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104 Chapter 10 Evaluation of hypercoagulable states and molecular markers of acute venous thrombosis
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ill patients with COVID-19. N Engl J
Med, 2021. 385(9): p.790–802.
84. Lopes, R.D., etal., Therapeutic versus
prophylactic anticoagulation for patients
admitted to hospital with COVID-19
and elevated D-dimer concentration
(ACTION): An open-label, multicentre,
randomised, controlled trial. Lancet,
2021. 397(10291): p.2253–63.
85. Spyropoulos, A.C., etal., Efcacy and
safety of therapeutic-dose heparin
vs standard prophylactic or intermediate-dose heparins for thromboprophylaxis in high-risk hospitalized patients
with COVID-19: The HEP-COVID
randomized clinical trial. JAMA Intern
Med, 2021. 181(12): p.1612.
86. Pilia, E., etal., Efcacy and safety of
heparin full-dose anticoagulation in
hospitalized non-critically ill COVID-19
patients: Ameta-analysis of multicenter
randomized controlled trials. J Thromb
Thrombolysis, 2022. 54(3): p.420–30.
87. Urano, T., etal., COVID-19 and
thrombosis: Clinical aspects. Curr Drug
Targets, 2022. 23(17): p.1567–72.
88. Paz Rios, L.H., etal., Prognostic value of
venous thromboembolism risk assessment
models in patients with severe COVID-
19. TH Open, 2021. 5(2): p. e211–9.
89. Ramacciotti, E., etal., Rivaroxaban versus no anticoagulation for post-discharge
thromboprophylaxis after hospitalisation for COVID-19 (MICHELLE):
An open-label, multicentre, randomised, controlled trial. Lancet, 2022.
399(10319): p.50–9.
90. Olson, J.D., Laboratory diagnosis of
thrombophilia: Why, who, what, when,
how to test. Lab Hematol, 2004. 10(3):
p.172.
91. Golemi, I., etal., Venous thromboembo-
lism prophylaxis using the Caprini score.
Dis Mon, 2019. 65(8): p.249–98.
♦92. Gould, M.K., etal., Prevention of VTE
in nonorthopedic surgical patients: Antithrombotic therapy and prevention of
thrombosis, 9th ed: American college of
chest physicians evidence-based clinical
practice guidelines. Chest, 2012. 141(2
Suppl): p. e227S–77S.
93. Wilson, S., etal., Thrombosis prophylaxis
in surgical patients using the Caprini
Risk Score. Curr Probl Surg, 2022.
59(11): p.101221.
★94. Lobastov K, Urbanek T, Stepanov E, Lal
BK, Marangoni J, Krauss ES, Cronin M,
Dengler N, Segal A, Welch HJ, Gianesini
S, Chen X, Caprini JA. The Thresholds
of Caprini Score Associated With
Increased Risk of Venous Thromboembolism Across Different Specialties: A
Systematic Review. Ann Surg. 2023 Jun
1;277(6):929–937.
95. Kakkar, V.V., etal., Prevention of Fatal
Postoperative pulmonary embolism
by low doses of heparin. Reappraisal
of results of international multicentre
trial. Lancet, 1977. 1(8011):
p. 567–9.
96. Collins, R., etal., Reduction in fatal
pulmonary embolism and venous thrombosis by perioperative administration
of subcutaneous heparin. Overview of
results of randomized trials in general,
orthopedic, and urologic surgery. N Engl
J Med, 1988. 318(18): p.1162–73.
97. Haas, S., etal., Prevention of fatal pul-
monary embolism and mortality in surgical patients: Arandomized double-blind
comparison of LMWH with unfractionated heparin. Thromb Haemost, 2005.
94(4): p.814–9.
98. Catterick, D., and B.J. Hunt, Impact of
the national venous thromboembolism
risk assessment tool in secondary care in
England: Retrospective population-based
database study. Blood Coagul Fibrinoly-
sis, 2014. 25(6): p.571–6.
99. Cassidy, M.R., Rosenkranz, P., and McAneny, D., Reducing postoperative venous
thromboembolism complications with a
standardized risk-stratied prophylaxis
protocol and mobilization program.
J Am Coll Surg, 2014. 218(6):
p.1095–104.
CHAPTER
11
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Duplex ultrasound scanning
for acute venous disease
Rhusheet Patel and Timothy K. Liem
11.1 INTRODUCTION
The incidence of rst-time extremity venous thromboembolism (VTE) has been estimated to range between 70 and
113 per 100,000 population/year, with at least 350,000
cases of deep vein thrombosis (DVT) and pulmonary
embolism (PE) occurring each year in the United States.
is a frequent complication in patients who undergo major
surgery and prolonged hospitalization, and the Surgeon
General’s 2008 Call to Action described VTE as the most
common cause of preventable in-hospital mortality.
Successful therapy requires prompt diagnosis and initiation of antithrombotic therapy within the rst 24hours
after onset of symptoms. Prior to the 1980s, patients were
more commonly diagnosed with impedance plethysmography (IPG), I
trast venography. However, the accuracy of IPG is limited,
demonstrating decreased sensitivity in patients with nonocclusive proximal thrombosis, those with duplicate femoral
or popliteal veins when only one channel is affected, and
those with isolated calf DVT. Labeled brinogen scanning
and contrast venography are invasive, more labor intensive,
time consuming, and not readily available at every medical
facility. The use of B-mode and Doppler for the assessment
of venous disease was rst introduced in 1968, but did not
become a validated diagnostic tool for another decade.
