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VENOUS DOPPLER SONOGRAPHY OF THE EXTREMITIES

The 35th Annual Vanderbilt Diagnostic Sonography Symposium

July 23-24, 2011E. JAMES ANDREWS, JR., M.D., FACR, FACC

DEPARTMENT OF RADIOLOGY AND RADIOLOGICAL SCIENCESVANDERBILT UNIVERSITY MEDICAL CENTER

DISCLOSURESTATEMENT

There are no financial relationships to disclose

As you can see, I have nothing elseto disclose.

“Longevity is a vascular question.”g y

Sir William Osler

MORTALITY FROM PULMONARY EMBOLUS AND OTHER CONSEQUENCES OF DVT

200,000 DEATHS PER YEAR FROM DVT AND IT’S CONSEQUENCESCONSEQUENCES

ANNUAL COMBINED INCIDENCE OF PE & DVT IN US: 70/100,000

American Public Health Association report 2004

SCOPE OF THE PROBLEM

UP TO 20 MILLION CASES OF DVT/YR

MANY ARE ASYMPTOMATIC

MAJORITY ARE INFRAPOPLITEAL

20-30% WILL PROPOGATE, RESULTING IN INCREASED RISK OF PE

30% MORTALITY IF UNTREATED

UP TO 50% WITH DVT HAVE SILENT PE

90% OF PE COME FROM LOWER EXT

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NUMBERS

26,279 Ultrasound studies were performed at Vanderbilt during a 12 month period in 2010-2011.

4,274 were venous sonograms of the extremities to evaluate for DVT.

DVT studies account for approximately 16% of all ultrasound exams at Vanderbilt.

The average is about 12 cases per day.

1. Discuss risk factors and compare various diagnostic tests for the diagnosis of DVT

OBJECTIVES

diagnosis of DVT.

2. Present sonographic technique for evaluation of the extremities for deep venous thrombosis (DVT).

3. Develop an algorithm for diagnostic testing for DVT including D-dimer.

DEEP VENOUS THROMBOSIS

CLINICAL DIAGNOSIS IS DIFFICULTRISK FACTORS ARE IMPORTANT PATHOPHYSIOLOGY – ANATOMY TECHNIQUE – PROTOCOLSACUTE VS. CHRONIC DVTUPPER EXTREMITY DVTA FEW INTERESTING CASE EXAMPLESD-DIMER AND ALGORITHM

DIAGNOSTIC TESTS FOR DVT

SonographyContrast venography (90% sensitive)Nuclear medicine MRI (MRV) - abdomen and pelvis Impedance pletysmographyCT PET ?D-DIMER

COMPARISON OF DIAGNOSTIC TESTS

Sonography – 97% sensitive for DVT

MRI (MRV) – 96% sensitive for DVT( )

CT – 97% sensitive for DVT

D-Dimer – 99% sensitive for DVT

48% specific

DVT - CLINICAL DIAGNOSIS

Clinical signs present in only 50%

Acute unilateral leg swelling

Calf asymmetry of more than 2 cmCalf asymmetry of more than 2 cm

Risk factors are important

Clinical evaluation is not reliable

Criado et al; Surgery 1997

Meyer et al; Ann Vasc Surg 1995

Anderson; J Vasc Tech 1989

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PULMONARY EMBOLUS

3rd most common form of CV disease

At autopsy, 64% have sub-clinical PE

Only approximately 30/100 cases diagnosed

CT FROM ER IN A PATIENT WITH SHORTNESS OF BREATH

THE PROBLEM CONTINUES

40-70% OF PATIENTS WITH DVT WILL DEVELOP POST PLEBOTIC SYNDROME

1 Pain1. Pain

2. Chronic swelling

3. Soft tissue ulceration

4. Valve injury with incompetence

5. Venous hypertension

RISK FACTORS – THE BIG 3

AGE OLDER THAN 75 YEARS

PREVIOUS HISTORY OF DVT

CANCER

Arch Intern Med.164:963-968,2004

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OTHER RISK FACTORS

PregnancyObesity SurgeryBurnsCHF Sepsis

MORE RISK FACTORS

PROLONGED SITTING PROLONGED SITTING

AIR OR BUS TRAVEL

26 yom duck hunter complained of pain and swelling in the left leg

RISK FACTOR SIMILARITIES

1 ENDOTHELIAL DAMAGE

What is common about these risk factors?

1. ENDOTHELIAL DAMAGE2. HYPERCOAGULABLE STATE3. VENOUS STASIS

VIRCHOW’S TRIAD

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COAGULATION ACTIVATED BY AIR TRAVEL ?

71 volunteers exposed to three conditions: 1. 8 hour plane flight; 2. 8 hours of immobilization in a cinema; 3. 8hours of immobilization in a cinema; 3. 8 hours of normal activity.

Thrombin-antithrombin (TAT) levels higher after plane flight.

