Abstracts Selected for the D. E. Strandness Scientific and Clinical Papers Session

Presented at the SVU 2023 Annual Conference

August 23-26, 2023

New Orleans, LA

Experience of Implementation of the 2021 Intersocietal Accreditation Commission (IAC) Recommended Modified SRU Consensus Criteria for Diagnosis of Internal Carotid Artery Stenosis: A Survey of IAC Accredited Facilities

Marge Hutchisson, Mary Beth Farrell, Michael Lilly, John Pellerito, Joseph Polak, Laurence Needleman, Heather L. Gornik, IAC Vascular Testing, Ellicott City, MD, USA

Introduction: There are no universally accepted duplex ultrasound carotid diagnostic criteria. The Society of Radiologists in Ultrasound Consensus Criteria (SRUCC) is one set of criteria. In 2021, a published validation study of the SRUCC proposed modifying the peak systolic velocity (PSV) cut-point for a more accurate diagnosis of >50% internal carotid artery stenosis. A 2021 statement by IAC Vascular Testing recommended the use of the modified SRUCC in its accredited facilities. We sought to assess awareness of this statement and experience with the implementation of the modified SRUCC.

Methods: An electronic email survey was sent to 2307 medical and technical directors of vascular laboratories accredited in extracranial carotid (EC) testing as of December 2022. The survey was sent on April 1, 2023, with 2 email reminders.

Results: There were 574 respondents (24.9% response rate): A total of 403 technical directors and 171 medical directors from 528 vascular laboratories (41.8% of EC accredited labs). Notably, 87% were familiar with the 2021 IAC statement; among those familiar, 60% had implemented the modified SRUCC, and 17% planned to do so. The experience of implementing the new criteria was positive (55%) or somewhat positive (15%). Negative reactions to implementing the new criteria by stakeholders were low (somewhat negative/negative: interpreting physicians 4%, technologists 9%, and referring physicians 8%). Among implementers, 26% evaluated the impact of discordance from prior studies, and 24% planned to do so within 6 months. Divergent interpretations from prior studies were most commonly managed by a comment in the written report. Only 32% of implementers educated referring providers regarding the new criteria. Among implementers, 77% supported IAC requiring implementation of the modified SRUCC in its standards.

Discussion and Conclusion: Notably, 60% of respondents familiar with IAC recommendations have implemented the 2021 modified SRUCC; another 17% plan to do so. Among implementers, the experience was largely perceived as positive. There are opportunities for educational initiatives and future studies to evaluate the impact of adopting the IAC-modified SRUCC.

Surveillance Post-endovascular Aortic Aneurysm Repair: Are We Getting It Right?

Brigid G. Hill, MSc, University of Otago, Otago, New Zealand

Introduction: An endoleak can occur following endovascular aortic aneurysm repair (EVAR). In Otago post-EVAR ultrasound imaging occurs at 1, 6, and 12 months, followed by life-long annual surveillance. Recent guidelines have proposed a less intensive regime: surveillance at 5 years if an endoleak was absent at the first follow-up. This audit was conducted to determine the timing and occurrence of endoleaks in our cohort as per our current surveillance protocol to guide the development of future guidelines for the New Zealand population.

Methods: A single-center retrospective audit of the post-EVAR ultrasound surveillance regime was conducted, including all records from 2008 to January 2023. General characteristics were obtained from patient records. Duplex ultrasound images were used to determine the timing and type of endoleak, with measurements of aortic sac size recorded at each visit. Descriptive data are shown with continuous data shown as mean (95% confidence interval (CI)).

Results: The cohort consisted of 342 patients (83% male) with >60% with 1+ risk factors (eg, smoking, dyslipidemia, and hypertension) with EVAR conducted at 77 years of age (76.1-77.7). At the database interrogation date, 170/342 remain under surveillance with all-cause mortality or frailty as the major reason for loss to follow-up between 4 and 5 years post-EVAR. Endoleak was detected in 43.3% of patients, with 18.3%, 73.7%, 6.9%, and 1.1% Type 1, 2, 3, and 4/5 endoleak, respectively, and categorized into early (initial scheduled scan) or late (at/after 6-month scan). On average, an endoleak was detected at 2.2 (1.7-2.6) years post-EVAR. Scans conducted between 0.5 and <5 years detected an endoleak, 81% type 1 (a or b), and approximately 28% significant type 2.

