Compression sonography as a procedure in the diagnosis of acute deep venous thrombosis of the leg

It is well known that clinical symptoms of deep venous thrombosis of the leg are not reliable. We studied the diagnostic value of compression sonography in the diagnosis of venous thrombosis of the lower extremity. Ultrasound examination was performed in patients in the supine position. The venous segments were evaluated almost exclusively with transversal scanning. In the thigh lacking compressibility of the venous lumen was the only criterion for thrombosis. In the calf, unobstructed veins can usually not be seen in the patient supine. In thrombosis however the vessel is dilated by the clot and appears as sonolucent incompressible channel. 178 patients were examined comparatively by venography and ultrasound (226 one extremity phlebogramms). Phlebography demonstrated 113 thromboses which could be demonstrated by ultrasound with a sensitivity of 95% and a specificity of 100%. In 92% the extension of thrombosis was estimated accurately. Thigh vein thrombosis was detected with a sensitivity of 97% and a specificity of 99%. Occlusion or patency of the common femoral vein was seen correctly in each case. Ultrasonic diagnosis of the superficial femoral vein thrombosis had a sensitivity of 97%, that of the popliteal vein of 98% and a specificity of 100% in both. Venous occlusion confined to the calf was detected with a sensitivity of 89% and a specificity of 99%. We conclude that compression sonography is a highly accurate diagnostic procedure for the diagnosis of deep venous thrombosis of the thigh as well as the calf. It should be the first choice of imaging method in the diagnosis of venous thrombosis of the leg.     

A prospective study of the efficacy of B-scan sonography in the detection of deep venous thrombosis in the lower extremities

Between 1 July and 31 December, 1985, 53 patients, clinically suspected of having deep venous thrombosis (DVT), were prospectively studied by B-scan ultrasound prior to lower-limb venography. Criteria for a positive ultrasound examination included visualization of frank clot, failure of the vein to collapse with compression, and absence of normal phasic flow with pulse Doppler sampling. All (100%) of the contrast venograms were considered of diagnostic quality. Fifty of the 53 ultrasound examinations (94%) were considered diagnostic. Of the 50 patients having venous ultrasound of diagnostic quality, contrast venography was positive in 25 and negative in 25 for DVT. Venous ultrasound was correct in 46 patients, for an accuracy of 92% (46/50). Sensitivity was 88% (22/25), specificity was 96% (24/25), the positive predictive value was 96% (22/23), and the negative predictive value was 89% (24/27). The single most useful sign of thrombosis in ultrasound examinations was the failure of the involved vein to collapse with compression. Venous ultrasound appears to be highly accurate in the detection of deep venous thrombosis of the lower extremity.     

血浆D-二聚体联合床旁超声对下肢深静脉血栓的诊断价值

目的:探讨血浆D-二聚体水平联合床旁超声对下肢深静脉血栓的诊断价值。方法:回顾性分析2018年4月至2019年3月复旦大学附属中山医院厦门医院69例重症监护室行床旁下肢静脉彩超检查患者的病例资料,记录血浆D-二聚体水平以及彩超检查结果,计算彩超发现下肢深静脉血栓的血浆D-二聚体水平截断值,分析血浆D-二聚体水平对床旁彩超发现下肢深静脉血栓的诊断效能。结果:床旁彩超诊断无血栓组39例,血栓组30例,男女比例分别为26∶13和15∶15,平均年龄分别为(63.7±13.8)岁和(65.9±12.6)岁,血浆D-二聚体水平分别为3.26(0.91,6.22)mg/L和6.72(3.33,13.24) mg/L(P0.05)。血浆D-二聚体截断值为4.54 mg/L,其对应的灵敏度为66.7%,特异度为69.2%,阳性预测值为60.6%,阴性预测值为72.2%,诊断准确率为68.1%。结论:血浆D-二聚体水平大于4.54 mg/L可作为临床医师申请床旁下肢静脉彩超检查的参考依据,从而减少医疗资源的浪费。     

Acute lower extremity pain in an adult patient secondary to bilateral popliteal cysts

Lower leg and calf pain is a common presenting complaint in the Emergency Department and may involve a variety of etiologies, including musculoskeletal and vascular pathology such as deep venous thrombosis. Baker's cysts are a periodic finding in patients suspected of having deep venous thrombosis. As more emergency physicians perform their own lower extremity ultrasound examinations, they encounter Baker's cysts as the cause of unilateral leg pain or swelling. Bilateral Baker's cysts are very rare and may present a diagnostic challenge in the Emergency Department if bedside ultrasound is not available. We present a case of bilateral Baker's cysts in a young dancer who presented complaining of bilateral lower extremity pain and upper calf swelling. The bilateral cysts were diagnosed on bedside ultrasound by the treating emergency physician and a disposition quickly made.     

