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ITER DIAGNOSTICO
- Lo scopo dell’esame è l’accertamento di un venosa trombosioppure di una reflusso
superficiale e/o profonda.
- Nei due casi l’ iter diagnostico e procedure sono differenti.
- Il circolo venoso profondo deve sempre essere valutato.
L' esame venoso è indicato:
- Sospetto clinico di trombosi venosa profonda
- Sospetto clinico di trombosi superficiale
- Insufficienza valvolare del circolo profondo
- Insufficienza valvolare circolo superficiale
- Indicazioni terapeutiche
- Controlli a distanza
Doppler US in DVT
Anatomy of lower extremity veins
Normal venous flow
Doppler US techniques in lower extremities
Doppler US in DVT: acute – chronic
Differential diagnosis
Sistema venoso Superficiale
- Safena interna
- Safena esterna
- Vene perforanti
- Vene collaterali
Profondo
- Compartimento soprainguinale
- Compartimento femorale (tra il cavo popliteo e il legamento inguinale)
-Compartimento surale
Venous anatomy of lower extremity
• Deep Accompanied by artery – larger than artery
Calf veins duplicated or triplicated
Popliteal & femoral may be duplicated
Valves: calf (1 every inch) – IVC (no valve)
• Superficial Not accompanied by arteries
GSV: Longest vein- 10-20 valves-duplicated
SSV: Anatomy extremely variable
• Perforators
The long saphenous vein
Thrush A, Hartshorne T. Peripheral vascular ultrasound: How, why and when.
Elsevier Churchill Livingstone, London, 2nd edition, 2005.
• Distal LSV located in front of MM
• Runs up medial aspect of calf & thigh
• Number of superficial tributaries
• Number of major perforating veins
• Drains into the CFV at SFJ
2.5 cm below inguinal ligament
Perforator veins
Myers KA & Clough A. Making sense of vascular ultrasound. Arnold, London, 2004.
Flow from superficial to deep veins
Do not connect directly to main trunks of LSV or SSV
Communicate via side branches of main trunks
Major perforators in the LSV
Crocket’s perforators
Lower medial calf
6, 13 & 18 cm above medial malleolus
Connect branches of LSV to PTV
Boyd’s perforator
Upper calf – 10 cm below knee joint
Connect LSV or its branches to PTV
Dodd’s perforator
Middle third of the thigh
Connect LSV or its branches to SFV
Thrush A et al. Peripheral vascular ultrasound. Elsevier Churchill Livingstone, 2nd edition, 2005.
Anatomy of the saphenofemoral junction
At least 6 other tributaries draining to LSV at level of SFJ
Can be source of primary or recurrent varicose veins
Thrush A, Hartshorne T. Peripheral vascular ultrasound: How, why and when.
Elsevier Churchill Livingstone, London, 2nd edition, 2005.
The short saphenous vein
Anatomy of SSV extremely variable
Thrush A, Hartshorne T. Peripheral vascular ultrasound: How, why and when.
Elsevier Churchill Livingstone, London, 2nd edition, 2005.
