Clinician Update
Duplex Ultrasound in the Diagnosis of Lower-Extremity
Deep Venous Thrombosis
Heather L. Gornik MD, MHS; Aditya M. Sharma, MD
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Case Presentation
A 26-year-old woman presented with
progressive swelling and pain of the left
leg within 2 months after switching to
a different oral contraceptive preparation. On examination, she had marked
edema and erythema of the leg from
the calf to the thigh with significant
tenderness to palpation. Pedal pulses
were intact. The right leg was normal. Lower-extremity venous duplex
ultrasound (VDUS) with B-mode
compression maneuvers and Doppler
evaluation was performed, and she was
found to have an acute deep venous
thrombosis (DVT) of the left leg that
extended from the common iliac vein
into the left calf (Figure 1A–1E).
Components of the VDUS
Examination to Assess
for DVT
VDUS combines 2 components to
assess for DVT: B-mode or gray-scale
imaging with transducer compression
maneuvers and Doppler evaluation
consisting of color-flow Doppler imaging and spectral Doppler waveform
analysis.1 The technique of compression B-mode ultrasonography for the
diagnosis of DVT was first described by
technologist Steve Talbot in 1982 and
has subsequently been refined to become
the diagnostic standard.2 B-mode imaging is used while the lower-extremity
veins are compressed along their length
with the ultrasound probe and for direct
visualization of intraluminal thrombus.
A patent, thrombus-free vein will demonstrate complete vein wall coaptation
with compression by the transducer
(Figure 2). Loss of compressibility of
the vein is the most reliable indicator
of the presence of thrombus within the
vein.2 In addition to loss of compressibility, an acutely thrombosed vein
is commonly dilated with a diameter
greater than that of the adjacent artery.
Intraluminal echoes consistent with
thrombus may be imaged. Color-flow
Doppler is helpful to assess for residual
flow within a thrombosed venous segment (ie, nonocclusive DVT) and for
confirming patency of venous segments
that are not accessible for compression
maneuvers (eg, the iliocaval veins).
The pulsed Doppler spectral waveform
from a normal, widely patent lower
extremity demonstrates spontaneous
and respirophasic flow (Figure 3A).
Alteration of this expected waveform
(ie, monophasic flow) raises suspicion
of venous obstruction proximal to the
level of interrogation (Figure 3B), and
additional imaging may be required
to definitively establish the diagnosis
of DVT. In addition to assessment of
respirophasicity, distal augmentation
maneuvers (such as compressing the
calf) are performed during spectral
Doppler evaluation to further demonstrate patency of the veins. While the
distal augmentation maneuver is performed, there should be a sharp “spike”
of augmented anterograde venous flow
(Figure 3A). Blunted or absent flow augmentation suggests venous obstruction
distal to the level being interrogated.
Retrograde flow in the venous system
after a distal augmentation maneuver
indicates venous valvular incompetence, which may be a manifestation of
prior DVT and the postthrombotic syndrome (Figure 3C). A complete VDUS
of the lower extremities includes evaluation from the inguinal ligament (distal external iliac or common femoral
veins) into the calf.3 The accuracy of
VDUS compared with venography for
the diagnosis of proximal and calf DVT
has been well established.4,5
From the Department of Cardiovascular Medicine, Section of Vascular Medicine, Cleveland Clinic Heart and Vascular Institute, Cleveland, OH (H.L.G.);
and Cardiovascular Medicine Division, University of Virginia, Charlottesville (A.M.S.).
Correspondence to Heather L. Gornik, MD, MHS, Medical Director, Non-Invasive Vascular Laboratory, Cleveland Clinic Heart and Vascular Institute,
9500 Euclid Ave, Desk J3-5, Cleveland, OH 44195. E-mail [email protected]
(Circulation. 2014;129:917-921.)
© 2014 American Heart Association, Inc.
Circulation is available at http://circ.ahajournals.org
DOI: 10.1161/CIRCULATIONAHA.113.002966
917
918 Circulation February 25, 2014
although in many cases, there is overlap of findings, and aging the acuity of
thrombus is not possible. In such cases,
“DVT of indeterminate age” should be
reported. Murphy and Cronan6 previously demonstrated that dilated vein
diameter is the most accurate parameter
in aging the acuity of DVT.