D-Dimer values rose after plane flight

Rosendaal, F.; The Lancet; March 11, 2006

CT AFTER A LONG PLANE RIDE

ORIGINALLY DIAGNOSED AS PNEUMONIA

PATHOPHYSIOLOGY OF LOWER EXTREMITY DVT

Usually begins in the calf veins

Typically behind valve leaflets

40% l 40% resolve

40% organize

20% propagate

Acute/partially occlusive tend to embolize

VALVES

Deep and superficialMore common in calf veins

Di t th fl i t th d tDirect the flow into the deep systemCalf muscles work as a pumpUpper extremity valves end at first ribMost thrombus forms under a valve leaflet

THROMBUS UNDER VALVES

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THROMBUS UNDER VALVE

SLOW FLOW

VALVES PARTIALLY CLOSED WITH ECHOGENIC MATERIAL UNDERNEATH (ARROWS)

VALVES NOW OPEN WITHECHOGENICITY NOW GONE

CLOT OR SLOW FLOW?

SLOW FLOW

TECHNIQUE - PROTOCOLS

Linear array transducer 5 – 7.5 MHZ

Supine / decubitus / pronep p

Grey scale / color Doppler / pulse Doppler

Compression (transverse) w/wo color

Augmentation / valsalva

THE DIFFICULT PATIENT

Curved array transducer 2.5 – 3.5 MHZ

Reverse Trendelenberg / Erect

T i t Tourniquet

Augment non-visualized segment

Power Doppler

IV contrast

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Courtesy of Philips Medical Systems

IMAGES

COMPRESSION AUGMENTATION

SPECTORAL WAVE FORM COLOR FLOW

Courtesy of Phillips Medical Systems

DO YOU IMAGE CALF VEINS ?

5250 pts – 3 years (Hx DVT excluded)

84% symptomatic

4% adequate visualization of calf veins

14% had DVT

4.8% isolated calf vein DVT

Rare to have DVT in anterior tibial vein

Labropoulas et al; J Vasc Surg 1999

CHRONIC VERSUS ACUTE DVT

CHRONIC1. Brightly echogenic

ACUTE1. Lightly echogenicg y g

2. Rigid texture

3. Well attached

4. Vein contracted

g y g

2. Spongy texture

3. Poorly attached

4. Vein enlarged (if obstructed)

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33yom, ER complaint of pain & swelling LLE (previous VCFilter)

70 yom with acetabular fracture - ? Chronic DVT

NUCLEAR STUDY MAY BE USEUL TO ACCESS DVT AGE

ANTERIOR POSTERIOR

NORMAL

ANTERIOR POSTERIOR

POSITIVE FOR DVT

Brighton T et al. J Nucl Med. 2007; Vol. 48 No. 6 p 873-878

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SEQUENTIAL IMAGES

DAY 1 DAY 7 DAY 30

JNM: 2007;48, No 6, 873-878

DVT: DUAL-CONTRAST MRI

Li, W et al: Radiology 2007; 242:873-881

UPPER EXTREMITIES UPPER EXTREMITY FACTS

Prevalence of upper extremity DVT is increasing due to increase use of indwelling catheters

28-61% of UEDVT had indwelling catheter 23% thrombosis rate with PICC placement Pulmonary embolism present in up to 33% of

patients with UEDVT (rarely fatal)UEDVT common in patients with cancer (40%),

2X as frequent as in patients with catheters

ADDITIONAL FACTS

Other causes of UEDVT include “effort thrombosis” (Paget-Schroetter syndrome)

Clinical features are nonspecific (swelling, discoloration pain and tenderness)discoloration, pain, and tenderness)

Color Doppler sonogaphy is the modality of choice for evaluation of UEDVT

Sensitivity ranges from 78%-100% and specificity 82%-100%

False positive studies are rare

TECHNIQUE

Routine examination includes: internal jugular, brachiocephalic,subclavian, axillary, brachial, & basilic veins as well as contralateral internal jugular veinas contralateral internal jugular vein

Use compression on all accessible veins as well as color Doppler and spectral analysis

Use 5-7.5 MHz linear array transducer (?curved in axilla)

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SPECTRAL WAVEFORMS REFLECT CARDIAC CYCLE AND RESPIRATION

Chinn EE, J Ultrasound Med 24:829-838, 2005

ABNORMAL WAVE FORM

REFLECTION OF CARDIAC ACTIVITY IN PATIENT WITH CHF

DAMPENED WAVE FORMS LEFT SUBCLAVIAN VEIN

DAMPENED WAVE FORM

NORMALWAVE FORM

? NO THROMBUS

Patel MC. Radiology 211:579-583,1999

MEDIAL SUBCLAVIAN OCCLUSION

Patel MC. Radiology 211:579-583, 2005

PICC & ARM SWELLING

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51 YOM WITH PICC INTERNAL JUGULAR

JUGULAR THROMBUS 69 YO FEMALE WITH PICC

D-DIMER – IS IT USEFUL?