彩色多谱勒超声对下肢深静脉血栓的诊断价值

目的探讨下肢深静脉血栓形成的彩色多谱勒超声诊断价值。方法对32例临床确诊下肢深静脉血栓患者,以实时二维超声和探头适当加压观察,彩色血流显示和多谱勒检测,观察血栓形成的部位、范围、管腔宽度及栓塞程度。结果二维彩色多谱勒超声诊断右下肢血栓10例,左下肢血栓20例,双下肢血栓1例,漏诊1例,左下肢患病高于右下肢,左：右≈2：1,准确率97％。结论彩色多谱勒超声对诊断下肢深静脉血栓准确、无创伤、特异性高。     

Central adjudication of venous ultrasound in VTE screening trials: reasons for failure

Summary. Background: The accuracy of screening ultrasound for venous thrombosis in asymptomatic patients is still a matter of debate. The VENUS study evaluated the accuracy of centrally adjudicated venous ultrasound against venography in patients after major orthopedic surgery and found the sensitivity of ultrasound to be poor for both proximal and distal deep vein thrombus (DVT). Objectives: To evaluate whether thrombus characteristics such as location or size influence the diagnostic performance of centrally adjudicated venous ultrasound. Methods: All false negative sonograms of the VENUS study were re‐evaluated against the corresponding venograms. Discrepancies were categorized into types of diagnostic failures. Within these categories, thrombus characteristics such as location, length or size of thrombus were evaluated. Results: One hundred and twelve pairs of discrepant ultrasound and venography documents were compared with 28 pairs with concordant results. Discrepancies were caused by local documentation failure (37.5%), failure of the ultrasound method (43.7%) and failure of the central adjudication process (18.7%). The overall size of thrombi was small, which caused about 40% of all sonographic failures with a detection threshold of five Marder points, a thrombus length of 9.5 cm and a number of 3.5 pathological compression manoeuvres. Proximal or distal location of DVT did not affect thrombus detection. Conclusion: If centrally adjudicated ultrasound is to be used in future VTE screening trials, training of local sonographers and central adjudicators needs to be intensified, because asymptomatic DVTs seem to be small and ultrasound sensitivity depends on the number of pathological compression manoeuvres documented in the ultrasound document. In contrast, distal or proximal thrombus location itself does not influence sensitivity.     

Usefulness of hand-held ultrasound devices in out-of-hospital diagnosis performed by emergency physicians

OBJECTIVE: To evaluate the usefulness of ultrasonographic examinations as a diagnostic tool for emergency physicians in out-of-hospital settings. METHODS: Prospective study performed in a French teaching hospital. Eight emergency physicians given ultrasound training for out-of-hospital diagnosis of pleural, peritoneal, or pericardial effusion; deep venous thrombosis; and arterial flow interruption. After clinical examination, a probability of diagnosis ("clinical score") was assigned on visual analog scale from 0 (absent lesion) to 10 (present lesion). Clinical score between 3 and 7 was considered as clinically doubtful. After ultrasound examination, a second probability ("ultrasound score") was similarly determined. Potential usefulness of ultrasound examination was evaluated by calculating the absolute difference between clinical and ultrasound scores. Patients were followed up to determine final diagnosis: present or absent lesion. "Ultrasound usefulness score" (USS) was determined attributing a positive (when ultrasonography increased diagnostic accuracy) or a negative (when ultrasonography decreased diagnostic accuracy) value to the absolute difference between clinical and ultrasound scores. RESULTS: One hundred sixty-nine patients were included and 302 ultrasound examinations performed. Median duration of examination was 6 minutes (5-10 minutes). The suspected lesion was found in 45 cases (17%). Mean USS was +2 (0-4). Ultrasonographic examination improved diagnostic accuracy (ie, positive USS) in 181 (67%) cases, decreased it (ie, negative USS) in 22 (8%) cases, and was not contributive (ie, USS was 0) in 67 (25%) cases. When initial diagnosis was uncertain (n = 115), diagnostic performance reached +4 (3-5) and ultrasonographic examination improved diagnostic accuracy in 103 (90%) cases. CONCLUSION: Out-of-hospital ultrasonography increased diagnostic accuracy in out-of-hospital settings.     

