Deep vein thrombosis ultrasound
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Editor(s)-In-Chief: The APEX Trial Investigators, C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-In-Chief: Cafer Zorkun, M.D., Ph.D. [2] ; Kashish Goel, M.D.; Assistant Editor(s)-In-Chief: Justine Cadet
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Overview
Venous ultrasound (US) is the confirmatory test for the diagnosis of deep vein thrombosis (DVT). The most commonly used form is proximal compression ultrasound (CUS), which assesses the compressibility of femoral and popliteal vein. The diagnosis of DVT is established if the vein can not be collapsed under gentle ultrasound probe pressure. Serial CUS might be performed in some conditions, particularly if the CUS results are negative in a patient with moderate or high pre-test probability of DVT. Whole-leg ultrasound examines the deep veins of the proximal leg and calf; however, it is less commonly used. Iliac vein ultrasound may be performed if thrombosis is suspected in these veins (e.g.: pregnant women with swelling of the whole leg).[1]
Ultrasound
Compression Ultrasonography
The Society of Radiologists in Ultrasound Consensus Conference in 2018 stated[2]:
- "The panel recommends a comprehensive duplex ultrasound protocol from thigh to ankle with Doppler at selected sites rather than a limited or complete compression-only examination"
- "Limited protocols (not including calf veins) and selective evaluation of the calf are not recommended because limited protocols require a second study in 5 to 7 days to safely exclude DVT"
- "Repeat ultrasound may be required for patients who have a negative CDUS with persistent or worsening signs and symptoms, a technically inadequate CDUS, or an equivocal finding"
Compression ultrasonography in B-mode has high sensitivity and specificity for detecting proximal deep vein thrombosis in symptomatic patients. The sensitivity lies somewhere between 90 to 100% for the diagnosis of symptomatic deep vein thrombosis, and the specificity ranges between 95 to 100%.[3]
Compression ultrasound is currently the first-line imaging examination for DVT because of the following reasons:
- Relative ease of use
- Absence of irradiation or contrast material
- High sensitivity and specificity
Compression Ultrasound in Suspected Recurrent Lower Extremity DVT
Shown below are the definitions of negative, positive, and non-diagnostic ultrasound for recurrent DVT.[1]
- Negative ultrasound:
- Normal US, or
- Increase in residual diameter of less than 2 mm, or
- Area of prior non-compressibility with a decreased or stable residual diameter
- Non-diagnostic US:
- Ultrasound that is technically limited, or
- Area of prior non-compressibility with an increment in residual venous diameter of < 4 mm yet ≥ 2 mm, or
- Area of prior non-compressibility in the absence of a previous measurement of the residual diameter
- Positive US:
- New non-compressible segment, or
- Area of prior non-compressibility with an increment in residual venous diameter of ≥ 4 mm
Doppler Ultrasound
- Doppler US is indicated in suspected upper extremity DVT. Combined US that consists of compression and Doppler or color Doppler should be done.[1]
- Doppler US is also indicated in pregnant women suspected to have isolated iliac vein thrombosis and among whom the proximal CUS revealed no evidence of thrombosis.[1]
Ultrasound Images Demonstrating Upper Extremity Deep Vein Thrombosis
Whole Leg Ultrasound
Whole-leg ultrasound examines the deep veins of the proximal leg and calf; however, it is less commonly used. Shown below is an algorithm that depicts the interpretation of the results of whole leg US.[1]
| Whole leg US | |||||||||||||||||||||||
| Negative | Positive | ||||||||||||||||||||||
| DVT is excluded | Where is the location of the DVT? | ||||||||||||||||||||||
| Proximal DVT | Distal DVT | ||||||||||||||||||||||
| Treat DVT | Perform serial US (1st line) OR Treat DVT | ||||||||||||||||||||||
Limitations
- US has several limitations. As with impedance plethysmography, the results are limited in patients with deformities or a plaster cast.
- Isolated thrombi, present in the following locations, are not identified in:
- Iliac vein
- Femoral vein within the adductor canal
- Serial studies may be needed if the initial test is negative, particularly among patients with moderate or high pretest probability of DVT.
References
- ↑ 1.0 1.1 1.2 1.3 1.4 Bates SM, Jaeschke R, Stevens SM, Goodacre S, Wells PS, Stevenson MD; et al. (2012). "Diagnosis of DVT: Antithrombotic Therapy and Prevention of Thrombosis, 9th ed: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines". Chest. 141 (2 Suppl): e351S–418S. doi:10.1378/chest.11-2299. PMC 3278048. PMID 22315267.
- ↑ Needleman L, Cronan JJ, Lilly MP, Merli GJ, Adhikari S, Hertzberg BS | display-authors=etal (2018) Ultrasound for Lower Extremity Deep Venous Thrombosis: Multidisciplinary Recommendations From the Society of Radiologists in Ultrasound Consensus Conference. Circulation 137 (14):1505-1515. DOI:10.1161/CIRCULATIONAHA.117.030687 PMID: 29610129
- ↑ Lensing AW, Prandoni P, Brandjes D, Huisman PM, Vigo M, Tomasella G; et al. (1989). "Detection of deep-vein thrombosis by real-time B-mode ultrasonography". N Engl J Med. 320 (6): 342–5. doi:10.1056/NEJM198902093200602. PMID 2643771.