Rupture of Baker's cyst producing pseudothrombophlebitis in a patient with Reiter's syndrome

This is an unusual case of pseudothrombophlebitis resulting from rupture of Baker's cyst in a patient with Reiter's syndrome. The patient presented with a swollen, painful left calf and persistent itching on the skin of the calf. Ultrasonography showed a ruptured popliteal cyst with minimal hemorrhage and fluid collection within the fascial compartments and gastrocnemius muscle. Color Doppler ultrasound showed a patent popliteal vein and artery and duplex Doppler scans revealed a normal flow pattern. In conclusion, the clinical picture of deep vein thrombosis and that of pseudothrombophlebitis are difficult to distinguish by clinical examination and necessitate detailed examination by imaging techniques. Persistent pruritus on calf skin resulting from irritation of inflammatory synovial fluid may be an important clinical feature.     

Deep vein and isolated calf muscle vein thrombosis following long-haul flights: pilot study.

The risk of venous thromboembolism associated with long-haul flights is the subject of controversy. In a prospective, controlled study, we examined 160 passengers before and after return from a long-haul flight and 160 age-matched and sex-matched, non-travelling volunteers using venous compression ultrasound. Deep vein thrombosis was not observed in either group. Isolated calf muscle vein thrombosis (ICMVT) was present in 4/160 (2.5%) flight passengers and in 1/160 (0.6%) controls. All subjects with ICMVT were clinically asymptomatic, and ICMVT was located in the soleal muscle veins in all four subjects. Three of the four passengers with ICMVT had other risk factors for thrombosis.     

Impedance plethysmography using the occlusive cuff technique in the diagnosis of venous thrombosis.

Impedance plethysmography using the cuff technique has been compared with venography in 346 consecutive patients with suspected venous thromboembolism. The limbs were classified according to the venographic results as no thrombosis, proximal (popliteal, femoral, or iliac) vein thrombosis, and calf thrombosis. A discriminant analysis was performed. The impedance plethysmographic result was normal in 386 of 397 limbs which were normal on venography, a specificity of 97%, and abnormal in 124 of 133 limbs which showed proximal vein thrombosis, a sensitivity of 93%. Seventy-three of 88 limbs with calf vein thrombi and a normal impedance plethysmographic result. The sensitivity in 29 limbs with asymptomatic proximal vein thrombosis was 83%. Impedance plethysmography is an accurate method for detecting proximal vein thrombosis but has limitations which include the possibility of false positive results due to arterial insufficiency and muscle tension.     

Therapy of isolated calf muscle vein thrombosis with low-molecular-weight heparin.

There are no data from prospective studies concerning the treatment of isolated calf muscle vein thrombosis (soleal and gastrocnemial muscle veins), found in 20-40% of patients with lower extremity thrombosis of the calf. We investigated the outcome in two cohorts of consecutive patients, the first receiving low-molecular-weight heparin for 10 days at therapeutic doses and compression therapy; the second cohort, compression therapy alone. In patients on therapeutic heparin (n = 52), no progression to deep vein thrombosis occurred [0%; 95% confidence interval (CI), 0-6.8%]. Patients without anticoagulation (n = 32) showed a statistically significant higher percentage of progression into the deep calf veins (25%; 95% CI, 11.5-43.4%) as well as recurrent muscle vein thrombosis. No symptomatic pulmonary embolism or bleeding event occurred; one patient died in each group, both related to malignancy. The data suggest a need for short-term anticoagulation in such patients to prevent further thromboembolic complications. Randomized prospective studies are now warranted in a larger study population.     

Thromboses veineuses profondes distales des membres inférieurs : to treat or not to treat?: Épidémiologie,prise en charge et problématique

Calf vein thrombosis corresponds to infrapopliteal deep vein thrombosis which accounts for roughly 50% of all cases of deep vein thrombosis and shares the same risk factors as proximal deep vein thrombosis. The complication rate and proper management remain debated. Recent studies suggest that the risk of proximal extension of calf vein thrombosis is 1 to 5% and that the risk of postthrombotic syndrome is 3%. In France, calf vein thrombosis is usually treated with compression stockings associated with a six week to three month regimen of anticoagulation therapy in patients presenting a transient triggering factor or longer otherwise. However, the benefit of such treatment, in terms of the hemorragic risk incurred, remains uncertain. The randomized double blind trial CACTUS (compression stocking + placebo versus compression stocking + heparin, for six weeks) that will start in September 2007, should provide answers the following question: should calf vein thrombosis be treated with anticoagulants?     