Deep venous thrombosis: diagnosis in spinal cord injured patients

Because the acute spinal cord injured patient is at high risk for the development of deep venous thrombosis (DVT), accurate diagnosis is critical. Clinical evaluation is unreliable 50% of the time, however, and the two highly accurate diagnostic procedures--venography and 125I-labelled fibrinogen scanning--are invasive and present serious drawbacks. The literature concerning the effectiveness of the two most widely used noninvasive diagnostic alternatives (Doppler ultrasound and venous occlusion plethysmography [VOP]) is equivocal. In our systematic evaluation of a series of 21 patients, using clinical examination, Doppler ultrasound and VOP, all patients who developed DVT were identified by all three methods. Overall accuracy, sensitivity and specificity were 100%.     

Safety and sensitivity of two ultrasound strategies in patients with clinically suspected deep venous thrombosis: a prospective management study

Summary. Background: It remains unclear whether a single complete ultrasound examination, which detects calf vein thrombosis, is as safe as a baseline rapid ultrasound examination, repeated after 1 week when negative, which examines the veins in the groin and the knee. Therefore, we compared the safety and feasibility of two diagnostic ultrasound strategies, involving rapid and complete compression ultrasound (CUS) examination. Methods: Consecutive patients with suspected deep vein thrombosis (DVT) underwent clinical probability assessment. In patients with an unlikely clinical probability and a normal D‐dimer finding, DVT was considered to be excluded. All others were randomized to undergo a rapid or a single complete CUS examination. Patients in whom DVT was excluded were followed for 3 months to assess the incidence of venous thromboembolism (VTE). Results: A total of 1002 patients were included. A clinical decision rule indicating DVT to be unlikely and a normal D‐dimer finding occurred in 481 patients (48%), with a VTE incidence of 0.4% [95% confidence interval (CI) 0.05–1.5%] during follow‐up. DVT was confirmed in 59 of the 257 patients (23%) who underwent rapid CUS examination, and in 99 of the 264 patients (38%) who underwent complete CUS examination. VTE during follow‐up occurred in four patients (2.0%; 95% CI 0.6–5.1%) in the rapid CUS arm, and in two patients (1.2%; 95% CI 0.2–4.3%) in the complete CUS arm. Conclusions: A diagnostic strategy with a clinical decision rule, a D‐dimer test and a CUS examination is safe and efficient. Both the rapid and the complete CUS test are comparable and efficient strategies, with differing advantages and disadvantages.     

彩色多普勒超声对慢性阻塞性肺疾病急性加重期患者下肢深静脉血栓的诊断价值

目的采取彩色多普勒超声对慢性阻塞性肺疾病急性加重期的患者进行检查,判断其对于患者出现下肢静脉血栓的诊断价值。方法从我院确诊为慢性阻塞性肺疾病的患者中随机抽出100例分为对照组和试验组各50例,试验组患者采取彩色多普勒超声对患者的下肢深静脉血栓情况进行检查,对照组患者采取D-二聚体检测,比较两组患者检查的灵敏度及特异度、准确率情况。结果试验组患者检查的灵敏度为62.00%,对照组患者为72.00%,比较不具有统计学意义(P>0.05),而在检查的特异度方面,试验组患者为94.00%,明显高于对照组的34.00%,在统计学上有意义(P<0.05),试验组患者检查的准确度为84.00%,对照组患者仅为44.00%,P<0.05,差异具有统计学意义。结论彩色多普勒超声检查在慢性阻塞性肺疾病患者的急性加重期,可以特异的检测出患者下肢静脉血栓的情况,并且具有很高的准确性,具有诊断意义,可以作为首选检查应用于临床。     

The venous stasis syndrome after deep venous thrombosis or pulmonary embolism: a population-based study