Since the 1980s, the venous duplex examination has been
the mainstay for the diagnosis of acute DVT and supercial
venous thrombosis (SVT). Although venous duplex imaging initially was utilized to detect thrombosis in the upper
and lower extremity venous beds, duplex now is being utilized for the detection of thrombosis in the iliocaval and
mesenteric veins as well. This chapter will discuss indications for testing, examination techniques, accuracy of the
venous duplex examination in various anatomic beds, and
controversies in the imaging of acute venous disease.
121
-labeled brinogen nuclear scanning, and con-
1,2
It
3
4–6
11.2 INDICATIONS FOR TESTING
Venous duplex ultrasound has become the imaging test of
rst choice to aid in the diagnosis of venous thrombosis.
This is related to multiple factors, which include its relatively high accuracy in detecting upper and lower extremity
DVT and very low risk for complications. Duplex imaging also has become widely adopted due to the capacity
for portable bedside examinations and the greater availability of vascular laboratories and ultrasound services at
more health care facilities. In fact, this mode of imaging
is so widely available, it may have become a victim of its
own success, with multiple reports suggesting that health
care providers generally have a low threshold for ordering
duplex scans in order to “rule out” DVT.
to an overutilization of venous ultrasound, with ultrasound
testing demonstrating the absence of DVT in as many as
80%–90% of patients.
More recent criteria have been published to standardize
the appropriate use of duplex scanning for acute venous
disease.
from numerous professional societies and categorizes various clinical indications as either appropriate or rarely
appropriate, based on the anatomic region in question.
Extremity pain and edema are common and appropriate indications for duplex imaging of the upper or lower
extremity veins. Additional indications include follow-up
surveillance for patients with isolated calf DVT who are
unable to receive therapeutic anticoagulation and patients
with isolated supercial vein thrombosis when near a junction with the deep venous system. Although duplex surveillance after endothermal ablation is a listed and widely
practiced indication (Figure11.1), the utility and cost-effectiveness of routine venous imaging after radiofrequency
or laser ablation remain debated in the literature.
duplex testing, the majority of patients will test negative
for deep or supercial vein thrombosis. In patients with
clinical suspicion for lower extremity DVT, clinical decision rules, in combination with qualitative or quantitative
D-dimer assays, have been evaluated as a means to “rule
out” DVT without having to perform further diagnostic
testing.
ical decision scoring system and is shown in Table 11.2.
Earlier descriptions of the Wells rule dichotomized patients
into likely versus unlikely for DVT. An unlikely Wells
rule score (<1), combined with a negative D-dimer assay,
is associated with a very low probability of DVT (<2%),
except in patients with active malignancy and those with
recurrent VTE.
undergo further testing with venous duplex imaging. Use
9
Table 11.1 summarizes the recommendations
Despite the use of standardized indications for venous
8,11,12
The Wells rule is the most widely studied clin-
12
Patients with a Wells score >1 should
7,8
This contributes
10
DOI: 10.1201/9781003328971-13
105105
106 Chapter 11 Duplex ultrasound scanning for acute venous disease
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TABLE 11.1 Guidelines regarding the appropriate use of venous duplex scanning for patients with venous disease,
categorized according to anatomic region
Anatomic region Appropriate Rarely appropriate
Upper extremity • Limb edema
• Nonarticular upper extremity pain or palpable cord
• New pain or edema in presence of known UEDVT
Lower extremity • Limb edema
• Nonarticular lower extremity pain or palpable cord
• Pulmonary embolism
• New pain or edema in presence of known LEDVT
• Surveillance of calf DVT for proximal extension when anticoagulation contraindicated
• Surveillance for GSV or SSV SVT when near a deep vein junction
• Early follow-up after endovenous saphenous ablation
• Patent foramen ovale with suspected paradoxical embolism
• Evidence of LE venous obstruction on plethysmography suggesting DVT
Inferior vena cava
and iliac veins
Hepatoportal and
renal veins
• Routinely or selectively in conjunction with lower extremity scanning if proximal DVT was identied or if abnormal ow pattern in
one or both common femoral veins
• May be appropriate for procedure planning prior to IVC lter placement
• Evaluation of cirrhosis without ascites/hepatomegaly/splenomegaly/
portal hypertension
• Evaluation of abnormal LFTs and jaundice if no alternative diagnosis
• Surveillance after TIPS
• Fever of unknown origin in absence of
indwelling venous catheter
• SOB in patient with known UEDVT
• Screening asymptomatic patients with
prolonged ICU stay, prior to pacemaker/
debrillator, for monitoring of a functional
venous catheter, patients with hypercoagulable state, or positive D-dimer testing
• Screening asymptomatic patients with
prolonged ICU stay, after orthopedic
surgery, with hypercoagulable state, or
positive D-dimer testing
• Stand-alone testing without LE venous
scanning
• Abdominal pain
• Abdominal bruit
• Fever of unknown origin
• Initial diagnostic test for jaundice
Abbreviations: UEDVT=upper extremity deep vein thrombosis, LEDVT=lower extremity DVT, SOB=shortness of breath, GSV=great saphenous vein,
SSV=small saphenous vein, SVT=superficial vein thrombosis, LFT=liver function test, TIPS=transjugular intrahepatic portosystemic shunt.
Source: Adapted from Heather Gornik, etal. “ACCF/ACR/AIUM/ASE/IAC/SCAI/SCVS/SIR/SVM/SVS/SVU 2013 Appropriate Use Criteria for Peripheral
Vascular Ultrasound and Physiological Testing Part II: Testing for Venous Disease and Evaluation of Hemodialysis Access,” Journal of the American College
of Cardiology 62 (2013): 649–665.
of such a clinical decision algorithm potentially can eliminate the need for venous duplex imaging in about one-third
of patients.