Discussion and Conclusion: Our audit data show that the proposed modified surveillance regime would result in a missed opportunity to identify many occurrences of clinically significant endoleak in our Otago Vascular Diagnostic post-EVAR cohort, including approximately 41% of endoleaks clinically deemed to require intervention.

A Deep Learning Network to Perform Reconstruction and Automated Detection of the Carotid Artery Using 2D Ultrasound Images

Kashif Khan, PhD, Sonaro, Montreal, Québec, Canada

Introduction: Vascular ultrasound examinations are prone to misdiagnoses and lengthy examination times due to the dependence on the user’s expertise. Important vascular metrics, such as vessel size and thickness, can be misinterpreted based on the angle of the probe with no means to confirm the validity of the examinations. We have created a program that utilizes 2D ultrasound images and deep learning to reconstruct 3D images of the carotid arteries. These reconstructed images provide automated and accurate detection of vessel characteristics.

Methods: A Clarius L15 linear ultrasound probe (Clarius Inc, Utah, United States) captured all B-mode ultrasound information, and a camera consisting of a red-green-blue sensor, an infrared sensor, and an inertial measurement unit (IMU) was placed on the probe to capture positional information. A total of 400 ultrasound images were used to train the deep learning network, separated into 60% training, 20% validation, and 20% testing data. Two independent vascular experts performed annotations on the training data using CoreSlicer (Version 5.0.3) to segment the carotid artery from other vascular structures. The intersection-over-union (IOU) metric was used to measure the agreement between manual segmentation and those generated by the deep learning model.

Results: The IOU for carotid artery detection was 99.5%. Accurate 3D reconstructions were achieved by combining 2D ultrasound data with positional information to obtain metrics such as vessel diameter and wall thickness.

Discussion and Conclusion: This is the first study to analyze vascular metrics from 3D ultrasound reconstructions of 2D examinations combined with deep learning. These 3D reconstructions provide a fast and cost-effective strategy for complex vascular ultrasound examinations. Furthermore, these images provide diagnostic standardization of ultrasound images which allow for accurate and early diagnosis, especially in regions where ultrasound expertise may not be readily available.

Ischemic Stroke Risk for an Internal Carotid Artery Peak Systolic Velocity Between 125 and 180 cm/s

Joseph F. Polak, MD MPH, Tufts Medical Center, Jamaica Plain, MA, USA

Introduction: A Doppler peak systolic velocity (PSV) of 125 cm/s has been used to indicate the presence of a significant 50% internal carotid artery stenosis, a marker for increased risk of ischemic stroke. Shifting this cut-point to 180 cm/s might affect assessing the risk of ischemic stroke.

Methods: Color Doppler-assisted measurements of PSV were performed at the baseline visit of a large longitudinal cohort study in the United States: The Cardiovascular Health Study (CHS). Incident ischemic stroke within the following 6 years was ascertained by an adjudicated review of medical records. The side of the ischemic stroke was recorded. Incidence rates and odds ratios (logistic regression models) were estimated at the respective 125 and 180 cm/s cut-points.

Results: The mean age was 72.8 years with 57.6% women. A total of 11,425 carotid bifurcations had PSV measurements. There were 514 bifurcations with PSV above 125 cm/s and 126 bifurcations with PSV above 180 cm/s. The incidence rate of ischemic stroke was 2.0 (95% confidence interval (CI): 1.8, 2.3) per 1000 bifurcations-years for PSV <125 cm/s, 3.9 (95% CI: 2.3, 6.5) for PSV between 125 and 180 cm/s, and 6.1 (95% CI: 2.7, 13.5) for PSV ≥180 cm/s. The odds ratio of 1.75 (95%, CI: 1.01, 3.02) for incident stroke for a PSV between 125 and 180 cm/s was significantly increased (p<.05) when compared with a PSV < 125 cm/s (baseline = 1).

Discussion and Conclusion: Shifting the PSV for a 50% internal carotid artery stenosis from 125 to 180 cm/s would have significant implications when identifying the risk of ischemic stroke.

Medial Artery Calcification Score and Pedal Acceleration Time in Diabetic Patients Are Comparable as Predictors of Wound Healing: A Pilot Study

Irene Ahmed, Washington State University, Spokane, Washington, USA

Introduction: Diabetic foot ulcers (DFU) are common occurrences that can lead to amputation. Non-invasive tests such as ankle-brachial index and toe pressure can be erroneous due to medial arterial wall calcification. Pedal acceleration time (PAT) is a novel test that directly evaluates foot perfusion. Our group has shown that PAT predicts wound healing if the PAT is less than 180 ms (class 1 or 2). Ferraesi et al. published a scoring system to classify small artery disease (SAD) in the pedal arteries using a medial artery calcification (MAC) score. A MAC score of 2 or greater predicts major adverse limb events. We sought to analyze the MAC score and compare it with PAT in diabetic patients with non-healing ulcerations. We hypothesized that these 2 novel techniques are comparable in predicting limb salvage.

