DVT ultrasound: Difference between revisions
 
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==Background==
==Background==
*Non-compressible vein may be mistaken for an artery, leading to a false negative result
*Bedside ultrasound can be used to conduct compression testing on lower extremity vasculature to assess for DVT
*An artery may be mistaken for a non-compressible vein, leading to a false positive result
*Intended to be rapid, limited, but revealing most clinically significant DVTs
*The superficial femoral vein is part of the deep venous system
*Amongst ED providers, there is a sensitivity of 95% and specificity of 96%<ref>Burnside P, Brown M, and Kline J. Systematic review of emergency physician-performed ultrasonography for lower-extremity deep vein thrombosis. Acad Emerg Med. 2008; 15:493–498.</ref>


==Anatomy==
==Indications==
#Significant risk of PE:
*Clinical suspicion of [[DVT]]: edema, tenderness over the calf, Homan's sign
##Common femoral vein
*Clinical suspicion of [[PE]]: chest pain, shortness of breath, tachycardia, tachypnea
##'''(Superficial) femoral vein'''
###(Superficial) femoral vein is part of the deep system, not the superficial system as the name suggests!
##Popliteal veins


==Technique==
==Technique==
#Transducer
===Sites of Compression for 3-Point Evaluation===
##Linear array vascular probe 6–10 MHz
[[File:Compression of Lower Extremity Veins.png|200px]]
##6–8cm width ideal (for larger patients, consider abdominal probe) 
#Compression
##Compress vein with transducer (probe transverse to vein)
##Touching of anterior and posterior walls = normal
##No touching with pressures sufficient to deform the artery = likely DVT
#Common Femoral Vein
#Common Femoral Vein
##Patient positioning
#Saphenofemoral Junction
###Reverse trendelenberg or semi-sitting with 30 degrees of hip flexion
#Popliteal Vein
###Mild external rotation (30 degrees) hip
===Steps===
##10cm distal to the inguinal crease
#Select transducer
##Apply compression every centimeter
#*Linear array vascular probe 6–10 MHz
##Continue distal to 1-2cm beyond bifurcation of the common femoral vein (into superficial and deep branches)
#*For morbidly obese patients, consider abdominal probe
#Common Femoral Vein and Saphenofemoral Junction
#*Patient positioning
#**Reverse Trendelenburg or semi-sitting with 30 degrees of hip flexion
#**Mild external rotation (30 degrees) hip
#*Probe at medial inguinal crease
#*Apply generous compression every centimeter
#*Continue distal to 1-2cm beyond bifurcation of the common femoral vein  
#Popliteal vein
#Popliteal vein
##Patient positioning
#*Patient positioning
###Prone, decubitus position, or seated on edge of gurney
#**Prone, decubitus position, or seated on edge of gurney
###Knee flexed 10–30 degree
#**Knee flexed 10–30 degree
###Reverse trendelenberg
#**Reverse Trendelenburg
##12cm superior, to 5cm inferior to the popliteal crease
#*Start with light pressure to better visualize vessels
###Vein usually superficial to artery
#*Apply generous compression over the popliteal vessels to test compressibility
#*Vein usually superficial to the artery ('''a'''rtery is '''a'''nterior)
 
==Findings==
*Each segment of vein identified must be assess as compressible and noncompressible
**Touching of the anterior and posterior walls indicates a normal exam
**No touching with pressures sufficient to deform the artery indicates DVT
 
==Images==
===Normal===
[[File:Compression of Femoral Vein.png|400px|Compression at the Level of the Femoral Vein]]
[[File:Popliteal artery and vein.png|400px|Compression at the Level of the Popliteal Vein]]
===Abnormal===
[[File:DVT in the Femoral Vein.png|400px|DVT of the Femoral Vein]]
[[File:DVT Bowra|thumbnail|Incompressible left Common Femoral Vein<ref>http://www.thepocusatlas.com/soft-tissue-vascular/</ref>]]
 
==Pearls and Pitfalls==
*Arteries are the thick walled and more circular vessels identified
*Doppler flow can be used to identify different directions of flow in vessels and to identify no vascular structures
*Noncompressible vein may be mistaken for an artery, leading to a false negative result
*An artery may be mistaken for a non-compressible vein, leading to a false positive result
*Lymph nodes may be confused with noncompressible vein and if found, can be identified by moving up or down 1 cm
*Does not rule out calf DVTs
*For a more thorough exam, scan from the saphenofemoral junction down through the adductor canal in addition to the areas described above
*Use a curvilinear probe for obese or edematous patients
*An appropriate amount of pressure gives complete collapse of the vein as well as some (but not full) compression of the adjacent artery.<ref>Kline JA et al. Annals of Emerg Med, 2008. PMID: 18562044</ref>
 
==Documentation==
===Normal Exam===
A bedside ultrasound was conducted to assess for [[DVT]] with clinical indications of edema and pain. The extremity was assessed at 3 locations – common femoral vein, saphenofemoral junction, and the popliteal vein. Sequential compressions at these sites showed fully compressible veins. No sonographic evidence of [[DVT]] at these sites.
===Abnormal Exam===
A bedside ultrasound was conducted to assess for [[DVT]] with clinical indications of edema and pain. The extremity was assessed at 3 locations – common femoral vein, saphenofemoral junction, and the popliteal vein. Sequential compressions at these sites showed a noncompressible popliteal vein. [[DVT]] is present at the level of the popliteal vein.
 
