Deep Vein Thrombosis
Todd A. Jaffe
Jarone Lee
1. A 47-year-old man presents to the Emergency Department with a 1-day history of right leg swelling. He was in a motor vehicle collision 2 weeks prior and underwent emergent orthopedic surgery for bilateral tibia fractures. Physical examination is notable for 2+ pitting edema of the entire right leg. Pulses are normal. Compression ultrasound at the level of the common femoral vessels (A, B) and popliteal vessels (C, D) as well as pulsed-wave Doppler at the level of the common femoral vessels (E) are shown in Figure 70.1:
 Figure 70.1 |
Which of the following describes the findings and recommended management?
A. Ultrasound with popliteal deep vein thrombosis (DVT); start therapeutic anticoagulation
B. Ultrasound with common femoral DVT; start therapeutic anticoagulation
C. Ultrasound without evidence of DVT; start lower extremity compression for postoperative edema
D. Ultrasound without evidence of DVT; obtain abdominal (iliocaval) imaging to assess for proximal occlusion
View Answer
1. Correct Answer: D. Ultrasound without evidence of DVT; obtain abdominal (iliocaval) imaging to assess for proximal occlusion
Rationale: The patient in this question has evidence of significant asymmetric lower extremity edema and is at high risk for a DVT given his recent trauma and operations. The ultrasound provided does not demonstrate any evidence of DVT, as both the common femoral and popliteal veins are compressible. Swelling of the whole leg with a normal compression ultrasound raises concern for more proximal obstruction. Pulsed-wave Doppler interrogation of the femoral venous flow also gives additional information. Image E shows a loss of normal respirophasic variation in venous flow, which suggests there is a proximal occlusion. In these patients, guidelines recommend further investigation, including pelvic and abdominal imaging to further assess the vasculature.1
Selected References
1. Brant WE, Helms CA. Chapter 39, Vascular Ultrasound. In: Fundamentals of Diagnostic Radiology, 4th ed. Lippincott, Williams & Wilkins; 2012.
2. Cosby KS, Kendall JL. Chapter 17, Lower Extremity Venous Studies. In: Practical Guide to Emergency Ultrasound. Wolters Kluwer; 2013. ProQuest Ebook Central.
3. Needleman L, Cronan JJ, Lilly MP, et al. Ultrasound for lower extremity deep venous thrombosis: multidisciplinary recommendations from the society of radiologists in ultrasound consensus conference. Circulation. 2018;137:1505-1515.
2. Which of the following is the correct pairing of a lower extremity DVT ultrasound modality and its description?
A. Two-region compression: compression of the upper leg from the common femoral to popliteal vein, and compression of the lower leg from the popliteal vein to the ankle
B. Extended compression: compression ultrasound of the femoral veins 1 to 2 cm above and below the saphenofemoral junction and the popliteal veins up to the calf veins confluence
C. Complete compression: compression from common femoral vein through the popliteal vein up to the calf veins confluence
D. Complete duplex: compression from the common femoral vein to the ankle, including color and spectral Doppler
View Answer
2. Correct Answer: D. Complete duplex: compression from the common femoral vein to the ankle, including color and spectral Doppler
Rationale: Multiple modalities for assessment of DVT have been studied with varying efficacy. Most of these modalities include compression, Doppler flow, or both. Complete duplex ultrasound of the lower extremity includes compression from the common femoral vein to the ankle, also including color and spectral Doppler (Figure 70.9).
 Figure 70.9 Deep vein thrombosis with Doppler. A. Transverse orientation. B. Longitudinal orientation. |
Deciding on the appropriate study for patients may depend on both operator comfort and available resources. Studies have demonstrated relatively similar failure rates for two-region compression and extended compression ultrasound, yet these studies are limited by the heterogeneity of patient population and operators. Further studies have shown that duplex ultrasound has the greatest sensitivity of the modalities at detecting DVT with a sensitivity of 96.5% for proximal DVTs and >70% for distal DVTs. Table 70.1 summarizes the other commonly utilized modalities for DVT assessment and their description.