Methods: This is a retrospective review of a prospectively kept database in a single center. Inclusion criteria are all diabetic patients with varying degrees of tissue loss. Demographic data included PAT in the dorsal metatarsal, arcuate, medial, and lateral plantar arteries and at the base of the wound. Hemoglobin A1c and MAC score of standard foot X-rays were analyzed using the Kruskal-Wallis test.

Results: A total of 33 limbs met inclusion criteria from 2022 to 2023. The mean age is 68 years, gender is 65% male, 20% of patients had a history of smoking, 5% were on dialysis, and 17% had osteomyelitis. We can conclude that there is a significant correlation between PAT and MAC scores with a 90% confidence level. Patients with a MAC score of 2 or less and PAT class of 2 or less achieved full wound healing.

Discussion and Conclusion: In the setting of a DFU, wound healing is associated with a PAT Class of 2 or less and a MAC score of 2 or less. More studies are needed to correlate MAC scores and PAT in all patients with chronic limb-threatening ischemia.

The Use of Intravascular Lithotripsy in Patients with Calcified Lesions

A Mannan Vohra, BS RVT, University of Chicago Medicine, Chicago, IL, USA

Introduction: Patients with peripheral arterial disease and diabetes are at a higher risk of developing calcified lesions. Those with calcified lesions remain symptomatic, as arterial calcification has been included in exclusion criteria in the utilization of endovascular treatments. Alternative methods are now available for the treatment of significant calcified lesions. One method that has gained considerable recognition is the use of intravascular lithotripsy/lithoplasty (IVL). Our institution encounters a large patient demographic that presents with significant calcified lesions, which inhibit our vascular surgeons from performing endovascular treatments. The use of IVL has made it possible to treat these lesions.

Methods: A literature search was performed to study the effectiveness of using IVL in patients with vascular disease. Data were analyzed to determine if the use of IVL resulted in a significant difference in the treatment regimen in patients with calcified vessels. Preoperative and postoperative ultrasound images and angiograms were then compared to determine if perfusion improved.

Results: A review of the literature suggests the use of IVL in patients with severe arterial calcification has resulted in significant improvement in vessel perfusion, allowing completion of endovascular procedures. Intravascular lithotripsy/lithoplasty has reduced surgical complications involving the arterial walls when compared to alternative methods. Follow-up duplex ultrasound studies suggest improvement in perfusion in the IVL-treated vessels.

Discussion and Conclusion: As rates of calcified arterial disease rise and remain clinically challenging to treat, standard mechanisms have yielded suboptimal results. The use of IVL has become a proven treatment for severe calcific lesions, making it possible to perform endovascular treatments. The literature review suggests a lower probability of arterial injuries. With the emergence of IVL in the vascular field, IVL now offers interventional surgeons an opportunity to modify calcified plaque and utilize additional treatment plans, yielding improved long-term results.

Use of a Mini-Practice Audit Model to Improve Ultrasound Reporting

Elizabeth Wooster, BComm MEd PhD, Toronto, Ontario, Canada

Introduction: The application of current guidelines is vital to patient care, but implementation is low. Physicians are often unable to accurately self-assess; however, guided self-reflection, such as audits, can assist in identifying areas of strengths and weaknesses. Audits are often viewed as intimidating. The mini-Practice Audit Model (m-PAM) involves personalized mini-audits (m-PA) which reflect the individual’s practice profile and allow planned education. This has been shown to improve physician knowledge, change behavior, and impact patient care.

Methods: Mini-practice audits were developed for carotid, aortic, and lower extremity (LE) arterial and venous studies. Reports in each study area were obtained from 5 RPVI-registered reporting physicians and parsed by one of the authors to obtain data to populate the m-PA matrices. These were analyzed to identify strengths and weaknesses in each domain for each study area. These were collated with educational activities and opportunities for re-audit. The identities of the patients and the physicians were anonymized and stored in secure password-protected files.