10
The American College of Chest Physicians
(ACCP) Evidence-Based Clinical Practice Guidelines suggest the use of a clinical assessment tool in combination
with D-dimer assays and venous duplex scanning (Grade
2B recommendation). However, the algorithms suggested
by the ACCP guidelines trichotomize the Wells rule into
requiring intervention.
Doppler imaging is used to identify portal vein thrombosis in patients with appropriate clinical exam and history,
including cirrhosis, hepatocellular carcinoma, intrabdominal sepsis, acute pancreatitis, hematologic malignancy, or
other known hypercoagulability. If portal thrombosis is
identied, further imaging with CT or MRI is warranted
to identify the extent of the clot and associated pathology.
16
Beyond liver transplantation,
low (<0), moderate (1–2), and high probability (>3). The
suggested diagnostic algorithms are signicantly more
complicated, potentially decreasing their utility and appeal
for many health care providers.
13
Similar clinical decision
rules also have been described for patients who are suspected of upper extremity DVT, but further conrmation is
warranted before they can be applied.
14
Acute indications for ultrasound imaging of the portal
and renal vein are largely limited to liver transplantation.
While no consensus recommendations for the frequency
and timing of post-transplantation imaging exist, portal
venous duplex, as part of a complete liver ultrasound, is
the imaging modality of choice in cases of suspected early
vascular complication.
15
Routine duplex imaging in the
immediate postoperative period has also been shown to be
effective in early identication of vascular complications
11.3 EXAMINATION TECHNIQUE
11.3.1 Lower extremity venous exam
The patient is placed supine and comfortable, with the
bed in a slight reversed Trendelenburg position. Optimally,
the room is warmed, but this is not always possible when
portable venous examinations are performed in the emergency department, hospital ward, or intensive care unit.
Examination for lower extremity venous thrombosis usually is performed with slight external rotation of the hip
and exion of the knee, the latter of which allows access
to the popliteal vein from the posterior approach. Alinear transducer with a broadband frequency in the range of
11.1 Grayscale images of patients who developed endothermal
https://t.me/med1917
heat-induced thrombosis (EHIT) after endovenous ablation of
the great saphenous vein (a) and small saphenous vein (b).
TABLE 11.2 Clinical model for predicting pretest proba-
bility of deep vein thrombosis (DVT)
Clinical characteristic Score
Active cancer (<6 months)
Paralysis, paresis, or recent plaster immobilization
of leg
Recently bedridden >3 days or major surgery <4
weeks
Localized tenderness along deep venous system
Entire leg swollen
Calf swelling >3cm than asymptomatic side (10cm
below tibial tuberosity)
Pitting edema conned to symptomatic leg
Collateral supercial veins
Previous documented DVT
Alternative diagnosis at least as likely as DVT
Source: Adapted from Geersing, G.J., etal. “Exclusion of Deep Vein Thrombosis Using the Wells Rule in Clinically Important Subgroups: Individual
Data Meta-Analysis.” British Medical Journal 348 (2014): g1340
DVT unlikely if score < 1 and likely if > 1.
1
1
1
1
1
1
1
1
1
–2
5–10 MHz usually is employed for assessment of the lower
extremity and upper extremity veins. Some anatomic locations require the use of lower frequencies within this range,
especially in patients with large body habitus.
11.3 Examination technique 107
Exam standardization is of paramount importance,
not only to improve diagnostic accuracy but also to allow
comparison with prior imaging studies, whether or not
performed at the same institution. Standards and guidelines for duplex assessment of acute venous disease may
be found with the Intersocietal Accreditation Commission
(IAC) for vascular testing.
17
Venous segments are examined
for thrombosis or patency using the following criteria: (1)
venous compressibility (or coaptation); (2) spectral Doppler waveform assessments of spontaneous venous ow,
phasic ow, or ow with distal augmentation; and (3)
thrombus visualization. Not all of these criteria are applicable to all venous segments.
Compressibility of the vein should be assessed with
transverse grayscale imaging at the saphenofemoral junction, as well as the common femoral, femoral (proximal,
mid, and distal), popliteal, posterior tibial, and peroneal
veins (Figure 11.2). The IAC standards and guidelines
include Doppler waveform assessment of the common
femoral and popliteal veins at a minimum. Our institutional protocol adds an evaluation of the great saphenous
veins for compressibility and Doppler assessment of deep
femoral, femoral, posterior tibial, and peroneal veins for
evaluation of phasic ow or ow in response to distal augmentation (Figure 11.3). The supercial veins (varicose
veins, small saphenous) and muscular veins of the calf (gastrocnemial and soleal) also should be imaged if the patient’s
symptoms warrant further examination. The anterior tibial
veins are excluded from most routine venous duplex studies due to their small size and relatively low likelihood of
anterior tibial DVT (1%).
18
Thrombus visualization is accomplished with both
B-mode and color ow imaging, allowing for direct visualization of occlusive and nonocclusive thrombus as well
(Figure11.4). B-mode imaging is useful when evaluating
the degree of echogenicity within a visualized thrombus,
the thickness of a vein wall, and the size of the vein (contracted versus dilated). Aneurysmal or ectatic segments
of the deep and supercial system should also be noted.
Hyperechoic thrombus, a thickened vein wall, and a contracted vein suggest a more chronic process. Doppler and
color ow assessment typically are performed with the
probe oriented longitudinally, with color sensitivity set for
low ow, and proper Doppler angulation.
11.3.2 Iliac vein and inferior vena cava
exam
Any suggestion of DVT extending above the inguinal ligament should warrant evaluation of the iliac veins and
inferior vena cava (IVC). This includes direct evidence,
such as visible thrombus above the common femoral
vein, or indirect evidence, such as continuous ow in the
common femoral vein with lack of respiratory variation.