Table 70.1. Lower Extremity Ultrasound Modalities | ||||||||||
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Selected References
1. Cosby KS, Kendall JL. Chapter 17, Lower extremity venous studies. In: Practical Guide to Emergency Ultrasound. Wolters Kluwer; 2013. ProQuest Ebook Central.
2. Kraaijpoel N, Carrier M, Le Gal G, et al. Diagnostic accuracy of three ultrasonography strategies for deep vein thrombosis of the lower extremity: a systematic review and meta-analysis. PLoS One. 2020;15:e0228788.
3. Goodacre S, Sampson F, Thomas S, van Beek E, Sutton A. Systematic review and meta-analysis of the diagnostic accuracy of ultrasonography for deep vein thrombosis. BMC Med Imaging. 2005;5:6.
4. Needleman L, Cronan JJ, Lilly MP, et al. Ultrasound for lower extremity deep venous thrombosis: multidisciplinary recommendations from the society of radiologists in ultrasound consensus conference. Circulation. 2018;137:1505-1515.
3. A 67-year-old man with a history of metastatic prostate cancer is admitted to the intensive care unit (ICU) at a rural hospital with urosepsis. He develops acute onset left lower extremity swelling and pain. The facility does not have full ultrasound capabilities so you perform a point-of-care ultrasound to evaluate his leg. A two-region compression ultrasound with images at the level of the femoral vessels (A, B) and popliteal vessels (C, D) is shown in Figure 70.2.
 Figure 70.2 |
Which of the following best describes the findings?
A. DVT including the deep femoral and popliteal veins
B. Isolated deep femoral vein thrombus
C. Isolated popliteal vein thrombus
D. No evidence of DVT
View Answer
3. Correct Answer: C. Isolated popliteal vein thrombus
Rationale: The patient has signs and symptoms of acute DVT at a hospital with limited resources. The gold standard test for assessment of lower extremity DVT is complete duplex ultrasound; however, skilled ultrasonographers and necessary equipment may not be available in low-resource settings. Two- or three-region compression ultrasound, as well as extended compression ultrasound may be alternatives if complete duplex ultrasound capabilities are not available.1 Two-region compression ultrasound includes assessment of the common femoral vein and popliteal vein and may not capture isolated superficial femoral vein thromboses. Three-region compression ultrasound, which includes the superficial femoral vein, has greater sensitivity for diagnosis of lower extremity DVT when compared with two-region compression. Both techniques include evaluation of the popliteal vein. In this question, the femoral vein is compressible while the popliteal vein is not. This finding is indicative of an isolated popliteal vein thrombus as shown in Figure 70.10.
 Figure 70.10 |
Selected References
1. Burnside PR, Brown MD, Kline JA. Systematic review of emergency physician-performed ultrasonography for lower-extremity deep vein thrombosis. Acad Emerg Med. 2008;15:493-498.
2. Kline JA, O’Malley PM, Tayal VS, Snead GR, Mitchell AM. Emergency clinician-performed compression ultrasonography for deep venous thrombosis of the lower extremity. Ann Emerg Med. 2008;52:437-445.
3. Zuker-Herman R, Ayalon Dangur I, Berant R, et al. Comparison between two-point and three-point compression ultrasound for the diagnosis of deep vein thrombosis. J Thromb Thrombolysis. 2018;45:99-105.
4. Hamper UM, DeJong MR, Scoutt LM. Ultrasound evaluation of the lower extremity veins. Radiol Clin North Am. 2007;45:525-47, ix.
5. Talbot SR, Oliver M. Duplex imaging of the lower extremity venous system. In: Kupinski AM, ed. LWW Sonography: The Vascular System. Wolters Kluwer; 2013:209-229. Figure 14.23.
6. Fox JC, Vandordaklou N. Lower extremity venous studies. In: Cosby KS, Kendall JL, eds. Practical Guide to Emergency Ultrasound. 2nd ed. Wolters Kluwer; 2014: 254-263.
4. A 48-year-old woman with a history of factor V Leiden presents with 2 days of chest pain and shortness of breath. Her vital signs on presentation include HR 102 bpm, BP 130/80 mm Hg, and SpO2 94% on 2 L nasal cannula. Point-of-care echocardiogram parasternal long- and short-axis views are shown in Figure 70.3.