Results: A total of 86 reports were audited with 14 to 64 elements in 5 to 8 domains in each matrix. The total data points collected were 2694. Specific elements that fell below expectations included: for carotid reports—external carotid artery, change from previous (Cp), and critical finding (CF); for aortic reports—suprarenal and iliac extent; for LE arterial reports—size, TBI, Cp, and CF; and for LE venous reports—incidental findings, Cp, and CF. Eleven potential personalized education activities and re-audit opportunities were identified.

Discussion and Conclusion: The m-PAM process can identify domains for improvement in vascular ultrasound reporting. The m-PAM process links directly with education and re-audit opportunities. Broader application and possible uptake by accrediting agencies or specialty societies for quality improvement activities on both individual and group basis is suggested.

Upper Extremity Arterial Aneurysms: Correlation of Clinical, Ultrasound, and Operative Findings

Douglas Wooster, MD, DFSVS, RVT, RPVI, Toronto West Vascular Lab, Toronto, Ontario, Canada

Introduction: Upper extremity arterial aneurysms are an unusual finding, usually characterized by a pulsatile mass but sometimes complicated by peripheral embolism or rupture. Color duplex evaluation can be definitive to identify and measure the aneurysm and demonstrate its relationship to other arteries and adjacent structures. Ultrasound findings can be used to determine management options and conduct post-intervention surveillance. The aims of collating this series are to (1) outline appropriate upper extremity arterial duplex assessment protocols, (2) define interpretation criteria, (3) optimize ultrasound findings for interventions, and (4) describe surveillance strategies and findings.

Methods: A review of archived teaching files was undertaken to identify patients with upper extremity arterial aneurysms. Data related to initial ultrasound findings, intervention planning, operative procedures, and surveillance were gathered. A focused literature search was conducted to support the collated material.

Results: Seven patients were identified with full data sets of ultrasound and interventional material. Three had atherosclerotic aneurysms, 1 was mycotic, 1 was toxic (spider bite), and 2 were traumatic aneurysms. None of the patients were identified as having had COVID. The ultrasound protocols showed that standard studies identified the aneurysms and characterized them, and extended studies were needed to rule out complications and plan interventions. Reporting criteria reflected the extent of the study. All patients underwent primary open repair with or without bypass. Surveillance, extending out to 12 years, confirmed patency and durability of the repairs.

Discussion and Conclusion: Upper extremity duplex ultrasound is used to identify and define aneurysmal disease and is considered the definitive imaging methodology. Intervention can be planned based on the findings. Surveillance confirms the durability of interventions.

Non-invasive Vascular Elastography and Distensibility of the Carotid Artery in Children: A Comparison Based on Weight Status

Emilie Alchourron, Université de Montréal, Montreal, Québec, Canada

Introduction: Childhood obesity predisposes one to hypertension and premature vascular aging (artery stiffening). Atherosclerosis begins during childhood with subtle vascular changes. Non-invasive vascular elastography (NIVE) is a new ultrasound technique that calculates vascular wall strain, axial and lateral translation, and shear strain. Non-invasive vascular elastography has been validated in adults but not in children. The objective of this study is to compare the reproducibility of NIVE and vascular distensibility of the common carotid artery in children and to compare these metrics between children of normal weight versus overweight.

Methods: This was a prospective study in which 77 participants were recruited from May 2021 to January 2023 (42% were overweight based on body mass index). Anthropometric and blood pressure measurements were acquired. Videos of 5 cardiac cycles visualizing the common carotid artery were recorded on B-mode ultrasound following accepted recommendations for image acquisition. Vascular wall mechanical properties were measured using 3 different techniques: (1) NIVE, (2) distensibility coefficient formula (DC), and (3) M’ATH SR semi-automatic distensibility detection software. Statistical analyses included descriptives, reproducibility, correlation analysis, and a detection of mean differences between techniques and weight groups.

Results: Among the 3 techniques, only the DC had a good intra-class correlation coefficient (ICC) of 0.7, and therefore was reproducible, compared with the poor ICCs obtained for the other techniques (<0.4). Spearman correlation showed a poor non-significant (P>.05) correlation between the 2 distensibility techniques (DC and M’ATH SR distensibility software) as well as a significant mean difference. For the 4 NIVE parameters, wall strain and axial translation were significantly decreased in the overweight group. For the 2 distensibility techniques, only the DC was able to document a significantly lower arterial elasticity in the overweight group.

Discussion and Conclusion: The only effective, reproducible, and easy technique to work on children was the DC. Non-invasive vascular elastography is promising, but further validation studies are needed before application on children.