Sonographic evaluation of these deeper structures usually
requires lower-frequency abdominal probes, ranging from
2.0 to 5.0 MHz. Optimal visualization of the IVC and iliac
veins may require positioning in the supine, semi-right
lateral, or semi-left lateral decubitus positions, with the
patient fasting for at least 6hours prior to the duplex scan.
Iliac veins and the IVC are too deep to compress, and the
imaging evaluation typically is limited to the Doppler ow
11
108 Chapter 11 Duplex ultrasound scanning for acute venous disease
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11.2 Transverse grayscale image of the left common femoral vein (CFV) at the saphenofemoral junction without compression (a) and
with compression (b). Similar grayscale image of the left femoral vein (FV) without compression (c) and with compression (d). The
white arrows indicate the location of the compressed vein.
evaluation in combination with color ow imaging. Body
habitus may ultimately limit exam of the iliac veins, and if
proximal thrombosis of the pelvic and abdominal veins is
suspected, CT or catheter-based venography may be indicated in symptomatic patients.
11.3.3 Upper extremity venous exam
Duplex examination of the upper extremity veins is more
challenging than that of the lower extremity veins. The
mid-portion of the subclavian vein is partially obscured by
the overlying clavicle, and the innominate vein is obscured
at the thoracic inlet. The examination is started with the
patient in the supine position, with the ipsilateral arm
abducted and externally rotated to facilitate access to the
axillary and brachial veins. The head is rotated away to
allow imaging of the internal jugular vein. A5- to 10-MHz
probe is utilized for the upper extremity veins, with curved
probes reserved for larger patients, especially in the region
of the axilla.
Assessment for upper extremity venous thrombosis
and patency is similar to that of the lower extremity. The
IAC standards include transverse grayscale imaging for
compressibility of the internal jugular, subclavian, axillary,
brachial, basilic, and cephalic veins, with additional assessment of antecubital and forearm deep veins if symptoms
suggest thrombosis.
DVT, attention should be paid to distinguish a peri-catheter
brin sheath from true vein wall thrombus. Fibrin deposition upon the thrombogenic catheter surface is expected
in almost all cases, while mural thrombus or thrombus at
the catheter tip may warrant antithrombotic treatment.
Spectral Doppler waveform assessments for spontaneous
and phasic ow and/or ow with augmentation usually is
performed with longitudinal views of the ipsilateral internal jugular and axillary veins and bilateral subclavian veins
(Figure11.3). In contrast to the lower extremities, upper
extremity venous phasic ow is more pronounced during
inspiration.
14
In the evaluation of catheter-related
19
11.3.4 Portomesenteric and hepatic
venous exam
Ultrasound diagnosis of portomesenteric venous thrombosis was rst reported in the late 1970s, and duplex
assessment of the hepato-portal and mesenteric venous circulation remains an important tool in the evaluation and
follow-up of patients with liver disease.
20
Portal and mes-
11.3 Examination technique 109
(b
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(a)
P
(c)
P
11
)
P
(d)
11.3 Doppler waveform assessment of the common femoral vein (a) and femoral vein (b) in response to distal augmentation. Tib-
ial veins often are smaller and multiple, and assessment usually is made with B-mode imaging and color ow. Color ow at the
posterior tibial vein (c) and at the conuence of the posterior tibial and peroneal veins (d). In image (d), the paired peroneal veins
demonstrate an opposite color ow signal (red) than the paired posterior tibial veins (blue) due to the angle of the veins in relation
to the transducer.
enteric venous imaging is one component of a more comprehensive evaluation, which includes the intrahepatic and
extrahepatic portal vein, superior mesenteric and splenic
veins, hepatic veins, IVC, liver parenchyma, and any portosystemic shunts or collateral pathways.
17
Scanning of the portomesenteric veins often requires
the use of a curved abdominal transducer with a lower frequency range of 2–5 MHz for better tissue penetration, and
visualization is improved when the patient has fasted for at
least 6hours. The sonographer should be familiar with the
anatomic variations that occur, since they may be present
in about 35% of patients. The most common variant is a
trifurcation of the portal vein into right anterior, right posterior, and left portal branches.
21
Scanning often begins with
the patient in the supine position but may require left lateral decubitus positioning to obtain the appropriate transabdominal, subcostal, and intercostal windows. The normal
Doppler venous waveform in the portal venous circulation
11.4 Representative images demonstrating thrombus visualiza-
tion in the subclavian vein with B-mode imaging (a) and color
ow (b). Color ow of one of two paired peroneal veins demonstrates a sizable peroneal DVT (c). Color ow imaging of the
popliteal artery and vein (V) show absent ow in the popliteal
vein.
is described as a continuous ow with a mildly pulsatile
waveform (Figure11.5). Hepatic venous ow is multiphasic,
with an early retrograde component during atrial contraction and a double peaked forward ow, which is affected
by ventricular contraction and relaxation, tricuspid opening
and closure, and respiration.
21
110 Chapter 11 Duplex ultrasound scanning for acute venous disease
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P
11.5 Doppler waveform of the portomesenteric venous circulation (splenic vein depicted), demonstrating continuous ow with a
mildly pulsatile waveform.
11.4 ACCURACY AND OUTCOMES
AFTER VENOUS DUPLEX
SCANNING
The accuracy of venous duplex imaging for lower extremity DVT varies, depending on the presence or absence of
symptoms and the anatomic location of the thrombosis
(Table11.3). In a large meta-analysis, duplex imaging for
patients with symptomatic DVT was associated with a
signicantly higher sensitivity (89%) when compared to
asymptomatic patients (47%). However, the specicities
remained equivalent between the two groups (94%).
