein. Connections could be seen to iliac artery branches. Our wonderful vascular team fixed her up in no time and her leg returned to it's usual size - much to her delight.
As far as advice, when you see one you will know it. I didn't see red patches in this case, but that was a good clue to discover the AVM. About the best way I can describe them is think of a jumbled up speghetti mop with flow in it. They're not always associated with varicosities, as in this case. And it is essential to document flow in the associated vein and artery.
As for the gentleman who said other imaging modalities are better, he may be right, but we vascular techs will see them - after all we are looking at arteries and veins. Good luck

I have seen two patients with AVM's. The most recent was a young woman who has significant varicose veins, patchy large red areas on her lateral thigh and medial calf (port wine staining). The patient was diagnosed with Klippel-Treaunay syndrome prior to her visit at our facility. Here are a few tips if you should ever come across a patient with this presentation:
1. Follow the usual protocol for r/o dvt study. Get that out of the way.
2. Use the red patchy areas as your guide to the AVM.
These areas are a cluster of small highly pressurized veins that tend to bleed when the skin is nicked. Use care. These are associated with the AVM
3. Identify the varicosities that are are directly associated with this area and follow it proximally in transverse. You should run into a large vessel that is pulsing.
4. Put color on these large vessel. You should have color filling and spectral flow characteristics consistent with a AVM. Take diameter measurements.
5. The AVM(s) will be above the level of the large varicosites and red patchy areas. There can be more than one in an extremity.
6, If it is congenital, these patient's tend to be young. They will say that they have "always had that spot on my leg and it got bigger as I got older" They will have chronic swelling, sometimes lymphedema is associated with this disorder.
7.An aquired AVM will present differently, I did see a man two weeks ago who had complaints of right lower quadrant pain. A CT scan showed a dialted right iliac veins, the left was of normal size. The patient reports having been shot 65 years before. I do the iiocaval segment evaluation and I do see that the right external iliac is dilated with rather pulsatile flow. The left external iliac vein has normal appropriate venous flow. I move on the right leg and find that the veins son't compress as easily as they should and at mid thigh I find a very large femoral vein. I place my color on the vessel and low and behold the patient has high velocity low resistence and turbulent flow consistent with a acquired AVM.
As Mark said before, these can be quite varied and complex. The take away for me was paying attention to the venous system when evaluating for AVM or if your duplex findings are pushing you in that direction. Always ask if the patient has had traumatic injury in the limb and or area in question.
Hope this is helpful!

There is really very little if any role for duplex ultrasound in most of these patients, unless there are secondary symptoms referrable to claudication or deep vein thrombosis (uncommon). This is a clinical diagnosis for which CT and MR imaging is done where there is an intention to treat.

As an RVT scanning patients like it is a production job at fox con ( Chinese I phone assembly), I have seen a few cases. But, nothing like you are describing. Example one: Female, mid 30s, fit, c/o pulsing throbbing sensation during and after she has ran a few miles with the lateral thigh becoming "Puffy". A Physiological arterial was ordered. The exam was normal of course. The whole runner thing kinda gave it away there. But, she didn't look that crazy, so I put the ol transducer down on the symptomatic site, saw what appeared to be varicosities, hit the color button and it looked like the fourth of July. Checking the flow in the femoral and popliteal really sealed the deal. Lot of edv very similar to an AVF, but to a lesser degree. Example 2: 12 y/o female athlectic has an unusual red patch on her upper back, very small. This was more of a micro vessel, much like reticular veins, but definitely there was an arterial component. The 30 y/o had an intervention with no further complications. I believe the 12 y/o was just monitored. So, there are many variations some may have multiple, complex issues like someone posted a few weeks back. But there are a broad range of variants for sure. Talk to your patients, do not allow a Radiologist or any Dr. to make you check your brain at the door!