Superior Mesenteric Artery Aneurysm

Chad Bennett, Vascular Institute of Chattanooga, Chattanooga, TN, USA

Introduction: Superior mesenteric artery (SMA) aneurysms are very rare and account for less than 15% of all visceral artery aneurysms. The following case involves a large SMA aneurysm.

Methods: A 41-year-old female with a past medical history of headaches, atrial fibrillation, and tachycardia was referred to the Vascular Institute of Chattanooga (VIC) for evaluation of the mesenteric arteries. She recently had a CTA of the chest to assess for possible pulmonary embolism. The CTA revealed incidental findings of dilation of the ascending thoracic aorta, a 3.5-cm SMA aneurysm, and possible splenic artery aneurysms. The patient complained of chest pain, thoracic outlet syndrome, and abdominal pain. A mesenteric artery ultrasound was performed to further assess the SMA.

Results: A 3.4-cm fusiform aneurysm was found in the proximal segment of the SMA. Elevated velocities were identified as proximal and distal to the aneurysm, of uncertain significance. The splenic artery was imaged adequately; however, no aneurysm was visualized. No other stenosis or aneurysm was identified in the mesenteric arteries or the abdominal aorta. Results were given to the ordering nurse practitioner, who then consulted with one of the VIC vascular surgeons. The patient was referred to Emory Hospital for follow-up and possible surgical intervention. The results of this patient’s treatment will be sent back to the referring provider for review.

Discussion and Conclusion: Ultrasound is an excellent modality to ascertain the severity and monitor the progression of an abdominal artery aneurysm. Speaking of the rarity, neither I nor my coworkers had ever seen an SMA aneurysm. Although it was a challenge to determine the exact origin of the aneurysm initially, it ended up being a fulfilling experience professionally to help this patient move forward with treatment.

Lateral Geniculate Artery Pseudoaneurysm after Arthroscopic Medial Meniscectomy

Theja Bhamidipati, Einstein Medical Center, Philadelphia, PA, USA

Introduction: Vascular complications after arthroscopic knee surgery are rare but most commonly involve the popliteal and medial genicular arteries. However, there is a paucity of literature reporting on lateral geniculate arterial injuries. We present a case of a lateral geniculate artery pseudoaneurysm (PSA) following an arthroscopic medial meniscectomy.

Methods: Dedicated color flow, grayscale, and spectral Doppler were used as the diagnostic modality. Computed tomography (CT) angiography demonstrated nonspecific hematoma versus postsurgical material overlying the lateral tibial plateau. Thereafter, a dedicated anterolateral color Doppler ultrasound (CDU) was performed given the pulsatile nature of the mass.

Results: Dedicated ultrasound imaging demonstrated a 2.3 cm × 2.9 cm echogenic collection with pulsatility on grayscale cine loops. Color and spectral Doppler imaging of this collection revealed a PSA of the lateral inferior geniculate artery. The patient was taken for a left lower extremity arteriogram, which confirmed the findings from CDU. This artery was coil embolized, and the completion arteriogram showed no flow in the PSA.

Discussion and Conclusion: Previous literature has outlined injury to the medial geniculate artery as a rare complication of arthroscopic knee surgery. This case illustrates damage to the lateral geniculate artery during a medial meniscectomy, which manifested as a PSA. We believe this to be the first case of a lateral geniculate artery PSA after arthroscopic medial meniscectomy. This case highlights the utility of CDU in the identification of PSA, not only in the setting of a rare complication but also in an anatomically unique location.

Diagnosis of Adventitial Cystic Disease of the Right Common Femoral Vein by Ultrasound in a Patient With a History of Persistent Right Lower Extremity Swelling

Ronda Cupstid, Hoag Hospital Presbyterian, Newport Beach, CA, USA

Introduction: Venous adventitial cystic disease (ACD) is a rare vascular anomaly, occurring in 0.1% of all vascular disorders. Venous ACD is characterized by a collection of mucinous gelatinous material in the adventitia of the involved blood vessel and most commonly affects the common femoral vein. This case report describes an uncommon finding of ACD of the right common femoral vein causing the clinical presentation of asymmetrical right lower extremity edema.

Methods: Right lower extremity venous ultrasound was performed with B-mode imaging (Philips EPIQ, Bothell, WA), color, and spectral Doppler using an L9-3 linear array transducer (Andover, MA). Images were obtained in longitudinal and transverse orientations confirming characteristics of cystic structures.