With regard to location, the duplex detection of isolated
calf vein thrombosis was less sensitive than for proximal
veins of the lower extremities.
Accuracy of ultrasound in other anatomic locations
is not as well known, typically with data from the 1990s.
Based on limited information, venous duplex scanning of
the IVC and iliac veins is less sensitive for detecting thrombosis than computed tomography (CT) or magnetic resonance imaging (MRI).
23
Data regarding the accuracy of
portal venous duplex imaging also comes from single-institution studies, with results shown in Table11.3.
presence of underlying portal hypertension may confound
the direction of ow evaluation and give a false-positive
result. Careful adjustment of Doppler gain and beam positioning, as well as clinical context, are essential to avoiding
ambiguous results. More information is available regarding duplex diagnosis of upper extremity DVT, since this
modality has largely replaced venography and CT angiography for most patients with suspected upper extremity venous thrombosis. The sensitivity of upper extremity
venous duplex imaging ranges from 78% to 100%, and
specicity ranges from 82% to 100%.
26–28
24,25
22
19
The
TABLE 11.3 The sensitivity and specicity for venous
duplex diagnosis of DVT for symptomatic and
asymptomatic patients, categorized according to
anatomic venous beds
Venous bed Sensitivity Specificity
All Lower Extremity DVT*
Symptomatic patients
Asymptomatic patients
Proximal Lower Extremity Veins*
Symptomatic patients
Asymptomatic patients
Isolated Calf Lower Extremity DVT*
Symptomatic patients
Asymptomatic patients
IVC and Iliac Veins
Portal Veins
Upper Extremity Veins
* From Kearon, Clive, etal. “Noninvasive Diagnosis of Deep Venous Thrombosis.” Annals of Internal Medicine 128 (1998): 663–677.
‡
From Laissy, J. P., “Assessment of Deep Venous Thrombosis in the Lower
Limbs and Pelvis: MR Venography versus Duplex Doppler Sonography.”
American Journal of Roentgenology 167 (1996): 971–975.
¶
From Tessler, Frank N., etal. “Diagnosis of Portal Vein Thrombosis: Value
of Color Doppler Imaging.” American Journal of Roentgenology 157 (1991):
293–296; Parvey HR, Eisenberg RL, Giyanani V, Krebs CA. “Duplex Sonography of the Portal Venous System: Pitfalls and Limitations.” AJR Am J
Roentgenol. Apr 1989;152(4):765–70. doi:10.2214/ajr.152.4.765.
†
From Sajid, M., etal. “Upper Limb Deep Vein Thrombosis: ALiterature
Review to Streamline the Protocol for Management.” Acta Haematologica
118 (2007): 10–18.
‡
¶
†
89%
47%
97%
62%
73%
53%
46%
89%
78%–100%
94%
94%
100%
67–92%
82%–100%
These accuracy studies, comparing duplex ultrasound
with cross-sectional imaging, differ from “management
studies,” in which patients who test negative for DVT and
in whom anticoagulation is withheld are followed for the
development of subsequent VTE. Results from manage-
11.5 Controversies in duplex scanning for acute venous disease 111
Patient presents with signs and symptoms of DVT (first episode)
sN
cluded
DV
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ment studies conrm the efcacy of ultrasound, especially
in symptomatic patients and those with more proximal
extremity DVT. The previously mentioned meta-analysis
demonstrated that patients who test negative on venous
duplex imaging have a consistently low rate of developing
conrmed VTE (2.0%) during an average of 6 months of
follow-up.
22
11.5 CONTROVERSIES IN DUPLEX
SCANNING FOR ACUTE VENOUS
DISEASE
11.5.1 Whole leg versus proximal venous
duplex
The arguments for performing a whole leg venous duplex,
versus a more limited assessment of the proximal veins
(femoral and popliteal), are related to numerous factors,
which include not only the clinical decision regarding therapeutic anticoagulation for a patient with an isolated calf
DVT but also the sensitivity and specicity of calf venous
duplex, the pretest probability of DVT, and D-dimer assay.
In the past, patients with an isolated calf DVT did not
routinely receive therapeutic anticoagulation. However,
the updated 2021 ACCP guidelines recommend therapeutic anticoagulation for 3 months in patients with severe
symptoms or risk factors.
anticoagulation for at least 3 months in patients with an
unprovoked DVT (including isolated distal DVT).
29
The guidelines also recommend
30
Therefore, whole leg venous duplex imaging may signicantly
affect the decision regarding antithrombotic therapy.
Another argument in favor of performing a whole leg
venous duplex is the relative simplicity of the diagnostic
algorithm: a technically adequate whole leg ultrasound
that is negative for DVT leads to no further treatment or
testing, and a test that is positive for proximal DVT leads to
anticoagulation therapy. In a whole leg scan that is positive
for isolated distal DVT, the clinician must decide between
a follow-up duplex scan (in approximately 1–2 weeks) versus therapeutic anticoagulation.
13
In contrast, the diagnostic algorithm for patients who receive a limited proximal
venous duplex scan becomes more complicated. A scan
that is positive for proximal DVT would lead to anticoagulation, whereas intersocietal guidelines suggest that a
limited proximal venous duplex that is negative for DVT
in patients with high clinical suspicion for DVT should be
followed by one of the following: whole leg venous duplex,
repeat imaging in 1 week, D-dimer assay, or conventional
venography. Based on the more efcient algorithm associated with a whole leg venous duplex (as shown in Figure11.6), we favor this approach.
