SCREENING COMPRESSION ULTRASOUND FOR LOWER EXTREMITY DVT
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1 SCREENING COMPRESSION ULTRASOUND FOR LOWER EXTREMITY DVT R. Eugene Zierler, M.D. The D. E. Strandness, Jr. Vascular Laboratory University of Washington Medical Center Division of Vascular Surgery University of Washington, School of Medicine
2 DISCLOSURE INFORMATION R. Eugene Zierler, M.D. No relevant financial or commercial relationships to declare!
3 Points for Discussion" Anatomy of the lower extremity veins Clinical significance and diagnosis of DVT Technique of compression ultrasound Ultrasound features of lower extremity DVT Differences between a screening compression ultrasound and a complete diagnostic duplex examination for DVT
4 LOWER EXTREMITY VENOUS ANATOMY Deep Veins " vein Superficial Veins "
5 Lower Extremity Deep Vein Thrombosis Magnitude of the Problem" Deep Vein Thrombosis 800,000 patients / year Fatal Pulmonary Emboli 50, ,000 patients / year Non-fatal Pulmonary Emboli 150,000 patients / year Post-thrombotic Syndrome 500,000 patients / year
6 Lower Extremity Deep Vein Thrombosis Proximal or Above-knee DVT IVC, iliac veins Clinical Significance" Common femoral, femoral, and popliteal veins Distal or Below-knee or Calf DVT Axial calf veins anterior tibial, posterior tibial and peroneal veins Muscular calf veins soleal and gastrocnemius veins HIGH risk for pulmonary embolus LOW risk for clinically significant pulmonary embolus
7 Lower Extremity Deep Vein Thrombosis Clinical Presentation" Leg pain and swelling are non-specific findings Clinical diagnosis is unreliable - history and physical examination are only 50% accurate Risk of pulmonary embolism can be high Need for immediate anticoagulant therapy Objective diagnostic tests Duplex ultrasound CTV. MRV, Contrast venography Screening emphasizes detection of proximal DVT
8 Technical Notes - Instrumentation" High resolution B-mode ultrasound system Linear array transducers: 3-5 MHz - Large legs 5-10 MHz Small legs
9 Technical Notes Interpretation Diagnostic Criteria for DVT" B-mode image 1. Visualization of thrombus in the vein lumen 2. Non-compressibility with direct probe pressure Doppler Not part of a screening compression ultrasound"
10 Technical Notes - Protocol" Evaluate compressibility of deep veins at two points in the lower extremity Fully Compressible Normal Non-compressible Abnormal Non-diagnostic Poor image Vein not seen Common Femoral Popliteal
11 Technical Notes - Protocol" Imaging and compression done in transverse view Adjacent artery helps to identify the vein Artery should not compress Normal Non-compressible
12 Technical Notes - Protocol" Patient position Start supine for the common femoral vein Prone or leg externally rotated for the popliteal vein Common femoral vein Image from inguinal crease to the confluence of the deep femoral and femoral veins Popliteal vein Image from the proximal popliteal fossa to 10 cm distal to the mid-patella
13 Proximal CFV Technical Notes - Protocol" Common Femoral Vein Mickey Mouse View Distal CFV CFA CFV GSV Vein is medial to the artery DFA SFA CFV Patient s Right (for both sides) Patient s Right (for both sides)
14 Technical Notes - Protocol" Popliteal Vein A V Post erior Vein is superficial to the artery (closer to the skin)
15 Technical Notes - Images" Left Common Femoral Vein - Normal Right Common Femoral Vein - Thrombus V A A V Compression Compression
16 Technical Notes - Images" Right Common Femoral Right Popliteal Vein Vein Normal Compressions
17 Technical Notes - Images" Common Femoral Vein Thrombus Popliteal Vein Thrombus Direct Visualization of Thrombus
18 Results for Above-Knee (Proximal) DVT Author n Sensitivity Specificity Cronan 51 25/27 24/24 Appelman /52 58/60 Vogel 53 19/20 30/33 O Leary 50 22/24 25/26 Lensing /66 142/149 Total / /292 95% 95%
19 A Complete Venous Duplex Examination" B-mode Image Identify vessels, visualize thrombus, test compressibility Spectral Display Flow direction, respiratory phasicity, augmentation maneuvers, reflux Color-flow Imaging Flow around partially occlusive thrombus
20 A Complete Venous Duplex Examination" Doppler Flow Information" Femoral vein Femoral vein with occluded iliac vein Phasic with respiration" Normal Continuous" Abnormal
21 A Complete Venous Duplex Examination Doppler Flow Information" " Normal femoral vein augmentation by calf compression" Femoral vein reflux with Valsalva"
22 A Complete Venous Duplex Examination" Common Femoral Vein Thrombus Popliteal Vein Thrombus Color-flow Around Thrombus
23 B-mode Image Features - Acute vs. Chronic DVT" Acute Homogeneous, smooth Hypoechoic Soft, spongy (deforms with compression) Vein is dilated Free floating tail Chronic Heterogeneous, irregular, synechiae Echogenic Stiff (not deformable) Vein normal or small size Thickened vein wall (recanalization) Collaterals present
24 Final Thoughts" Screening for proximal lower extremity DVT with two point compression ultrasound is sensitive and specific Will not detect below-knee (calf) DVT May not detect non-occlusive proximal (IVC/iliac vein) thrombus Abnormal and non-diagnostic exams should be followed-up with a complete diagnostic venous duplex Normal exam can be repeated if clinical suspicion remains high (or request a complete duplex study)
25
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