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230 oracic ultrasound
ultrasound, a careful clinical and instrumental follow-up and probably the dosage of D-dimer
performed with sensitive method (ELISA or similar).
Introduction to venous Doppler ultrasound
e veins of the lower limbs show a normal spontaneous flow with Doppler interrogation.
is flow can be very slow during the respiratory cycle, so its color can appear only during
its spontaneous or provoked acceleration and with more sensitive settings of the device.
Physiologically it is a non-turbulent motion, with homogeneous color.
e flow is phasic with respiration and is easily accelerated with distal compression, the suspension of the Valsalva maneuver and the removal of proximal compression. All these technique
are useful for the inspective detection of the vascular patency. A qualitative inspection of the
vascular flow is implemented using Color Doppler mapping, whereas Pulsed Doppler interrogation is useful to assess quantitative flow data. An induced flow in a vein indicates distal
(if the flow is induced by distal pressure), or proximal (if the flow changes by the Valsalva
maneuver and by respiration) venous patency.
Concluding remarks on thromboembolic disease
To conclude, it is useful to reiterate some unanimous essential points:
• Venous compression ultrasound is a useful examination in emergency, even if limited to
the main venous trunks. It has high diagnostic accuracy for the evaluation of symptomatic
patients with suspected proximal DVT.
• Before conducting CUS, it is appropriate to define the probability of a thrombotic disease,
based on an appropriate risk score (Wells, Geneva, and similar).
• Among symptomatic patients, approximately 95% of those who show an abnormal CUS
actually has DVT. Conversely, among those who show no abnormalities on CUS, 98%
does not really have a proximal DVT.
• Ultrasound has a low accuracy in the diagnosis of thrombi in the deep veins distal to the
popliteal trifurcation. Among the subjects with negative symptoms and negative ultrasound
examination, approximately 5% risks a proximal extension of venous thrombosis of the
calf. About 2% of symptomatic patients with negative CUS can have small proximal
thrombi unidentified.
• Isolated distal thrombosis is relatively uncommon (about 15% of the symptomatic throm-
bosis), and it is rarely associated with embolic complications.
• CUS repetition in a short-term follow-up in all subjects with negative or not significant
initial instrumental test, but with intermediate pretest risk of ongoing disease, is useful.
Table 20 shows some recommendations for the diagnosis of DVT in different types of
patients
200
.
Table 20 – Recommendations for the diagnosis of DVT in different types of patients
The lack of compressibility of the common femoral or the
Symptomatic patients with
suspected DVT
popliteal vein confirms the diagnosis. If this sign is confined
to the superficial femoral vein, to the distal portion of the
popliteal vein or to the deep veins of the leg, the positive
predictive value of ultrasound is lower (80%)

Parenchymal lung patology 231
Table 20 – Recommendations for the diagnosis of DVT in different types of patients
Patients with suspected DVT,
but non-significant initial tests
Asymptomatic patients
Recurrent DVT
Patients with non-diagnostic
abnormalities in tests for
recurrent DVT
Pregnant patients
Over the following seven days, one or more ultrasound tests
can be used as a follow- up, trying to visualize the popliteal
vein with its trifurcation
The role of venous ultrasonography, however performed, is
uncertain
A new finding of non-compressibility of the common femoral
or popliteal vein, or an increase (compared to previous
examinations) in its diameter greater than 4 mm strongly
suggests the diagnosis of recurrent DVT
The absence of a recent increase in size greater than 1
mm of a common femoral or popliteal vein may exclude
recurrent DVT, but the finding should be checked after 1-3
days and after 1 week. However, in these cases it is necessary
to consider in a comprehensive way the results of clinical
examination, dimer test, venous serial ultrasound, lung scans
and any other tests
Pregnant patients have an increased incidence of isolated iliac
vein thrombosis, undiagnosed accurately with ultrasound.
In pregnant patients, the occurrence of non-thrombotic
causes of edema of the lower limbs is frequent. Ultrasound
findings should be interpreted as in non-pregnant subjects.
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