Chapter 14 duplex imaging of lower extremity venous system. Nonthrombotic abnormalities on lower extremity venous duplex. The objective of this study was to determine the prevalence of non. Sequential compressions at these sites showed fully compressible veins. Dvts in the upper extremities have become more commonplace and require a heightened index of suspicion from clinicians. Realtime bmode ultrasound in the ed saves time in the diagnosis of deep vein thrombosis dvt. Ultrasound for lower extremity deep venous thrombosis circulation. Bedside upper extremity vascular ultrasonography can assist in the rapid diagnosis of upper extremity deep venous thrombosis in the emergency department. Ultrasound of the lower extremity venous system is indicated for patients with signs, symptoms, andor laboratory evidence of deep venous thrombosis.
Direct ct venography for evaluation of the lower extremity. Compression ultrasound exam at only two sites, the common femoral vein and popliteal vein, permits rapid and accurate assessment of deep. Our data show that, similarly to the lower extremity, a negative complete ultrasound assessment of the upper extremity can safely exclude dvt. It was thought that upper extremity deep vein thrombosis was more of a nuisance than a true medical. Negative ultrasound study can rule out upper extremity dvt. After your exam your study will be read by a physician who will send the results to your doctor.
In conclusion, deep venous thrombosis, risk factors, presentation, indications, protocol, optional, patient positioning, calf scan, overcoming the adductor canal. Define standard diagnostic criteria for evaluation of dvt and venous insufficiency 5. Lower extremity arterial evaluation is an excellent diagnostic tool that accurately reports the extent of arterial insufficiency or occlusive disease and localizes and quantifies stenoses within the lower extremities utilizing a noninvasive approach. Upper extremity deep vein thrombosis uedvt accounts for approximately 5 to 10 percent of all cases of dvt with incidence increasing due to higher frequency of intravenous catheter use. Lower extremity venous ultrasound protocol manual papdvd edition by lori green author, corky hecht author isbn. Deep vein thrombosis deep vein thrombosis dvt most commonly occurs in the lower limbs, however, are not uncommon in the upper limb and neck veins. The total amount of contrast material used was 30 ml 105 mg i for each extremity in adults. Apr 08, 2015 volume 16, issue 2, march 2015 srikar adhikari, md, ms et al. Explain test procedure to patient in order to minimize anxiety. Intended to be rapid, limited, but revealing most clinically significant dvts. An outpatient upper and lower extremity duplex ultrasound is scheduled for these patients within 2 weeks after discharge to rule out dvt. There is variability and disagreement among authoritative groups regarding the necessary components of the test.
The presence of dvt at screening, the location of dvt along the lower extremity, and the outcome of calf dvt were analyzed in terms of gender, underlying diagnosis, and history of dvt prophylaxis. Duplex ultrasound in the diagnosis of lower extremity deep. A peripherally inserted central catheter picc line was subsequently placed for. Ultrasound 1 month later showed retraction of thrombus into the great saphenous vein at the proximal thigh, with saphenous reflux obtained throughout. In conclusion, repeat duplex ultrasound identifies proximal extension of lower extremity dvt, which may be associated with an increased prevalence of highprobability vq scans. Emergency ultrasound extremity swelling upper extremity dvt. Ultrasound scanning for deep venous thrombosis ultrasound. Some protocols use grayscale ultrasound alone, whereas others include doppler interrogation. Some protocols include scanning the entire lower extremity, whereas others.
This trial evaluated the efficacy of mri in diagnosing dvt. Lower extremity venous ultrasound protocol manual, 2nd edition. Idiopathic upper extremity deep vein thrombosis is believed to occur in the absence of any obvious risk factor. Patients can be otherwise asymptomatic but commonly present with limb swelling. Venous ultrasound is the standard imaging test for patients suspected of having acute deep venous thrombosis dvt. Connect with sonosite log in leave this field blank. Implications for 2 point compression ultrasonography of the lower extremity.
While there are a number of risk factors for developing a dvt, two of the most common are experiencing an injury to your lower body and having. This can happen if a vein becomes damaged or if the blood flow within a vein slows down or stops. A focused history and physical examination should be performed. Upper extremity arterial doppler updated 112712 indications. Ultrasonography is a noninvasive and reliable method for examining the upper extremity ue venous system, particularly with respect to the diagnosis or exclusion of thrombus in symptomatic patients. To compare the sensitivity and specificity of the twopoint. Lower extremity venous duplex protocol sonographic. A bedside ultrasound was conducted to assess for dvt with clinical indications of edema and pain. Apr 16, 2012 a 27yearold man presents to the emergency department with a 1day history of severe right upper extremity pain and swelling.
These form the major veins we evaluate during a lower extremity duplex. Lowerextremity doppler for deep venous thrombosiscan emergency physicians be accurate and fast. Sonographic evaluation of upper extremity deep venous. Lower extremity dvt was detected in 34% of patients. Acraiumsru practice guideline for the performance of. Lower extremity dvt most commonly originates in the calf veins at the. Transverse sfv proximal with and without compression 4.