Controversies in VDUS
Repeat Ultrasound and
Residual Vein Thrombus After
Completion of Therapy
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More than half of patients with proximal DVT have residual vein thrombosis
seen on VDUS 6 months to 1 year after
diagnosis and completion of therapy.7,8
Indeed, the presence of residual DVT
has been shown to be a risk factor for
recurrent venous thromboembolism.8–10
However, residual vein thrombosis
is not yet established as a marker to
assess the duration of anticoagulation
therapy beyond clinical factors such as
the circumstances of the DVT (ie, provoked or unprovoked event), presence
of ongoing risk factors, and follow-up
D-dimer levels. Regardless, obtaining a repeat VDUS 6 months to 1 year
after treatment for proximal DVT is
clinically useful because it establishes
a new baseline for future comparison
in the case of recurrent ipsilateral limb
symptoms, when differentiating recurrent DVT from the postthrombotic syndrome can be challenging.
Figure 1. Acute iliofemoral deep venous thrombosis (DVT) in a 26-year-old woman
with left leg swelling. A, B-mode image of a dilated external iliac vein (arrow) next to
the external iliac artery (arrowhead). Intraluminal echoes are present, consistent with
thrombus. B, Nearly complete loss of compressibility of the external iliac vein, consistent
with acute DVT. C, Spectral Doppler waveform analysis with absent venous flow in the
thrombosed and occluded external iliac vein (EIV). Lt DIST indicates left distal. D, B-mode
image of acute DVT involving the profunda and femoral confluence into the common
femoral vein. E, Color-flow Doppler image demonstrating absent flow in the common
(CFV) and femoral (FV) vein and minimal flow in the profunda femoral vein (PFV; arrow).
Assessing the Acuity of DVT
Thrombus is typically referred to as
acute (within the first 2 weeks after
the thrombus forms), subacute (>2
weeks and potentially up to 6 months
after thrombus forms), or chronic (usually >6 months old).1 Acuity of the
DVT is assessed by the appearance of
the thrombus on B-mode imaging (eg,
hypoechoic, isoechoic, or hyperechoic),
vein lumen size, vein wall appearance,
venous compressibility, function of the
venous valves, and presence of collateral circulation. The classic ultrasound
characteristics of acute, subacute, and
chronic DVT are shown in the Table,
Lower-Extremity VDUS in the
Evaluation of Patients With
Suspected Pulmonary Embolism
VDUS may be used as an adjunct to
more definitive imaging modalities
in the evaluation of patients with suspected pulmonary embolism (PE). One
question frequently asked is whether
to perform VDUS before chest computed tomography among patients
presenting with symptoms of PE, perhaps eliminating the need for chest
computed tomography among those
with DVT who will require anticoagulation. In general, this practice is
discouraged because fewer than half
of patients with PE will have residual
Gornik and Sharma Venous Ultrasound for Diagnosis of DVT 919
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Figure 2. B-mode imaging of the veins with compression maneuvers, expected normal findings. A, Duplicating femoral veins in the thigh
(V) next to superficial femoral artery (A). B, Both femoral veins compress completely with pressure of the ultrasound transducer. Only the
superficial femoral artery (A) is seen. C, Calf vein imaging. Shown are the paired posterior tibial veins (PTV) and artery and the 2 peroneal
veins (Pero V) and artery. D, During the compression maneuver, the calf veins compress completely, and only the arteries are visualized
(A). Acoustic shadowing from the fibula can be seen (arrowhead).
DVT on VDUS (ie, the majority of
thrombus has already embolized to the
lungs).11–15 In addition, patients with
DVT may have other causes of dyspnea
and pleurodynia besides PE such as
pneumonia or pleural effusion. Thus,
VDUS should not be used solely for the
assessment for PE. Diagnostic testing
algorithms for PE have been developed
that include pretest probability assessment, D-dimer testing, and VDUS
to eliminate the need for computed
Figure 3. Spectral Doppler waveform analysis of the lower-extremity veins. A, Spontaneous and respirophasic flow with normal
response to an augmentation maneuver and aliasing of the pulsed Doppler signal (arrow). B, Monophasic venous flow suggesting
venous obstruction proximal to this segment. EIV indicates external iliac vein. C, Retrograde flow in the popliteal vein (POP V) after an
augmentation maneuver (arrow), consistent with valvular incompetence in a patient with a history of deep venous thrombosis and the
postthrombotic syndrome.