Very sensitive for DVT (99-100%)

Not very Specific (50%)

False positives are common in any p ycondition with fibrinolysis (diabetes, pregnancy, GI conditions, liver disease, heart conditions, recent surgery)

Conclusion: A negative test is helpful, but a positive test may be misleading

34 yom with recent hernia repairER complaining of chest pain

D-dimer – Positive Portable Chest Film – Normal Chest CT - Normal Venous Doppler US – Normal Cardiac Nuclear Scan – Normal Repeat Chest Film (PA & Lat) – Normal

Total cost of workup - $6682

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ALGORITHM FOR DVT EVALUATION

NO RISK FACTORS FOR DVT

NO RISK FACTORS FORFALSE + D-DIMER

D-DIMER

AT RISK FOR FALSE + D-DIMER

ULTRASOUNDPOSITIVE

NEGATIVE

STOP

OR,IF STILL CONCERNED CLINICALLY

ALGORITHM FOR DVT EVALUATION

HIGH RISK FOR DVT

CLINICAL SUSPICION OF DVT

AT RISK FOR FALSE + NO RISK FACTORS FORD-DIMER

ULTRASOUND

FALSE + D-DIMER

D-DIMERPOSITIVE

NEGATIVEOR,

IF STILL CONCERNEDCLINICALLY

STOP

ALGORITHM FOR DVT EVALUATION

RISK FACTORS FOR DVT

RISK FACTOR FOR FALSE + D-DIMER

PE SUSPECTED

LOW RISK FOR FALSE + D-DIMER

CT – PE PROTOCOLCT VENOGRAM ?

POSITIVE

NEGATIVEOR,

IF STILL CONCERNEDCLINICALLY

D-DIMER

STOP

PROPAGATION POPLITEAL - 6/07

42 YOM DIABETIC WITH LEFT LEG PAIN –NORMAL STUDY ON 6/07

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POPLITEAL – 6/10

REPEAT STUDY THREE DAYS LATER

3 DAY COMARISON

DAY 1 DAY 3

FEMORAL

POPLITEAL

41 YOF NSC LUNG CA – 5/10 FOLLOW-UP MAY 19

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BEFORE AND LATER

5/10 5/19

SUMMARY

DVT is very common in both lower and upper extremities

It is difficult to diagnose clinically It can lead to PE which is often fatal Sonography is very accurate in diagnosing

DVT when proper techniques are used Sonography remains the “Gold Standard”

of diagnostic tests for DVT

TAKE HOME POINTS

DVT IS VERY COMMON DIAGNOSIS IS OFTEN NOT MADE SONOGRAPHY REMAINS THE TEST OF

CHOICE FOR DIAGNOSIS AND F/UCHOICE FOR DIAGNOSIS AND F/U PROPAGATION IS NOT INFREQUENT,

SO DO NOT HESITATE TO SUGGEST REPEAT EXAM IF SUSPICION REMAINS

2 NEGATIVE EXAMS A WEEK APART ESSENTIALLY EXCLUDES DX OF DVT

CALLEN’S LAWS

A DVT STUDY THAT SHOULD ONLY TAKE 10-15 MINUTES TO PERFORM WILL USUALLY TAKE 20-30 MINUTES

THE DISTAL SFV IS A FIGMENT OF ONE’S IMAGINATION

THE LIKELYHOOD A STUDY WILL BE POSITIVE IS DIRECTLY PROPORTIONAL TO THE TIME YOU SPEND ARGUING AGAINST IT

REFERENCES

1. Andrews, EJ, Jr., Fleischer, AC. Sonography for Deep Venous Thrombosis: Current and Future Applications. Ultrasound Quarterly 21(4): 2005

2. Chin EE, Zimmerman PT, Grant EG. Sonographic Evaluation of Upper Extremity Deep Venous Thrombosis. J Ultrasound Med 24:829-838, 2005

3. Gaitini D, Beck-Razi N, et al. Prevalence of Upper Extremity Deep Venous Thrombosis3. Gaitini D, Beck Razi N, et al. Prevalence of Upper Extremity Deep Venous Thrombosis Diagnosed by Color Doppler Duplex Sonography in Cancer Patients With Central Venous Catheters. J Ultrasound Med 25:1297-1303, 2006

4. Giess CS, Thaler H, et al. Clinical Experience With Upper Extremity Venous Sonography in a High-Risk Cancer Population. J Ultrasound Med 21:1365-1370, 2002

5. Heron E, Lozinguez O, et al. Long-Term Sequelae of Spontaneous Axillary-Subclavian Venous Thrombosis. Annals of Intern Med 131(7):510-513, 1999

6. Joffe HV, Goldhaber SZ. Upper-Extremity Deep Vein Thrombosis: Current Perspective. Circulation 106 (14):1874-1889, 2002

7. Patel MC, Berman LH, Moss HA, et al. Subclavian and Internal Jugular Veins at Doppler US: Abnormal Cardiac Pulsatility and Respiratory Phasicity as a Predictor of Complete Central Occlusion. Radiology 211:579-583, 1999

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