Recurrent isolated calf muscle thrombosis due to a venous aneurysm of the soleal muscle veins

A rare case of venous aneurysm involving the soleal muscle vein in an 18-year-old woman is presented. The patients showed three episodes of ultrasonographically proven calf muscle thrombosis within 2 years. After a short course of low-molecular-weight heparin at a therapeutic dosage, complete thrombus recanalization was achieved. To prevent further thrombotic episodes, surgery including ligation and resection of the aneurysm was performed. At the 3-month follow-up study the patient had completely recovered.     

A swollen, febrile leg]

The authors report the case of a young man, of Algerian origin, with edema of the right lower limb accompanied by an inflammatory syndrome present for several months. This symptomatology, clinically suggestive of a deep venus thrombosis, but not confirmed by sonography, proved to be due in fact to pulmonary tuberculosis with septicemic spread to the muscle masses of the right calf. The diagnosis was made by direct paracentesis of the right calf. It is important to remember that pulmonary tuberculosis with septicemic spread to muscle masses but without bone lesions remains rare. The special interest of this case thus concerns its tuberculous etiology and clinical similarity to a deep venous thrombosis. Nevertheless, the diagnosis should have been eliminated earlier in view of the clinical course and worsening of systemic manifestations.     

Isolated nonfilling of contrast in deep leg vein segments seen on phlebography, and a comparison with color Doppler ultrasound, to assess the incidence of deep leg vein thrombosis

Nonfilling of contrast in deep veins on phlebography is claimed to be an indirect sign of deep vein thrombosis (DVT) by some authors but rejected by others. The aim of this study was to prospectively assess, with color Doppler ultrasound (CDU), the occurrence and distribution of DVT in isolated, nonfilling, deep vein segments seen on a phlebogram. One hundred consecutive patients with clinical signs of acute DVT, in whom phlebography displayed nonfilling of the posterior tibial veins and/or the deep calf muscle veins, were examined with CDU on the same occasion. Ultrasound confirmed a DVT in 31 (31%) patients; in another 38 (38%) patients other pathology, without concomitantly detected DVT, such as edema, bleedings, ligament and muscle ruptures, Baker cysts, or superficial thrombophlebitis were found instead; and in the remaining 31 (31%) patients no pathology that could explain the nonfilling was identified. Isolated, nonfilling of the posterior tibial and/or deep muscle veins of the calf found by phlebography may be an indirect sign of DVT but is equally commonly caused by other pathological conditions or arises without any detectable explanation. When the thrombotic burden is to be scored, and to facilitate the establishment of the correct diagnosis, additional CDU is recommended when isolated nonfilling is present.     

Deep vein versus pseudo deep vein thrombosis: the role of imaging techniques in differential diagnosis and management

An acutely swollen, painful calf is usually caused by deep vein thrombosis or pseudo deep vein thrombosis; however, the differential diagnosis and management of these 2 entities can prove difficult and even hazardous unless a careful, systematic approach is used. This article describes the use of 2 invasive techniques (ascending venography and arthrography) and several noninvasive methods (magnetic resonance imaging, computerized axial tomography, and non-Doppler ultrasound) to differentiate between deep vein thrombosis and pseudo deep vein thrombosis. The author discusses a practical, cost-effective approach to diagnosing and managing the acutely swollen, painful calf.     

Suspected acute deep vein thrombosis in patients with rheumatoid arthritis

Real-time venous ultrasound has replaced phlebography for making the diagnosis of clinically relevant lower extremity DVT. Phlebography is still useful in suspected calf vein thrombosis when an immediate diagnosis is required and in the postoperative patient. A combination of sonography and contrast phlebography is used to sort out the extent of chronic and acute venous changes in patients with chronic deep vein thrombosis.     

腓肠肌血肿和深静脉血栓无创血管检查的诊断价值

目的 :腓肠肌血肿和深静脉血栓的症状极为相似 ,即都有单侧肢体的突发肿胀、疼痛。但因为二种病的治疗截然不同 ,前者禁忌溶栓、抗凝 ,而后者恰恰需要及时溶栓、抗凝。所以本文研究旨在用无创血管检查 (包括血管B超和Doppler血管检查 )及患者的症状、体征几个方面如何避免将腓肠肌血肿误诊为深静脉血栓的方法。方法 :对 11例下肢突发肿胀、疼痛的患者分别做血管B超和Doppler血管检查。结果 :11例患肢有 9例血管B超证实下肢深静脉通畅 ,并且存在腓肠肌血肿 ;Doppler血管检查提示 4肢深静脉回流不通畅 ,5肢深静脉回流尚通畅 ;另外 2例血管B超和Doppler血管检查皆为阴性结果。结论 :从患者的症状、体征及血管B超和Doppler血管检查避免将腓肠肌血肿误诊为深静脉血栓是可能的 ,而且B超对鉴别诊断腓肠肌血肿和深静脉血栓比Doppler血管检查有优势及诊断价值。     