920 Circulation February 25, 2014
Table. Distinguishing Ultrasound Features of Acute, Subacute, and Chronic DVT*
Features
Case Resolution
The patient was immediately started on
subcutaneous low-molecular-weight
heparin and was ultimately referred for
catheter-directed thrombolysis, given
the extensive iliofemoral DVT and her
severe symptoms.
Acute
Subacute
Chronic
Attachment of thrombus
to vein wall
Loosely attached
Firmly attached
Firmly attached
Thrombus echogenicity
Hypoechoic or
isoechoic
Variable (more echoic
than acute DVT)
Hyperechoic (appears as a
bright fibrous web or scar
attached to the vein wall and
protruding into the lumen)
Presence of free-floating
or mobile thrombus tail
May be present
Generally absent
Absent
Disclosures
Dr Gornik is a noncompensated (volunteer)
member of the Board of Directors of the
Intersocietal Accreditation Commission–
Vascular Testing Division representing
the American College of Cardiology. Dr
Sharma reports no conflicts.
Vein wall appearance
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Vein lumen
Compressibility
Collateralization
Venous valve function
Variable
Variable
Venous wall thickening and
scarring
Calcium deposition may be
seen (phlebolith)
Distended
Starts to retract to
normal size
Smaller than normal size
(atrophic)
Slightly deformable,
“spongy”
More compressible
than acute
Partly noncompressible,
likely partially recanalized
Generally absent
May be present
May be present
Usually competent
May be competent or
incompetent (reflux
present)
Often incompetent (reflux
present)
DVT indicates deep venous thrombosis.
*In some cases, there is overlap of ultrasound features, in which case the DVT should be reported as being
of indeterminate age.
tomographic angiography among lowrisk patients.16
Pitfalls of Venous Ultrasound
for Diagnosis of DVT
Duplicate Veins
Duplication of the femoral or popliteal veins is commonly encountered
during VDUS and venography.17,18
Unrecognized venous duplication can
lead to misdiagnosis of DVT when
the thrombus-free vein of a pair is
identified and the vein with thrombus
is missed. To minimize this error, it is
important to note venous duplication
on the written report. In 1 study, 15%
of duplicated or triplicated veins were
missed on repeat evaluations.18
Misnomer of the Superficial
Femoral Vein
The superficial femoral vein is actually
a deep vein that is the continuation of
the popliteal vein that joins the profunda femoral vein to form the common
femoral vein. Thrombosis in this deep
vein warrants treatment with anticoagulation similar to any DVT. Given the
potential for diagnostic and treatment
errors related to the use of this term,
the International Interdisciplinary
Consensus Committee on Venous
Anatomic Terminology concluded in
2001 that the term superficial femoral
vein should not be used.19 Accreditation
organizations strongly recommend
against using this term, and this venous
segment is now referred to as the femoral vein.3,20
Conclusions
VDUS using B-mode imaging with
compression maneuvers and color and
spectral Doppler evaluation is now the
standard diagnostic modality for suspected lower-extremity DVT. Loss of
compressibility of a venous segment,
often with associated Doppler abnormalities, identifies DVT with a high
degree of accuracy, and no additional
testing is needed to initiate treatment.
Negative whole-leg VDUS has a very
high negative predictive value for suspected lower-extremity DVT, and no
further testing is required to withhold
anticoagulation. Whole-leg VDUS,
including calf vein assessment, is the
diagnostic standard.
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Duplex Ultrasound in the Diagnosis of Lower-Extremity Deep Venous Thrombosis
Heather L. Gornik and Aditya M. Sharma
Circulation. 2014;129:917-921
doi: 10.1161/CIRCULATIONAHA.113.002966
Downloaded from http://circ.ahajournals.org/ by guest on June 18, 2017
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