OBJECTIVES: To estimate the incidence and determine predictors of venous stasis syndrome and venous ulcers after deep venous thrombosis and pulmonary embolism. PATIENTS AND METHODS: This population-based retrospective cohort study reviewed medical records of 1527 patients with incident deep venous thrombosis or pulmonary embolism between 1966 and 1990. We recorded baseline characteristics, event type (deep venous thrombosis with or without pulmonary embolism or pulmonary embolism alone), leg side and site of deep venous thrombosis (proximal with or without distal deep venous thrombosis vs distal deep venous thrombosis alone), and venous stasis syndrome and venous ulcer. RESULTS: Two hundred forty-five patients developed venous stasis syndrome. One-year, 5-year, 10-year, and 20-year cumulative incidence rates were 7.3%, 14.3%, 19.7%, and 26.8%, respectively. By 20 years the cumulative incidence of venous ulcers was 3.7%. Patients with deep venous thrombosis with or without pulmonary embolism were 2.4-fold (95% confidence interval, 1.7-fold-3.2-fold) more likely to develop venous stasis syndrome than patients with pulmonary embolism and no diagnosed deep venous thrombosis. In patients aged 40 years or younger with proximal compared with distal-only deep venous thrombosis, venous stasis syndrome was 3.0-fold more likely (95% confidence interval, 1.6-fold-4.7-fold). In patients with unilateral leg deep venous thrombosis, venous stasis syndrome usually developed in the concordant leg (P < .001). There was a 30% (95% confidence interval, 2%-62%) increased risk for venous ulcer per decade of age at the incident venous thromboembolism. CONCLUSIONS: The cumulative incidence of venous stasis syndrome continues to increase for 20 years after venous thromboembolism. Pulmonary embolism alone is less likely to cause venous stasis syndrome.     

Lower‐extremity Doppler for Deep Venous Thrombosis—Can Emergency Physicians Be Accurate and Fast?

Clinical diagnosis of lower-extremity (LE) deep venous thrombosis (DVT) requires confirmation by an imaging study before committing the patient to anticoagulation therapy. Studies have shown that demonstrating compressibility of leg veins under ultrasound is accurate for ruling out DVTs when performed by vascular specialists. Although LE Doppler has become the preferred test for diagnosing DVTs, it is not always available 24 hours per day. OBJECTIVES: To evaluate the accuracy and speed with which emergency physicians (EPs) could perform LE color duplex ultrasonography for the detection of DVT. METHODS: Patients presenting to an urban community emergency department (ED) between August 1, 1998, and March 3, 1999, were enrolled into this prospective study. The EPs, who underwent brief and standardized training, scanned patients at high risk for DVT with leg pain, swelling, or both. Physicians performed color duplex ultrasound examinations with compression at the common femoral and popliteal veins. The time until completion of the ED scan was recorded with a standardized method. The vascular laboratory performed a complete duplex ultrasound examination within eight hours. RESULTS: One hundred twelve patients were enrolled in the study, with 34 positive for DVT. The median examination time was 3 minutes 28 seconds (95% CI = 2 min 45 sec to 4 min 2 sec; IQR 3 min 9 sec). Times ranged from 1:02 to 18:20 minutes. The ED results had a high correlation with vascular laboratory studies, giving a kappa of 0.9 and a 98% agreement (95% CI = 95.4% to 100%). CONCLUSION: Emergency physicians can perform LE duplex ultrasound examinations accurately and quickly.     

Current approaches and controversial issues in the diagnosis of deep vein thrombosis via duplex Doppler ultrasound

Duplex and color Doppler sonography (DUS) is currently the technique of choice for the diagnosis of deep venous thrombosis (DVT) in symptomatic patients, because it has proven safe and cost-effective, with a very high sensitivity and specificity (96% and 98%, respectively) for the diagnosis of proximal DVT. Several issues regarding its method and clinical indications remain controversial, however. Although isolated calf vein thrombosis does not seem to have a significant adverse outcome in the short term, scanning the calf only in patients with localized symptoms or signs is cost-effective. Bilateral examination is indicated in high-risk patients or when screening asymptomatic patients. When negative, a complete DUS examination of the proximal and distal veins, at least down to the level of the popliteal trifurcation, allows withholding anticoagulant therapy without the risk of major complications. This examination may be repeated if signs or symptoms worsen. Some populations of asymptomatic patients at high risk of DVT may benefit from DUS screening. Bilateral DUS examination of lower limb veins should be performed as the initial examination in the workflow of pulmonary embolism only in patients with risk factors for DVT. Recurrent thrombosis is a challenging diagnosis for all imaging modalities. A diagnostic strategy combining clinical probability score and D-dimer test may refine the selection of patients. The pitfalls and limitations of venous DUS are related to vein anatomy, flow changes, technical issues, and operator expertise.     