Results: Ultrasound showed sonographic evidence of multiple avascular cysts within the walls of the right common femoral vein suggesting ACD. Prior computed tomography (CT) with and without contrast reported multi-loculated low-density lesions abutting the right common femoral vein and measuring 2.1 cm × 1.2 cm. The patient is researching and assessing the most appropriate treatment options for ACD which include cyst evacuation and excision, cyst aspiration with drainage, or vein resection with graft interposition.

Discussion and Conclusion: Duplex imaging is a safe, effective, and sensitive aid when considering patient history and results of the physical examination. Adventitial cystic disease is rare and should be suspected in cases with luminal cystic structures. This case study demonstrates that ultrasound serves as a valuable noninvasive tool for the observation and analysis of vessel cystic structures documenting the location, size, and patency of the vessel involved.

Lemierre’s Syndrome: Case Report of Internal Jugular Vein Septic Thrombophlebitis

Lana Musatkana, Toledo Hospital, Temperance, MI, USA

Introduction: Lemierre’s syndrome (LS) is a rare condition characterized by septic thrombophlebitis of the internal jugular vein (IJV) following an acute oropharyngeal infection. Lemierre’s syndrome is more commonly reported as a complication of pharyngitis in young adults. This case study describes LS in an elderly male with catheter-related IJV thrombosis.

Methods: A 69-year-old male presented to the emergency room with acute onset of left neck pain and swelling above the clavicle. At the time of admission, the patient exhibited a left IJV port-a-catheter for dehydration infusions resulting from a long-term ileostomy. An upper extremity venous duplex examination and computed tomography (CT) imaging of the neck and chest were ordered.

Results: Findings of the left upper extremity venous duplex included a grossly enlarged (2.2-2.5 cm) non-compressible IJV with mixed echogenic intraluminal content, and absent color flow and spectral Doppler signals. A non-vascular heterogeneous mass was seen adjacent to the IJV, and a hypoechoic intraluminal thrombus was noted within the subclavian, axillary, and brachial veins. Computed tomography imaging of the neck revealed an enlarged left IJV with heterogeneous content and air foci within the adjacent inflamed tissue, suggestive of septic thrombophlebitis. The chest CT demonstrated IJV thrombus extension to the level of the innominate vein. The port-a-catheter was removed, and the patient was managed with intravenous antibiotics and heparin.

Discussion and Conclusion: Lemierre’s syndrome is a rare condition affecting the IJV and is most commonly associated with oropharyngeal infections in young adults. Our case demonstrates that LS can also be the result of bacteria introduced with intravenous catheters involving carotid sheath vessels. Awareness of the clinical manifestation of LS and its sonographic characteristics increases the utility of venous duplex ultrasound in the upper extremity.

New Lymphedema After Right Above-Knee Great Saphenous Vein Ablation

Jason Wheeler, Cleveland Clinic–Florida, Weston, FL, USA

Introduction: This case illustrates the importance of a history and examination focused on relief of symptoms with body position in patients with acute and atypical presentations of unilateral lower extremity edema and no significant medical history.

Methods: A 40-year-old female with no significant medical history presented for evaluation of progressive right lower extremity edema for the past 6 months that began after right great saphenous ablation which was done after the patient presented to another provider for right leg heaviness. Initially, the patient was diagnosed with ankle and knee osteoarthritis as the cause of her edema, but the symptoms did not improve with physical therapy or non-steroidal anti-inflammatory drugs (NSAIDs). The patient was then diagnosed with lymphedema tarda and sent for manual decompressive therapy without improvement. The patient noted a sensation of “suction and deflation” throughout her right leg while lying on her left side, which appeared to improve her edema by morning.

Results: The right common femoral vein waveform varied with body position. In the symptomatic position, there was a continuous waveform, consistent with obstruction. In the non-symptomatic position, the waveform returned to a normal respirophasic waveform.

Discussion and Conclusion: The ultrasound examination indicated a mobile, compressive mass and was helpful in ruling out lymphedema tarda, venous insufficiency, and osteoarthritis. This patient was found to have a large right-sided subserosal leiomyoma. She underwent a hysterectomy with complete resolution of her right leg lymphedema prior to any permanent fibrotic and epidermal changes. Especially in patients presenting with acute unilateral lower extremity edema and without significant medical history, symptomatic and asymptomatic positions are critical, along with a complete history and physical. The sonographer should also have a high degree of suspicion for and investigate these positions in young women during ultrasound examinations.