31
11
History and physical examination
DVT risk factor assessment
Low clinical probability
D-dimer assay
Negative
T unlikely
Technically adequate duplex study?
Yes
Negative
DVT excluded Acute DVT
11.6 Diagnostic algorithm using clinical probability testing, D-dimer assay, and whole leg venous duplex scanning. (From Zierler,
Brenda K. “Ultrasonography and Diagnosis of Venous Thromboembolism.” Circulation 109 (2004): [suppl I]: I-9-I-14.)
Positive
Duplex ultrasound
Positive
Clinical probability rating
*
No
Venography or repeat
duplex imaging
†
Moderate or high clinical probability
Positive
*
o
D-dimer assay
†
Negative
DVT ex
Duplex ultrasound imaging
Technically adequate duplex?
Ye
Positive
Acute DVT
Negative
DVT excluded
Venography or repeat duplex imaging
112 Chapter 11 Duplex ultrasound scanning for acute venous disease
https://t.me/med1917
11.5.2 Unilateral versus bilateral venous
duplex imaging
Bilateral venous duplex scans are performed frequently,
even when patients present with unilateral signs and symptoms. One rationale for routine bilateral scanning is the
concern for silent contralateral DVT. Among patients who
are diagnosed with an ipsilateral DVT, the reported rate at
which a contralateral DVT is identied ranges from 3.6%
to 29%.
diagnosed with an asymptomatic contralateral DVT in the
absence of an ipsilateral thrombosis (<1%).
from a contralateral asymptomatic DVT are more likely to
be chronic, are more likely to occur in hospitalized patients,
and are associated with active malignancy.
mon nding in patients with unilateral symptoms, some
authors have recommended that routine bilateral duplex
scans should be avoided, since the vast majority of these
patients would not have required any change in the management of their antithrombotic therapy.
recommended bilateral scanning in patients with active
malignancy
of contralateral thrombosis in these patient subgroups is
signicantly higher than in the outpatient setting (34%
versus 16%) or in patients without cancer (38.3% versus
12%). Of concern with this rationale, the absence of these
clinical risk factors (inpatient setting, malignancy) still is a
relatively poor negative predictor in excluding contralateral DVT. Scanning the contralateral asymptomatic limb,
at least at the initial duplex scan, does provide the clinician
with useful baseline information, since the rate of recurrent
VTE can be greater than 30%.
32–35
However, a smaller number of patients are
28,31,32
Thrombi
28,30
Although unsuspected bilateral DVT is a fairly com-
28
Others have
30–32
or in hospitalized patients,31 since the rate
36
11.5.3 Scanning for residual venous
obstruction (RVO) to guide
antithrombotic therapy
The presence of RVO at the time of discontinuing anticoagulation has been shown by some authors to correlate with
recurrent VTE, making it a potential tool to help optimize
the duration of therapy.
RVO are inconsistent, and signicant disparities remain
with regard to the denition of RVO.
37
However, the data regarding
38,39
A patient-level
meta-analysis demonstrated a mild association between
RVO and VTE recurrence (hazard ratio 1.32), present
only within the rst 3 months after diagnosis of the DVT.
Without a more denitive relationship, most validated VTE
recurrence prediction models exclude RVO as a factor.
40
41
That being said, a follow-up baseline venous duplex of the
affected limb at the time of discontinuing anticoagulation
does help clinicians interpret subsequent duplex scans in
questions of recurrent VTE.
42
11.6 CONCLUSION
Venous duplex scans play a critical role in the diagnosis of
acute venous thrombosis in multiple vascular beds. In general, they have a high rate of accuracy and a very low rate
of complications. However, imaging should be performed
for appropriate indications and may be more useful when
used in combination with pretest probability scoring and
D-dimer analysis. In patients with established DVT, follow-up duplex imaging at the time of discontinuing therapy
is likely to be useful for subsequent comparisons, especially
since the rate of recurrent VTE remains signicant.
Guidelines 11.0 of the American Venous Forum on duplex ultrasound scanning for acute venous disease
No. Guideline Grade of recommendation Quality of evidence
11.1 Duplex ultrasound scanning is the standard of care to diagnose acute deep vein thrombosis (DVT) of the limbs.
11.2 Duplex examination for DVT should include three components
in each vein segment studied: thrombus visualization, venous
coaptability or compressibility, and detection of venous ow.
11.3 Duplex scanning has a sensitivity of >90% for the detection
of symptomatic femoropopliteal thrombosis and a range of
50%–70% for calf vein thrombosis.
11.4 Duplex scanning for upper extremity DVT has a sensitivity
between 78% and 100% anda specicity between 82% and
100%.
1
(strong)
1
(strong)
2
(weak)
2
(weak)
A
(high)
A
(high)
B
(moderate)
B
(moderate)
REFERENCES
★ Systematic review
♦ Guidelines
1. Anderson FA, Jr., Wheeler HB, Goldberg
RJ, etal. Apopulation-based perspective of
the hospital incidence and case-fatality rates
of deep vein thrombosis and pulmonary
embolism. The Worcester DVT study. Arch
Intern Med. May1991;151(5):933–8.
2. White RH. The epidemiology of venous
thromboembolism. Circulation. Jun
17 2003;107(23 Suppl 1):I4–8. doi:
10.1161/01.cir.0000078468.11849.66
3. Ofce of the Surgeon G, National Heart
LaBI. Publications and reports of the
surgeon general. In: The Surgeon General’s
Call to Action to Prevent Deep Vein
Thrombosis and Pulmonary Embolism.
Ofce of the Surgeon General (US); 2008.