 Figure 70.3 |
While in the Emergency Department, she endorses the acute onset of significant right lower extremity pain. Left foot dorsalis pedis pulse is 2+; however, pulses are not palpable in the right foot. An ultrasound of the right lower extremity at the level of the common femoral artery is shown in Figure 70.4.
 Figure 70.4 |
What is the best next step in the management of this patient?
A. Surgical consultation for arterial thrombectomy
B. Systemic thrombolytics
C. Broad-spectrum antibiotics
D. Systemic anticoagulation for DVT
View Answer
4. Correct Answer: A. Surgical consultation for arterial thrombectomy
Rationale: This patient is hypercoagulable given her history of factor V Leiden, prompting a high suspicion for thromboembolic disease. The echocardiogram images demonstrate concern for a large thrombus in the left ventricle, but there is no flattening of the septum to suggest a PE. With the acute onset of severe lower extremity pain and asymmetric pulses, an arterial thromboembolic event is likely. The color Doppler ultrasound is included in Figure 70.11.
 Figure 70.11 Lower extremity Doppler with lack of arterial flow. |
Color Doppler ultrasound may be adequate for identifying arterial stenosis and occlusions. Studies have found no difference in surgical outcomes and survival for patients with acute arterial emboli preoperatively assessed with ultrasound compared with those assessed with computed tomography angiography (CTA).
Urgent surgical consultation is indicated as the next step in management. Although thrombolysis may be considered for limb-threatening ischemia if surgical or radiological interventions are not available, it is not the preferred treatment. There is no indication for antibiotics in this scenario, and while systemic anticoagulation is appropriate, there is no evidence of venous thrombosis in Figures 70.3 or 70.4.
Selected References
1. Crawford JD, Perrone KH, Jung E, Mitchell EL, Landry GJ, Moneta GL. Arterial duplex for diagnosis of peripheral arterial emboli. J Vasc Surg. 2016;64:1351-1356.
2. Hwang JY. Doppler ultrasonography of the lower extremity arteries: anatomy and scanning guidelines. Ultrasonography. 2017;36:111-119.
3. Armstrong WF, Ryan T. Masses, tumors, and source of embolus. Feigenbaum’s Echocardiography. 8th ed. Wolters Kluwer; 2019:651-691.
4. Moneta GL, Zaccardi MJ. Duplex evaluation of lower extremity arterial occlusive disease. In: Zierler R, Dawson D, eds. Strandness’s Duplex Scanning in Vascular Disorders. 5th ed. Wolters Kluwer; 2016:151-163.
5. A 72-year-old man with a history of lower extremity DVT is admitted to the ICU for pneumonia. While in the hospital, he develops worsening asymmetric lower extremity edema. You perform a point-of-care DVT evaluation and notice some venous abnormalities. Which of the following findings on ultrasound is more suggestive of residual venous thrombosis/scarring rather than acute DVT?
A. Thrombus firmly adherent to vessel wall
B. Vein dilation
C. Smooth intraluminal material
D. Intraluminal material that is deformable during compression
View Answer
5. Correct Answer: A. Thrombus firmly adherent to vessel wall
Rationale: In critically ill patients with a history of DVT, it may be difficult to differentiate between acute DVT and chronic venous scarring on ultrasound. Multiple findings are suggestive of acute venous thrombosis: (1) intraluminal material that is deformable during compression, (2) dilation of the vein, (3) smooth intraluminal material, (4) a free tail floating proximally from the attachment of the clot on the vein wall.1 Over time, acute DVTs may evolve and demonstrate ultrasonographic signs of chronic scarring. These findings are largely dependent on the evolution of the thrombus, including lysis, thrombectomy, or embolic phenomena.2 Residual thromboses may form chronic scars and are more likely to be firmly adherent to the vein wall. Acute DVTs are more likely to be free-floating with small attachment sites to the vessel wall. A list of ultrasonographic findings to differentiate acute DVT and chronic scarring is included in Table 70.2.
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