9 Doppler Imaging of Lower Extremity

Deep Venous Thrombosis

M. M. BALDT, T. ZONTSICH, G. H. MOSTBECK

CONTENTS Furthermore, a significant number of patients

develop a postphlebitic syndrome following DVT,
9.1 Introduction 115
leading to severe edema and inability to work (GAI-
9.2 Clinical Epidemiology 115
9.3 Ultrasound Assessment of DVT TINI et al. 1990; MONREAL et al. 1993). Early diagnosis
of the Lower Extremity 116 can lead to immediate treatment, possibly reducing the
9.3.1 Real-time B-mode US 116 incidence and the severity of postphlebitic syndrome.
9.3.2 Duplex Scanning 118 During the last 20 years, a significant number
9.3.3 CDDS 118 of published articles have described the different
9.4 Regions of the Lower Limb 119
9.4.1 Calf Veins 119 ultrasound techniques such as real-time B-mode
9.4.2 Femoropopliteal Veins 120 ultrasound, duplex scanning (DS), and color-coded
9.4.3 Iliac Veins 120 duplex Doppler sonography (CDDS) in the diagnosis
9.5 Bilateral vs Unilateral Imaging in DVT 122 of DVT and compared these results to other tests.
9.6 Recurrent DVT 122
Today, US is an established and widely available
9.7 Postphlebitic Syndrome 123
9.8 Ancillary Findings 124 technique for the diagnosis of DVT. However, several
9.9 The Future of Venous Ultrasound 124 critical issues remain unsolved , such as the accuracy
References 124 in the detection of free-floating thrombi and of iso-
lated calf vein thromboses, the usefulness of bilateral
examinations in the asymptomatic patient, and the
role of CDDS in the diagnostic algorithm of VTE in
9.1 times of increasing clinical application of spiral com-
Introduction puted tomography (CT) and magnetic resonance
imaging (MR) for the detection of PE and DVT.
Acute deep venous thrombosis (DVT) is a common This article will review the assessment of venous
and serious clinical entity that requires early and clot by US techniques compared with other imaging
accurate diagnosis and therapy before life-threat- modalities such as contrast venography (CV), CT
ening complications, e.g., pulmonary thromboem- and MR,the relationship of DVT to PE, and the long-
bolism (PE), occur. It is estimated that over 90% term-consequences of DVT.
of pulmonary emboli originate from the area of
the lower extremity and the pelvis, demonstrating
the intimate relationship between PE and DVT as
a pathophysiological entity (venous thromboembo- 9.2
lism, VTE) (WEINMANN and SALZMAN 1994). Clinical Epidemiology

DVT and PE generally are common disorders . In 1985,

M. M. BALDT, MD
a total of 187,000 patients was treated in the USA for
Associate Professor of Radiology, Bilddiagnostik Wolfsberg,
Rossmarkt 14,9400 Wolfsberg, Austria
DVT, PE contributed to more than 30,000 deaths and
T. ZONTSICH, MD was diagnosed 120,000 times in inpatients (GILLUM
Ambulatorium fur Computertomographie, Ultraschall und 1987). These figures have not improved over the inter-
moderne Schnittbilddiagnostik, Ferdinand Porsche Ring 10, vening years.The risk of DVTafter a knee or hip opera-
2700Wiener Neustadt, Austria tion is high, with estimated frequencies of 40-70%, and
G. H. MOSTBECK, MD
Professor of Radiology, Sozialmedizinisches Zentrum, Baum- a 2-5% risk for symptomatic PE (GALLUS et aI. 1973).
gartner Hohe mit Pflegezentrum, Otto Wagner Spital, Sanato- Most venous thrombi are clinically silent when
riumstrasse 2, 1140Vienna, Austria they are first detected by imaging methods (WEIN-

G. H. Mostbeck (ed.), Duplex and Color Doppler Imaging of the Venous System
© Springer-Verlag Berlin Heidelberg 2004
 116
MANN and SALZMAN 1994),probably because they do
not totally obstruct the vein or there is sufficient col-
lateral circulation. Therefore, the clinical diagnosis is
unreliable, and less than one-third of patients pres-
ent with classic symptoms (pain, discomfort, edema,
positive Homans's sign, etc.) (HAEGER 1969).In fewer
than 50% of patients with a clinical suspicion of DVT
is this diagnosis confirmed by imaging tests (WEIN-
MANN and SALZMAN 1994).
The most important risk factors for venous
thromboembolism are immobilization (after trauma
or operation, bus or air travel: 'economy class syn-
drome'), hypercoagulability, obesity, and neoplasm.
There is a significantly higher incidence of cancer
in patients with DVT in follow-up periods (BARON
et al.1998) .
9.3
Ultrasound Assessment of DVT
of the Lower Extremity
9.3.1
Real-time B-mode US
The compression technique of the deep veins is
usually performed from the level of the inguinal
ligament to the confluens of the peroneal and tibial
veins below the knee (CRONAN 1993). Adequate
gain settings require that normal vessels be free of
internal echoes . This can be managed by comparing
the US signal within the vein to that of the accom-
panying artery (or vein of the opposite side, where
appropriate). The examination is performed in the
longitudinal and transverse planes with respect to
a b
Fig. 9.1. a Thrombosis of the GSv. Echogenic material (clot) in the vein, the GSV cannot be compressed by the scan head. b
Thrombosis of the POPV.Lack of color coding and echogenic material in the POPV
M. M. Baldt et al.
the vessel's course. The longitudinal plane is used
for primary orientation and localization of the vein,
whereas the optimal plane for the compression tech-
nique is transverse, since the transducer cannot 'roll
off' the vein.
The compression should be sufficient to dimple
the overlying skin. The pressure is excessive when
the arterial vessel is compressed, too. Compression
of a normal vein completely collapses the venous
lumen, while DVT prevents venous wall collapse
(Fig. 9.1). In some patients, complete compression
of the vein in the adductor canal region may be
difficult or even impossible (CRONAN 1993). Some
authors report a very low specificity of vein incom-
pressibility for this part of the thigh (KILLEWICH et
al. 1989). The amount of compression required in
these areas may be significant.
Comparison with CV has demonstrated that US
may sometimes underestimate the extent of the clot.
Clot echogenicity is very variable, depending on the
age, localization, and extent of the clot and transducer
frequency (FOBBE et al. 1991). Fresh thrombi may
demonstrate no internal echoes and can be missed by
US (MURPHY and CRONAN 1990). Therefore, clot echo-
genicity is an unreliable parameter for determining
the age of a clot. Further confusion may arise because
slow-flowing blood can appear highly echogenic,
mimicking a clot (Fig.9.2). The only parameter which
allows us to estimate the age of a clot is the diameter of
the occluded vein. If the diameter of the vein exceeds
twice the diameter of the accompanying artery, the
age of the thrombus can be estimated to be less than
10 days (FOBBE et al.199l).
The normal response of veins of the lower extrem-
ity to the Valsalva maneuver is an increase in diam-
eter, while an occluded vein does not do this. While