4. Sumner DS, Baker DW, Strandness DE,
Jr. The ultrasonic velocity detector in a
clinical study of venous disease. Arch
Surg. Jul 1968;97(1):75–80. doi: 10.1001/
archsurg.1968.01340010105011
5. Hull R, Hirsh J, Sackett DL, Powers P,
Turpie AG, Walker I. Combined use of leg
scanning and impedance plethysmography in suspected venous thrombosis. An
alternative to venography. N Engl J Med.
References 113
https://t.me/med1917
Jun 30 1977;296(26):1497–500. doi:
10.1056/nejm197706302962604
6. Killewich LA, Bedford GR, Beach KW,
Strandness DE, Jr. Diagnosis of deep venous
thrombosis. Aprospective study comparing
duplex scanning to contrast venography.
Circulation. Apr 1989;79(4):810–4. doi:
10.1161/01.cir.79.4.810
7. Fowl RJ, Strothman GB, Blebea J, Rosenthal GJ, Kempczinski RF. Inappropriate
use of venous duplex scans: An analysis
of indications and results. J Vasc Surg.
May1996;23(5):881–5; discussion 885–6.
doi: 10.1016/s0741-5214(96)70251-3
8. Büller HR, Ten Cate-Hoek AJ, Hoes AW,
etal. Safely ruling out deep venous thrombosis in primary care. Ann Intern Med.
Feb 17 2009;150(4):229–35.
9. Gornik HL, Gerhard-Herman MD, Misra
S, Mohler ER, 3rd, Zierler RE. ACCF/
ACR/AIUM/ASE/IAC/SCAI/SCVS/SIR/
SVM/SVS/SVU 2013 appropriate use
criteria for peripheral vascular ultrasound and physiological testing part II:
Testing for venous disease and evaluation
of hemodialysis access: Areport of the
american college of cardiology foundation
appropriate use criteria task force. J Am
Coll Cardiol. Aug 13 2013;62(7):649–65.
doi: 10.1016/j.jacc.2013.05.001
10. Jones RT, Kabnick LS. Perioperative
duplex ultrasound following endothermal ablation of the saphenous vein: Is
it worthless? J Invasive Cardiol. Oct
2014;26(10):548–50.
11. Wells PS, Anderson DR, Rodger M, etal.
Evaluation of D-dimer in the diagnosis of
suspected deep-vein thrombosis. N Engl J
Med. Sep 25 2003;349(13):
1227–35. doi: 10.1056/NEJMoa023153
12. Geersing GJ, Zuithoff NP, Kearon C, etal.
Exclusion of deep vein thrombosis using
the Wells rule in clinically important subgroups: Individual patient data meta-analysis. Bmj. Mar 10 2014;348:g1340. doi:
10.1136/bmj.g1340
♦13. Bates SM, Jaeschke R, Stevens SM, etal.
Diagnosis of DVT: Antithrombotic therapy
and prevention of thrombosis, 9th ed:
American college of chest physicians
evidence-based clinical practice guidelines.
Chest. Feb 2012;141(2 Suppl):e351S–418S.
doi: 10.1378/chest.11-2299
14. Kleinjan A, Di Nisio M, Beyer-Westendorf
J, etal. Safety and feasibility of a diagnostic
algorithm combining clinical probability,
d-dimer testing, and ultrasonography for suspected upper extremity deep venous thrombosis: Aprospective management study. Ann
Intern Med. Apr 1 2014;160(7):451–7. doi:
10.7326/m13-2056
15. Crossin JD, Muradali D, Wilson SR. US of
liver transplants: Normal and abnormal.
Radiographics. Sep-Oct 2003;23(5):1093–
114. doi: 10.1148/rg.235035031
16. Lee H, Lim CW, Yoo SH, etal. The effect
of Doppler ultrasound on early vascular interventions and clinical outcomes
after liver transplantation. World J Surg.
Dec 2014;38(12):3202–9. doi: 10.1007/
s00268-014-2721-x
♦17. Commission IA. IAC standards and gui-
delines for vascular testing accreditation.
2015. https://intersocietal.org/programs/
vascular-testing/standards/
18. Mansour MA. Venous duplex ultrasound
of the lower extremity in the diagnosis of
deep venous thrombosis. In: AbuRahma
AF, DFB, ed. Noninvasive Vascular Dia-
gnosis: APractical Guide to Therapy, Third
Edition. Springer-Verlag; 2013:473–81.
19. Forauer AR, Theoharis CG, Dasika
NL. Jugular vein catheter placement:
Histologic features and development of
catheter-related (brin) sheaths in a swine
model. Radiology. Aug 2006;240(2):427–
34. doi: 10.1148/radiol.2402031129
20. Merritt CR. Ultrasonographic demonstration of portal vein thrombosis.
Radiology. Nov 1979;133(2):425–7. doi:
10.1148/133.2.425
21. Benson CB, Frates MC. Ultrasound of
the hepatoportal circulation. In: AbuRahma AF, Bandyk DF, eds. Noninvasive
Vascular Diagnosis: APractical Guide to
Therapy, Third Edition. Springer-Verlag;
2007:565–87.
♦22. Kearon C, Julian JA, Newman TE, Gins-
berg JS. Noninvasive diagnosis of deep
venous thrombosis. McMaster diagnostic
imaging practice guidelines initiative. Ann
Intern Med. Apr 15 1998;128(8):663–77.
doi: 10.7326/0003-4819-128-8199804150-00011
23. Laissy JP, Cinqualbre A, Loshkajian
A, etal. Assessment of deep venous
thrombosis in the lower limbs and pelvis:
MRvenography versus duplex Doppler
sonography. AJR Am J Roentgenol.