Utility of lower-extremity duplex sonography in patients with venous thromboembolism.

PURPOSE: We evaluated the utility of venous duplex ultrasonography (VDUS) of the lower extremities in patients with pulmonary embolism (PE) and studied the distribution of venous thrombi in deep vein thrombosis (DVT) patients with and without PE. METHODS: We retrospectively reviewed medical records of all inpatients with a final diagnosis of PE or DVT between 1989 and 2000. RESULTS: Venous thrombosis was detected by VDUS in 229 patients (191 without PE and 38 with PE). The left leg only was involved in 50% of patients (p < 0.05), the right leg only in 33%, and both legs in 17%. The overall distribution of veins affected by DVT was: popliteal vein, 77%; superficial femoral vein, 76%; common femoral vein, 65%; posterior tibial vein, 23%; external iliac vein, 21%; common iliac vein, 9%; great saphenous vein, 7%; and inferior vena cava, 2%. A single venous site was involved in 22% of patients. External iliac vein thrombosis was more frequent in patients with DVT only (24%) than with PE and DVT (5%) (p < 0.05). The venous obstruction was partial in 14% of patients. VDUS of the asymptomatic leg was positive in 14% of patients with unilateral symptoms of DVT, all of whom also had DVT in the symptomatic leg. VDUS was positive for DVT in 90% of patients with PE and concomitant pain or edema of the leg, compared to only 20% of PE patients with no symptoms of DVT. CONCLUSIONS: Sonography should be the first diagnostic test for patients suspected of having PE with any sign or symptom related to DVT. VDUS of the asymptomatic leg is unnecessary in the diagnosis and management of DVT. Omitting the superficial femoral vein examination would lead to some decrease in the sensitivity of VDUS.     

超声弹性成像在下肢深静脉血栓形成分期中的应用价值

目的 探讨超声弹性成像在下肢深静脉血栓形成分期中的应用价值。方法 选取我院110例下肢深静脉血栓患者,其中急性期43例、亚急性期37例、慢性期30例。应用超声弹性成像获取弹性成像评分及杨氏模量平均值（Emean）,比较急性期、亚急性期、慢性期下肢深静脉血栓形成患者弹性成像评分、Emean及实验室指标的差异;分析弹性成像评分、Emean与实验室指标的相关性。应用Logistic回归分析下肢深静脉血栓形成分期的影响因素;绘制受试者工作特征（ROC）曲线分析弹性成像评分联合Emean对下肢深静脉血栓形成急性期的诊断效能。结果 急性期下肢深静脉血栓形成患者弹性成像评分、Emean均减低,活化部分凝血活酶时间（aPTT）、凝血酶原时间（PT）、纤维蛋白原（Fbg）均增高,与亚急性期、慢性期血栓形成患者比较差异均有统计学意义（均P<0.05）。相关性分析显示,弹性成像评分、Emean与aPTT、PT、Fbg均呈负相关（均P<0.05）。Logistic回归分析显示,弹性成像评分、Emean均为下肢深静脉血栓形成分期的独立影响因素（OR=2.136,1.201,均P<0.05）。R...     