Popliteal cyst rupture and the pseudothrombophlebitis syndrome

Fifteen patients presented during a four-year period with a pseudothrombophlebitis syndrome, subsequently confirmed arthrographically as being due to popliteal cyst rupture. Initially the majority of patients (73%) were erroneously diagnosed as having calf vein thrombosis, and were anticoagulated for periods of three to ten days. Clinical differentiation from venous thrombosis was usually impossible. Contrast arthrography was the definitive diagnostic investigation, revealing popliteal cysts in all patients, and an active synovial leak into the calf in 13 cases (87%). The mean delay in performing arthrography was 5.3 days, the procedure usually being performed after normal contrast venography. Doppler and isotope venography yielded misleading or equivocal results (42%) delaying diagnosis, and prolonging periods of potentially dangerous anticoagulation. We suggest that the marked overlap in the emergency presentation of popliteal cyst rupture and calf vein thrombosis mandates the aggressive use of arthrography combined with venography in all patients presenting with a painful swollen leg.     

Deep vein thrombosis in the differential diagnosis of knee-joint capsule changes in rheumatoid arthritis]

The authors describe 5 patients with rheumatoid arthritis; in 3 patients rupture of the synovial membrane and in 2 patients a calf cyst caused symptoms resembling a deep vein thrombosis. Contrast arthrography is of great help in differential diagnosis in conjunction with thorough anamnesis and clinical examination. The joint effusion plays a dominating role in the disease process, and treatment of the effusion is of the greatest importance for both prophylaxis and therapy of membrane rupture and calf cysts.     

Differential diagnosis of the "fat leg"--a case report]

This is a report about a patient, who came to our hospital because of a painful thickening of her left calf. She was treated with Heparin 48,000 IU/24 hours. A crural vein thrombosis was suspected. Instead of improvement of the symptoms the diameter of the leg grew until the state of a complete Compartment-syndrome. After exact inspection (Sonography, Computertomogramm) we found a hematom of the calf, caused by a rupture of the tibial part of the gastrocnemius muscle. Fasciotomies and evacuation of the blood brought a restitutio ad integrum. Diagnostic methods and faults are discussed.     

Frequency of deep venous thrombosis in asymptomatic patients with coronary artery bypass grafts.

The frequency of deep vein thrombosis (DVT) in patients undergoing coronary artery bypass graft (CABG) surgery has not been established. Therefore to estimate the frequency of clinically silent DVT, we performed ultrasound examinations of the leg veins in 29 asymptomatic CABG patients before hospital discharge. We used high-resolution B-mode ultrasonography with color Doppler imaging. Fourteen (48.3%, 95% confidence interval 30.1 to 66.4%) had 20 documented leg vein thromboses, and all but one patient had DVT limited to the calf veins. Of the 20 thrombi 10 (50.0%) were present in the leg ipsilateral and 10 (50.0%) in the leg contralateral to the saphenous vein harvest site. None of the DVTs were suspected clinically. DVT was not associated with any local sign attributed to saphenous vein harvest such as pitting edema, incisional drainage, or local tenderness or with any putative risk factor for DVT such as cigarette use, distant history of malignancy, or varicose veins. Follow-up of these patients 5 to 11 months after CABG surgery showed no clinical evidence of DVT or pulmonary embolism. Our findings indicate that asymptomatic DVT of the calf occurs with surprisingly high frequency, 44.8% after CABG surgery. Future studies in patients undergoing CABG surgery should address the natural history of asymptomatic DVT, determine its clinical importance, and develop optimal strategies for prophylaxis and treatment.     

Compression stockings and venous function in patients with acute myocardial infarction.

Venous volume and venous outflow of the calf were studied in 49 patients with acute myocardial infarction. Graded compression stockings were randomly applied to one leg, the other serving as a control, and the above parameters were studied with strain gauge plethysmography during six days. Venous volume increased in the control legs during the first three days and it was significantly higher in the legs with stockings compared to the control legs throughout the study period. Venous outflow did not change during the study period or with the application of compression stockings. A restricted venous function in the calf may contribute to the initiation of deep vein thrombosis. Graded compression stockings improve the venous function in the leg and may thus reduce the incidence of deep vein thrombosis in patients with acute myocardial infarction. This remains, however, to be proved in a controlled clinical trial.     