Oct 1996;167(4):971–5. doi: 10.2214/
ajr.167.4.8819396
24. Tessler FN, Gehring BJ, Gomes AS, etal.
Diagnosis of portal vein thrombosis:
Value of color Doppler imaging. AJR Am
J Roentgenol. Aug 1991;157(2):293–6.
doi: 10.2214/ajr.157.2.1853809
25. Parvey HR, Eisenberg RL, Giyanani
V, Krebs CA. Duplex sonography of
the portal venous system: Pitfalls and
limitations. AJR Am J Roentgenol. Apr
1989;152(4):765–70. doi: 10.2214/
ajr.152.4.765
26. Sottiurai VS, Towner K, McDonnell
AE, Zarins CK. Diagnosis of upper
extremity deep venous thrombosis
using noninvasive technique. Surgery.
May1982;91(5):582–5.
27. Falk RL, Smith DF. Thrombosis of upper
extremity thoracic inlet veins: Diagnosis
with duplex Doppler sonography. AJR
Am J Roentgenol. Oct 1987;149(4):
677–82. doi: 10.2214/ajr.149.4.677
28. Sajid MS, Ahmed N, Desai M, Baker
D, Hamilton G. Upper limb deep vein
thrombosis: Aliterature review to
streamline the protocol for management.
Acta Haematol. 2007;118(1):10–8. doi:
10.1159/000101700
♦29. Stevens SM, Woller SC, Kreuziger LB,
etal. Antithrombotic therapy for VTE
disease: Second update of the CHEST guideline and expert panel report. Chest. Dec
2021;160(6):e545–608. doi: 10.1016/j.
chest.2021.07.055
♦30. Kearon C, Akl EA, Comerota AJ, etal.
Antithrombotic therapy for VTE disease:
Antithrombotic therapy and prevention of
thrombosis, 9th ed: American college of chest
physicians evidence-based clinical practice
guidelines. Chest. Feb 2012;141(2 Suppl):e419S–6S. doi: 10.1378/chest.11-2301
31. Zierler BK. Ultrasonography and
diagnosis of venous thromboembolism. Circulation. Mar 30 2004;109(12
Suppl 1):I9–14. doi: 10.1161/01.
CIR.0000122870.22669.4a
32. Strothman G, Blebea J, Fowl RJ, Rosenthal G. Contralateral duplex scanning for
deep venous thrombosis is unnecessary in
patients with symptoms. J Vasc Surg. Nov
1995;22(5):543–7. doi: 10.1016/s07415214(95)70035-8
33. Prandoni P, Lensing AW, Piccioli A,
Bagatella P, Girolami A. Ultrasonography
of contralateral veins in patients with
unilateral deep-vein thrombosis. Lancet.
1998;9130:786.
34. Le Gal G, Robert-Ebadi H, Carrier M,
Kearon C, Bounameaux H, Righini M.
Is it useful to also image the asymptomatic leg in patients with suspected deep
vein thrombosis? J Thromb Haemost.
Apr 2015;13(4):563–6. doi: 10.1111/
jth.12851
35. Pennell RC, Mantese VA, Westfall SG.
Duplex scan for deep vein thrombosis–Dening who needs an examination
of the contralateral asymptomatic leg. J
Vasc Surg. Aug 2008;48(2):413–6. doi:
10.1016/j.jvs.2008.03.046
36. Heit JA, Mohr DN, Silverstein MD, PettersonTM, O’Fallon WM, Melton LJ, 3rd.
Predictors of recurrence after deep vein
thrombosis and pulmonary embolism:
Apopulation-based cohort study. Arch
Intern Med. Mar 27 2000;160(6):761–8.
doi: 10.1001/archinte.160.6.761
37. Siragusa S, Malato A, Anastasio R, etal.
Residual vein thrombosis to establish
duration of anticoagulation after a rst
episode of deep vein thrombosis: The
Duration of Anticoagulation based on
Compression UltraSonography (DACUS)
study. Blood. Aug 1 2008;112(3):511–5.
doi: 10.1182/blood-2008-01-131656
38. Stephenson EJ, Liem TK. Duplex
imaging of residual venous obstruction
to guide duration of therapy for lower
extremity deep venous thrombosis. J
Vasc Surg Venous Lymphat Disord.
Jul 2015;3(3):326–32. doi: 10.1016/j.
jvsv.2014.08.003
★39. Carrier M, Rodger MA, Wells PS, Righini
M, Gal LEG. Residual vein obstruction
to predict the risk of recurrent venous
thromboembolism in patients with deep
vein thrombosis: Asystematic review and
meta-analysis. J Thromb Haemost. Jun
2011;9(6):1119–25. doi: 10.1111/j.1538-
7836.2011.04254.x
40. Donadini MP, Ageno W, Antonucci E,
etal. Prognostic signicance of residual
venous obstruction in patients with
treated unprovoked deep vein thrombosis:
Apatient-level meta-analysis. Thromb
Haemost. Jan 2014;111(1):172–9. doi:
10.1160/th13-04-0336
41. Kyrle PA, Eichinger S. Clinical scores
to predict recurrence risk of venous
thromboembolism. Thromb Haemost.
Dec 2012;108(6):1061–4. doi: 10.1160/
th12-05-0353
42. Hamadah A, Alwasaidi T, LEG, G,
etal. Baseline imaging after therapy for
unprovoked venous thromboembolism:
Arandomized controlled comparison
of baseline imaging for diagnosis of
suspected recurrence. J Thromb Hae-
most. Dec 2011;9(12):2406–10. doi:
10.1111/j.1538-7836.2011.04533.x
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