Start studying chapter 14 duplex imaging of lower extremity venous system. Peripheral arterial evaluations lower extremity arterial evaluation. Emergency department bedside ultrasound examination of both the right axillary vein and subclavian vein near the picc line tip revealed deep venous thrombosis of both veins. Clinical upperextremity dvt now accounts for about 8% of all cases of dvt. With supporting literature and a ton of sample photos and vids, you can walk away from this podcast understanding more about effective use of the ultrasound in scanning for dvts. Visit this video details the scanning techniques and use of ultrasound in the evaluation of deep vein. Pain upon exertion, parathesia, absence of pulse, color changes to fingers and any other indications determined by referring physician.
Deep venous thrombosis ultrasound evaluation statpearls ncbi. For most patients lower extremity rule out dvt ultrasound scanning should be performed when they are laying on their backs. Scanning tips positive anatomical identification deep veins lie deep to the facia between the muscle fascia accompanied by an artery and are paired distal to the knee muscular veins lie within the muscle and do not run in the facial planes accompanied by a small artery and are paired superficial veins usually lie between the deep and superficial fascia. Volume 16, issue 2, march 2015 srikar adhikari, md, ms et al. Emergency department diagnosis of upper extremity deep. It was thought that upper extremity deep vein thrombosis was more of a nuisance than a true medical entity.
Lower extremity deep venous thrombosis radiology key. Echogenic, noncompressible lumen is noted involving left internal jugular, external jugular, subclavian, brachial, ulnar radial veins. Upperextremity deep venous thrombosis acp hospitalist. Some make it a point to lower the head of the bed so that superfluous abdominal fat will not block the groin. Even idiopathic thrombus can be associated with extrinsic compression of the vein, often at the crossing of the first rib and the clavicle subclavian vein and by the pectoralis muscle axillary.
The american institute of ultrasound in medicine aium protocol calls for at the very least inclusion of bilateral eivs. Lower extremity venous duplex mint medical education. Upper extremity dvt is far less common than lower extremity dvt but still may account for as much as 10% of dvts. Deep venous thrombosis dvt, upper extremity statpearls.
Lower extremity venous duplex protocols verify patient, physician order and proper indication for examination. Learn the basics of dvt ultrasound in just 7 minutes. Each study type will have a slightly different testing protocol the upper extremity arterial examination nonatherosclerotic disease. The trial enrolled 338 consecutive patients suspected of having a dvt. Deep vein thrombosis, or dvt, occurs when a blood clot forms in one of the deep veins of the body. Protocols do vary from institution to institution, as such some places require you to examine from the ivc below, others just from the cfv. Upper extremity deep vein thrombosis american college of. The incidence of dvt is estimated to be close to 120 per 100,000 person years, 1 3 and recent modeling data suggest that over 900,000 cases of venous thromboembolism occur in the united states per year. Transverse sfv distal with and without compression 6. Deep vein thrombosis dvt most commonly occurs in the lower limbs, however. Key points providers can accurately detect lower extremity deep venous thrombosis with bedside ultrasound after limited training.
Ultrasound guidance may lead the operator to cannulate more proximally along the radial artery, or avoid the radial artery altogether and use the ulnar artery. Also as a screening tool in post operative lower limb surgery or patients with a known pulmonary embolus, looking for a source of their embolus. Ultrasound guidance can also help screen for high bifurcation of the radial artery, radial calcification, or small radial arteries 6, all of which can complicate radial artery access. Deep venous thrombosis dvt is an extremely common medical problem worldwide. Lower extremity deep vein thrombosis with ultrasound. Although the gold standard for diagnosis is the duplex ultrasound examination, the current study used for diagnosis of dvt in the ed by emergency physicians is the pointofcare compression ultrasound pocus. Extraluminal factors small vessel disease duplex ultrasound. Some protocols include scanning the entire lower extremity, whereas others recommend scans limited to the thigh and knee supplemented with serial testing. Comparison between twopoint and threepoint compression. Lower extremity venous duplex ultrasound vdus with bmode compression maneuvers and doppler evaluation was performed, and she was found to have an acute deep venous thrombosis dvt of the left. Bedside ultrasound can be used to conduct compression testing on lower extremity vasculature to assess for dvt.
Demonstrate a routine protocol for a complete venous duplex ultrasound examination of the lower extremity 3. To exclude deep vein thrombosis as a cause for pain and swelling in the lower limb. The contrast volume used varied between 10 and 20 ml 17. This video is an excerpt from the society for vascular ultrasound professional performance dvd series. Lower extremity venous protocols and interpretation. In the upper extremity the deep veins include the paired radial veins, paired. Lower extremity venous duplex dvt diagnosis image protocol 1. Emergency department diagnosis of upper extremity deep venous. Mar 30, 2002 ultrasound is 89% sensitive and 97% specific for dvts above the knee, but is limited in its ability to diagnose pelvic dvts and dvt recurrence. Sonographic evaluation of upper extremity deep venous thrombosis. Introduction the presence of upper extremity deep vein thrombosis was, for many years, neglected. The upper extremity arterial examination phillip j bendick, phd.