Isolated distal deep vein thrombosis: what we know and what we are doing

Summary. Thromboses that are restricted to the infra‐popliteal deep veins of the lower limbs (isolated distal deep vein thrombosis, IDDVT) are frequently diagnosed in subjects with suspected pulmonary embolism (PE; 7–10%) or DVT (4–15%), accounting for 31–56% of all diagnosed leg DVTs. Despite their frequency, IDDVTs still remain one of the most debated issues in the field of venous thromboembolism (VTE). Conflicting clinical results have resulted in differing opinions on the need to test for IDDVTs and how to treat them. Due to discordant results, the real risk of IDDVT‐associated PE is not well established. IDDVTs are associated with (i) lower risk of recurrence when compared with other VTEs, and (ii) fewer late sequelae than proximal DVT. Diagnosis of IDDVT is based on ultrasound examination of all calf veins, which is more operator‐dependent and less sensitive than proximal vein examination. A series of studies has shown, however, that a single complete ultrasound strategy in symptomatic patients has comparable clinical results to serial proximal ultrasound, allowing approximately 15% better DVT diagnosis. Optimal treatment of IDDVT is still controversial. Guidelines recommend anticoagulation for 12 weeks, although 6 weeks may be sufficient. There is, however, insufficient data to support the diagnosis and treatment of all IDDVTs, and the necessary criteria to identify subjects at higher risk of complication are lacking. It also seems likely that different approaches may be better for unprovoked or secondary events and for deep or muscle veins. Specifically designed and adequately powered clinical studies addressing the issue of IDDVT need to be urgently undertaken.     

高频超声诊断孤立性小腿肌间静脉血栓的价值

目的探讨高频超声对孤立性小腿肌间静脉血栓的诊断价值。方法回顾性分析临床确诊的175例（190条）孤立性小腿肌间静脉血栓的声像图特征并与临床随访结果进行对比分析。结果 175例（190条）孤立性小腿肌间静脉血栓,高频超声正确诊断158例（173条）,误诊7例（7条）,漏诊10例（10条）,诊断准确率91.1%（173/190）。误诊7例分别为神经纤维瘤1例,混合型血管瘤1例,腓肠肌血肿5例。所有患者发现后均进行溶栓及抗凝治疗,治疗后1、3、6个月复查彩色多普勒超声,血流部分再通或完全再通,均无小腿深静脉主干蔓延。小腿肌间静脉血栓声像图特征：静脉管腔明显增宽,管腔内低回声充填,长轴呈管状或树枝状,短轴为圆形或椭圆形,适度加压管腔不能被压瘪,管腔内大多无血流信号显示。结论高频彩色多普勒超声可以显示血栓的位置、形态、类型、管腔阻塞情况及血流状态,有助于明确诊断孤立性小腿肌间静脉血栓,同时对治疗效果可以进行动态评估。     

Real-time sonography in deep thrombosis of the pelvic and leg veins. A prospective comparison to phlebography

Real-time B mode ultrasound is a well accepted diagnostic procedure in the non-invasive vascular examination. In a prospective study we examined 101 patients with clinical suspected deep vein thrombosis of the pelvis or leg using ultrasound and contrast venography within 24 hours and we compared the results of both examinations. All veins of the pelvis and lower extremities were scanned in transverse and longitudinal planes. 113 venograms were obtained; they demonstrated the presence of isolated proximal vein thrombosis in seven patients, seven isolated calf vein thromboses and 43 thromboses of both proximal and calf veins. The sensitivity of ultrasonography for detecting deep vein thrombosis in the proximal veins of the lower extremity was 98%, the specificity was also 98%. In the veins of the pelvis the sensitivity was 78%, the specificity 98% and in calf veins 60% and 97% respectively. The sensitivity for the detection of isolated calf vein thrombosis was only 14%. We conclude that ultrasonography has a very good sensitivity for detecting proximal vein thrombosis of the lower extremity and thrombosis of the pelvic veins. Phlebography remains the better method in detecting isolated calf vein thrombosis because of the difficult visualisation of the small calf veins by ultrasonography.     

彩色多普勒超声探测小腿肌间静脉扩张与单纯肌间静脉血栓的关系

目的探讨彩色多普勒超声在观察小腿肌间静脉扩张与肌间静脉血栓关系中的价值。方法1500例疑为下肢深静脉血栓患者行彩色多普勒超声检查,检测其下肢肌间静脉有无扩张和栓塞。结果1500例患者3000条下肢血管中肌间静脉扩张482条（16．1％）,扩张病例中发生单纯小腿肌间静脉血栓者103条（21．4％）;无肌间静脉扩张2518条（83．9％）,发生单纯小腿肌间静脉血栓28条（1．1％）。小腿肌间静脉血栓发生于单侧肢体者109例（109条）,明显多于双侧肢体者（11例,22条）,其中左侧（76条）多于右侧（55条）。结论小腿肌间静脉扩张与肌间静脉血栓有明显相关性。