Venous thrombosis after long-haul flights

BACKGROUND: The risk for venous thromboembolism after long-haul flights represents a controversial issue. The aim of our study was to assess the incidence of venous thrombosis associated with long-haul flights in a prospective, controlled cohort study. METHODS: We included 964 passengers returning from long-haul flights (flight duration, > or =8 hours) and 1213 nontraveling control subjects. We excluded participants who were being treated with anticoagulant drugs or who used compression stockings. Main outcome measures were the incidence of ultrasonographically diagnosed thrombosis in the calf muscle and deep veins, symptomatic pulmonary embolism, and death. RESULTS: We diagnosed venous thrombotic events in 27 passengers (2.8%) and 12 controls (1.0%) (risk ratio [RR], 2.83; 95% confidence interval [CI], 1.46-5.49). Of these, 20 passengers (2.1%) and 10 controls (0.8%) presented with isolated calf muscle venous thrombosis (RR, 2.52; 95% CI, 1.20-5.26), whereas 7 passengers (0.7%) and 2 controls (0.2%) presented with deep venous thrombosis (RR, 4.40; 95% CI, 1.04-18.62). Symptomatic pulmonary embolism was diagnosed in 1 passenger with deep venous thrombosis (P =.44). All of these individuals had normal findings at baseline ultrasonography. Passengers with isolated calf muscle venous thrombosis or deep venous thrombosis had at least 1 risk factor for venous thrombosis (>45 years of age or elevated body mass index in 21 of 27 passengers). The follow-up after 4 weeks revealed no further venous thromboembolic event. CONCLUSIONS: Long-haul flights of 8 hours and longer double the risk for isolated calf muscle venous thrombosis. This translates into an increased risk for deep venous thrombosis as well. In our study, flight-associated thrombosis occurred exclusively in passengers with well-established risk factors for venous thrombosis.     

Venous plethysmography in a sitting position

We studied the venous capacity of the lower limbs by strain gauge plethysmography during venous occlusion (delta v60) and by a dependency test (delta v postural) (from the supine to the sitting position). We were also interested by the performance of the calf musculovenous pump, assessed in two positions: sitting and standing (delta v exercise). The volume changes are increasing when we consider limbs with sequelae of deep vein thrombosis, normal lower limbs and extremities with primary varices. delta v60: 2.13%, 2.84%, 4.24%; p less than 0.01. delta v postural: 1.32%, 1.94%, 3.66%; p less than 0.01. delta v exercise: 0.48%, 1.47%, 2.09%; p less than 0.01. The study of the expelled volume during calf muscle exercise is easier in the sitting than in the standing position and it leads to a better discrimination between normal limbs and limbs suffering from sequelae of deep vein thrombosis. The dependency test with measurement of the venous capacity when going from the supine to the sitting position (with the leg dependent) and the assessment of the calf muscles pump, also in the sitting position, are the basis of a simple approach to the quantitation of venous insufficiency.     

Compression ultrasonography in hospitalized patients with suspected deep venous thrombosis

Compression ultrasonography was compared with contrast venography in 215 hospitalized patients (218 limbs) with suspected deep venous thrombosis. All scans were performed using a 5-MHz linear-array scanner. The calf veins were not assessed owing to their small caliber. Distribution of deep venous thrombosis was proximal in 113 of 215 patients (number of limbs with deep venous thrombosis being the same as the number of patients) and limited to the calf veins (distal) in 29 patients. Deep venous thrombosis was detected by compression ultrasonography in 101 of 113 patients (sensitivity, 89%) and falsely diagnosed in two of 76 limbs (73 patients) with negative venographic results (specificity, 97%). The method was less sensitive below the knee, where deep venous thrombosis of the distal popliteal vein was not detected in five of 10 patients as compared with seven of 103 patients with thrombus extension above the knee. Pelvic vein deep venous thrombosis (n = 34) was detected by compression ultrasonography in 71% of the patients. The results of this study indicate that venography may be omitted in patients where compression ultrasonography demonstrates proximal deep venous thrombosis. In patients with negative compression ultrasonographic results, however, venographic verification is needed since venography has a considerably higher sensitivity than compression ultrasonography in detecting isolated iliac and calf vein deep venous thrombosis.     

Management of venous thromboembolism – controversies and the future

Despite the availability of comprehensive evidence‐based guidelines there are difficult and controversial areas in the management of venous thromboembolism. Institutions and even countries disagree on the importance of calf vein thrombosis, with some rigorously detecting and treating it and others deliberately not looking for it. The need to treat proximal deep vein thrombosis and pulmonary embolism is accepted but which patients with an unprovoked first event should have long‐term anticoagulation has become a difficult clinical decision. We are uncertain how to reduce the incidence of post‐thrombotic syndrome seen in a substantial number of patients. How hard to look for an undiagnosed underlying cancer has become a contentious issue particularly in the United Kingdom following the recent publication of a guideline from the National Institute for Health and Clinical Excellence. Whilst we are wrestling with these dilemmas we are entering an era of new anticoagulants and have to solve the logistical problems of introducing them into clinical practice despite cost pressures. These issues will be explored in this review.