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Looking and seeing. Is that correct? Yes. So I am talking today about the investigation of the femoral junction and including a little bit of provocation when it was just as an introduction. And then we will investigate two patients together. Of course, this presentation is supported by Sarris. I can only thank and I think also and again to Mahmoud um to Mohammed Faro, which is also a very, very brilliant person. II love to meet you a lot of times in different meetings and I think it's great you are supporting this. Moh just a short reminder, we have a lot of uh of local location maneuvers. Why do we need them in veins? We have not a regular flow when we are standing and you know that a venous investigation of the legs is in standing position. This um we have in the classical uh which was changed to criminal. And I think this is an interesting thing with the fold. It's short to um to uh uh blow inside when the minor compression of the calf. Everybody knows the to elevation and the dependency maneuver, we will come back to that later. So everybody knows and everybody knows that it is a little bit difficult for people to understand sometimes how it is to be done. And uh this deep inspiration and not exhaling and pressing simultaneously, but closing the mouth and press without exhaling. And sometimes it is so difficult to explain to the patients and they are not able to perform it. And if you do it in standing position, they have fainting so that um um Cla Frances and introduce this for stroke thing and called it anyway, you blow into a um close stroke and then uh you, you finally have a, a pressure build up in the abdomen and you will provoke a reflux if there is an incompetent valve below the most classical and surely the most often applied uh maneuver is the manual compression and decompression of the calf. When you provoke, when you press, you provoke an entero red flow and you don't need the patient to understand what you're doing and it can be done while you're talking to the patient. And surely afterwards, we will do this the most because I will be talking to you about what I'm doing. And so I can do the compression. But it is not physiologic because it is not a movement of a muscle. If patients have pain in the leg, it is uh uh it is painful and uh it is difficult because this is a little bit exaggerated. And this was my little daughter and my husband and if she compresses his calf or he compresses her calf, you can understand and imagine that the flow amount provoked by this disc uh this proportion uh influences the result. This is why it is not so perfect. Um coming from the uh maneuver, it is pushing the patients and I thought I can't push the patients in my office. Um We developed the, the wor maneuver or the toe elevation maneuver uh which is like you see in the picture to elevate the toe or to to, to make this and um contract the toes. And you, we will see that in our patients today and this is a physiologic role which is repeatable. And the patient understand that especially in in in fall, we will make the investigation of the perforating wave, especially in the perforating wave investigation. This one is the real life investigation of the walking person. And then sometimes you have a little flow in the vein which is obvious varicose. So you you see a varicose vein and like here, this is the Great Santino vein with minor compression decompression say this is not really a reflux, but obviously she has. And the funny thing is that in 2006 simultaneously, Chris Lati from London and me published the same maneuver. We had the same idea, two stupid persons, the same idea they say in Germany and we published this, it looks like we will do this also with the patient. You put this patient with this image and you say, I don't believe it. She has more flow. You put her laying down and wait a little bit like 20 seconds. And then this is the same right venous vein. And after emptying the vein with the leg up, it fills and feels and feels. And for me, this is the queen of the pro provocation maneuvers because if you have a reflux it, in this case, you have a reflux. And if you after the leg and standing again, have no reflux, the law are competent. This is like never false negative or positive. This is standing with minor compression and this is the same day just after laying down 10 days. OK. So this is the notion we need because we will apply it later in the investigation. And this is where we will investigate today. The terminal and the preterminal valve. It is all about these two valves, the terminal, the preterminal. Of course, there is a deep vein wall and there are tributaries, cranial ones, the media ones in the groin and the lateral one which is the accessory anterior subvenous vein. And um we do the investigation normally in standing, we look at the morphology, the large gene and cross section. We do color duplex because we see quick where the blood comes from and where it goes to but PW to document the findings because in color it is not over the time and to document the findings, the reflux duration you need to occur in the time maneuvers we haven't seen. So if there are competent walls, the flow is like this upstairs upstairs, I always say, but Lato go down to join the great subin vein in the groin. If we have a reflux in the right subvenous vein, we have to know from where, which, which mean is which lane is originating this reflux. Most of the compli complicated or more uh obvious reflexes come from the deep vein with a incompetent terminal and preterminal. And this is called axial reflex because it comes from the heart down the cava down the idiot vein into the great subvenous vein. This is like um this image along me to between a um cut of the groin. This is the cystoid, the deep vein and the superficial vein draining to the heart. And this is the diastole when the patient lowers the foot again, or you, you, you, you take away the hand in the manual compression and you have a reflux from the deep vein, excuse me from the deep vein into the superficial leg vein. Um And this is means that the terminal of is incompetent. Again, you measure at the, at the very point of the os of the ostium. This is a deep vein, this is the ostium, this is the superficial uh the sen vein and you measure here, this is the systole under retro and the diastole. You have a longlasting retro. This is for sure. The most often found situation in patients with large refluxes. But we have also another situation in 20 to 25% of patients coming for treatment that the terminal off is competent and you have a reflux from the, the tributary of the groin, for example, the epigastric in this case, and the preterm level is incompetent and the reflux goes down here. This is a so called para osteo reflux because this is the ostium. This is the ostium. The blood comes from the deep vein through the ostium. And here the ostium is competent. The terminal valve is competent and this is the paraostial reflux with competent terminal out. And we see again this longitudinal a cut of the leg, systolic blood goes to the deep vein and diastole. The blood does not come out here. It has come out from the epigastric vein. And as this is so important, I repeat it here in images, common femoral vein, Trib grade vein, systole under red flow, the ate no flow from the deep vein, no reflux. But from the epigastric, if you differentiate this, this is very important to plan the treatment because um I'm completely convinced that these cases are those that profit best from endoluminal techniques. And um because you leave a competent terminal valve untouched and you leave the flow from the epigastric vein draining to the deep vein. This is a cross section of the same leg. You see the reflux comes from the tributary, not from the deep vein. And if you compare both, this is a larger reflux from the deep vein and this is a small reflex terminal of competent and you have the reflux from the too high. I think this was my introduction. And now we go on.