Compression bedside ultrasound has however recently been shown to be a safe, rapid and accurate method for the diagnosis of proximal dvt in the emergency department with a high sensitivity and specificity combined sensitivity and specificity of 96. Technique upper extremity duplex evaluation consists of grayscale and doppler assessment of all the accessible portions of the subclavian, innominate, internal jugular, and axillary veins, as well as compression grayscale ultrasound of the brachial, basilic, and cephalic veins in the. Acute vs chronic dvt acute dvt venous distension probably the most important diagnostic criterion for acute dvt low echogenicity intraluminal material producing flow and colour void very recent clot may be completely anechoic compressibility non discriminatory. Hop on the dvt train and learn how to effectively master this technique in less than ten minutes and perform the scan in less than five. Pointofcare ultrasound for a deep venous thrombosis. Incidence and distribution of lower extremity deep vein. Deep vein thrombosis dvt, defined as coagulated blood or clot within a deep. To help prevent a venous thromboembolic event, it is important to diagnose a dvt. This disease process leads to 60,000 to 100,000 deaths annually due to pulmonary embolism.
Twosite compression pointofcare ultrasonography for dvt. The observed results are consistent with those reported in previous large cohort studies. Sonographic evaluation of upper extremity deep venous thrombosis eva e. The scanning protocol was from distal to proximal, and a bolustracking method was used. Lower extremity venous duplex dvt diagnosis image protocol. Amongst ed providers, there is a sensitivity of 95% and specificity of 96% clinical suspicion of dvt. This is a survey to localize and characterize disease of the upper extremity arteries bilaterally. This case aims to show the typical appearances of dvt on ultrasound. Twopoint compression ultrasonography for lower extremity. State imaging techniques for evaluation of the superficial venous system of the lower extremity 4. The most serious complication associated with any dvt, including upper extremity dvt, is a pulmonary embolus pe. To compare the sensitivity and specificity of the twopoint and threepoint. Does repeat duplex ultrasound for lower extremity deep. Compression ultrasound exams are as accurate as traditional duplex and triplex vascular ultrasound exams.
To exclude or confirm the presence of deep and or superficial venous thrombosis as a cause of pain and swelling in the upper limb. A 27yearold man presents to the emergency department with a 1day history of severe right upper extremity pain and swelling. Twentythree percent of patients had isolated calf vein thrombosis. Objectives, venous thromboembolism vte, cancer patients, clinical importance of dvt, which lower leg vessels may harbor deep vein thrombosis, normal anatomy, calf veins, posterior tibial veins, muscular calf veins are also deep veins, normal variants, duplicated femoral vein with thrombus in one, triplicated femoral vein, ledvt compression technique, cfv normal compression, ledvt.
These dvds are based and enlarge on svus professional performance guidelines for. Subclavian vein scv clot is usually associated with arm swelling. Lower extremity deep vein thrombosis dvt is a frequent cause of admission to the emergency departments ed. The sensitivity and specificity of mri were similar to venography and ultrasound. The extremity was assessed at 3 locations common femoral vein, saphenofemoral junction, and the popliteal vein. Findings of acute venous thrombosis involving upper limb. Emergency physicianperformed compression ultrasonography focuses primarily on the evaluation of the proximal veins of the lower extremity in patients with suspected deep venous thrombosis dvt.
Ultrasound to identify dvt of the lower extremity can be performed either by an experienced emergency medicine physician, an ultrasound. The patients status is post open reduction internal fixation for a left tibial plateau fracture, which was complicated by methicillinsensitive staphylococcus aureus osteomyelitis. To assess the venous anatomy of the lower extremity for the detection of deep venous thrombosis dvt. Pointofcare ultrasound is recommended in some settings. Dec 14, 2017 lower extremity deep vein thrombosis dvt is a frequent cause of admission to the emergency departments ed. Ultrasound for lower extremity deep venous thrombosis. Patients with known altered coagulation status, on oral contraceptive pill, weight lifters, upper limb, neck or breast surgery or trauma are.
Ultrasound guidance for upper extremity arterial and. Ultrasound diagnosis of lower extremity venous thrombosis. Lower extremity doppler for deep venous thrombosiscan emergency physicians be accurate and fast. The annual incidence of lower extremity deep venous thrombosis dvt in the united states is approximately 300,000 to 600,000 cases per year. Advised to use warm compresses as needed and keep leg elevated. Theodoro d, blaivas m, duggal s, snyder g, lucas m. The main indication for lower extremity venous ultrasound is the. An image from a vascular ultrasound of the left arm showing blood flow through the left subclavian artery. A detailed sonographic evaluation of lower extremity is not performed. Learn vocabulary, terms, and more with flashcards, games, and other study tools.