==Clips==
===Normal Study - No DVT===
[[File:No DVT fem.gif]]
[[File:No DVT fem 2.gif]]
[[File:No DVT pop.gif]]
===Abnormal Study - Incompressible left Common Femoral Vein===
[[File:DVT Bowra.gif|Incompressible left Common Femoral Vein<ref>http://www.thepocusatlas.com/soft-tissue-vascular/</ref>]]
 
==External Links==
*[http://www.acep.org/Clinical---Practice-Management/Focus-On--Emergency-Ultrasound-For-Deep-Vein-Thrombosis/ ACEP – Focus On Emergency Ultrasound for DVT]
*[http://www.fpnotebook.com/hemeonc/Rad/FcsdLwrExtrmtyVnsUltrsnd.htm Focused Lower Extremity Venous Ultrasound]


==See Also==
==See Also==
*[[Ultrasound (Main)]]
*[[Ultrasound (Main)]]
*[[DVT (Deep Venous Thrombosis)]]
*[[Deep venous thrombosis]]
*[[Pulmonary embolism]]
*[[Paget-Schroetter syndrome]]
 
==References==
<references/>


==Source==
[[Category:Ultrasound]]
Sonoguide.com
[[Category:Radiology]]
[[Category:Vascular]]

Latest revision as of 06:22, 31 December 2019

Background

  • Bedside ultrasound can be used to conduct compression testing on lower extremity vasculature to assess for DVT
  • Intended to be rapid, limited, but revealing most clinically significant DVTs
  • Amongst ED providers, there is a sensitivity of 95% and specificity of 96%[1]

Indications

  • Clinical suspicion of DVT: edema, tenderness over the calf, Homan's sign
  • Clinical suspicion of PE: chest pain, shortness of breath, tachycardia, tachypnea

Technique

Sites of Compression for 3-Point Evaluation

Compression of Lower Extremity Veins.png

  1. Common Femoral Vein
  2. Saphenofemoral Junction
  3. Popliteal Vein

Steps

  1. Select transducer
    • Linear array vascular probe 6–10 MHz
    • For morbidly obese patients, consider abdominal probe
  2. Common Femoral Vein and Saphenofemoral Junction
    • Patient positioning
      • Reverse Trendelenburg or semi-sitting with 30 degrees of hip flexion
      • Mild external rotation (30 degrees) hip
    • Probe at medial inguinal crease
    • Apply generous compression every centimeter
    • Continue distal to 1-2cm beyond bifurcation of the common femoral vein
  3. Popliteal vein
    • Patient positioning
      • Prone, decubitus position, or seated on edge of gurney
      • Knee flexed 10–30 degree
      • Reverse Trendelenburg
    • Start with light pressure to better visualize vessels
    • Apply generous compression over the popliteal vessels to test compressibility
    • Vein usually superficial to the artery (artery is anterior)

Findings

  • Each segment of vein identified must be assess as compressible and noncompressible
    • Touching of the anterior and posterior walls indicates a normal exam
    • No touching with pressures sufficient to deform the artery indicates DVT

Images

Normal

Compression at the Level of the Femoral Vein Compression at the Level of the Popliteal Vein

Abnormal

DVT of the Femoral Vein

File:DVT Bowra
Incompressible left Common Femoral Vein[2]

Pearls and Pitfalls

  • Arteries are the thick walled and more circular vessels identified
  • Doppler flow can be used to identify different directions of flow in vessels and to identify no vascular structures
  • Noncompressible vein may be mistaken for an artery, leading to a false negative result
  • An artery may be mistaken for a non-compressible vein, leading to a false positive result
  • Lymph nodes may be confused with noncompressible vein and if found, can be identified by moving up or down 1 cm
  • Does not rule out calf DVTs
  • For a more thorough exam, scan from the saphenofemoral junction down through the adductor canal in addition to the areas described above
  • Use a curvilinear probe for obese or edematous patients
  • An appropriate amount of pressure gives complete collapse of the vein as well as some (but not full) compression of the adjacent artery.[3]

Documentation

Normal Exam

A bedside ultrasound was conducted to assess for DVT with clinical indications of edema and pain. The extremity was assessed at 3 locations – common femoral vein, saphenofemoral junction, and the popliteal vein. Sequential compressions at these sites showed fully compressible veins. No sonographic evidence of DVT at these sites.

Abnormal Exam

A bedside ultrasound was conducted to assess for DVT with clinical indications of edema and pain. The extremity was assessed at 3 locations – common femoral vein, saphenofemoral junction, and the popliteal vein. Sequential compressions at these sites showed a noncompressible popliteal vein. DVT is present at the level of the popliteal vein.

Clips

Normal Study - No DVT

No DVT fem.gif No DVT fem 2.gif No DVT pop.gif

Abnormal Study - Incompressible left Common Femoral Vein

Incompressible left Common Femoral Vein[4]

External Links

See Also

References

  1. ↑ Burnside P, Brown M, and Kline J. Systematic review of emergency physician-performed ultrasonography for lower-extremity deep vein thrombosis. Acad Emerg Med. 2008; 15:493–498.
  2. ↑ http://www.thepocusatlas.com/soft-tissue-vascular/
  3. ↑ Kline JA et al. Annals of Emerg Med, 2008. PMID: 18562044
  4. ↑ http://www.thepocusatlas.com/soft-tissue-vascular/
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