• Arises behind lateral malleolus
• Runs up posterior calf
• Number of perforating veins
• Drains to PV at popliteal fossa (60%)
• Vein runs as continuation of SSV along
posterior thigh (Giacomini vein)
Normal venous flow
Spontaneity Spontaneous flow without augmentation
Phasicity Flow changes with respiration
Compression Transverse plane
Augmentation Compression distal to site of examination
Patency below site of examination
Valsalva Deep breath, strain while holding breath
Patency of abdominal & pelvic veins
Normal venous flow
Spontaneity Spontaneous flow without augmentation
Phasicity Flow changes with respiration
Compression Transverse plane
Augmentation Compression distal to site of examination
Patency below site of examination
Valsalva Deep breath, strain while holding breath
Patency of abdominal & pelvic veins
Normal venous flow
Spontaneity Spontaneous flow without augmentation
Phasicity Flow changes with respiration
Compression Transverse plane
Augmentation Compression distal to site of examination
Patency below site of examination
Valsalva Deep breath, strain while holding breath
Patency of abdominal & pelvic veins
Compressibility of veins
Do not press too hard since the normal vein collapses
very easily making it difficult to find
Normal venous flow
Spontaneity Spontaneous flow without augmentation
Phasicity Flow changes with respiration
Compression Transverse plane
Augmentation Compression distal to site of examination
Patency below site of examination
Valsalva Deep breath, strain while holding breath
Patency of abdominal & pelvic veins
Normal venous flow
Spontaneity Spontaneous flow without augmentation
Phasicity Flow changes with respiration
Compression Transverse plane
Augmentation Compression distal to site of examination
Patency below site of examination
Valsalva Deep breath, strain while holding breath
Patency of abdominal & pelvic veins
Venous valve
Two cups of a valve clearly seen
It is uncommon to see venous valves with this clarity
Stasis of blood evident behind one of the valve cups
Grading of venous reflux
Grade
Reflux duration
Normal valve function
Reflux duration of < 0.5 sec
Rapid closure of venous valves
Moderate reflux
Reflux duration of 0.5 – 1 sec
Mild to moderate retrograde flow
Significant reflux
Reflux duration of > 1 sec
Large volume of retrograde flow
Thrush A, Hartshorne T. Peripheral vascular ultrasound: How, why and when.
Elsevier Churchill Livingstone, London, 2nd edition, 2005.
Venous stasis
Echogenic speckle pattern of a deep calf vein
Movement of blood is visible in real time
Echogenic
Blood
Examining femoral veins & popliteal fossa
Leg bent at the knee & rotated outward
Best exposure of the femoral veins & the popliteal fossa
Ma OJ, Mateer JR, Blaivas M. Emergency Ultrasound, 2nd edition.
Compression test at level of adductor canal
Compression test inadequate at level of adductor canal
Rather, examiner additionally presses the vein against
transducer from below with flat hand
Schäberle W. Ultrasonography in vascular diagnosis.
Springer-Verlag, Berlin Heidelberg, 2004
Examining popliteal & leg veins
Leg allowed to hang over the edge of the bed with the
probe positioned in the popliteal fossa
Ma OJ, Mateer JR, Blaivas M. Emergency Ultrasound, 2nd edition.
Variations in formation of popliteal vein
Quinlan DJ et al. Radiology 2003 ; 228 : 443 – 448.
True duplication
of PV At knee joint Distal to
knee joint
Proximal to
knee joint
Evaluating valve competence of saphenous veins
Compression-decompression test
Schäberle W. Ultrasonography in vascular diagnosis.
Springer-Verlag, Berlin Heidelberg, 2004
Long saphenous vein Short saphenous vein
Sapheno-femoral junction
SFJ
LSV
Superior
tributary
Thrush A, Hartshorne T. Peripheral vascular ultrasound: How, why and when.
Elsevier Churchill Livingstone, London, 2nd edition, 2005.
Normal greater saphenous vein
Transverse image
Useche JN et al. RadioGraphics 2008 ; 28 : 1785 – 1797.
Echogenic elliptical fascial sheath
Stylized ‘‘Egyptian eye’’
The Giacomini vein
Giacomini V SSV
PV
GV
SPJ
Thrush A, Hartshorne T. Peripheral vascular ultrasound: How, why and when.
Elsevier Churchill Livingstone, London, 2nd edition, 2005.
It is possible to confuse posteromedial branch of LSV
with Giacomini vein
Sapheno-popliteal junction incompetence
Thrush A, Hartshorne T. Peripheral vascular ultrasound: How, why and when.
Elsevier Churchill Livingstone, London, 2nd edition, 2005.
Distal augmentation
Flow toward the heart
PV
SSV
SPJ
Following squeeze release
Retrograde flow in SSV
PV
SSV
SPJ
Vein scan report
Use of diagrams makes it easier for clinician to interpret
findings of a venous duplex examination
Thrush A et al. Peripheral vascular ultrasound. Elsevier Churchill Livingstone, London, 2005.
Clinical presentation of symptomatic DVT
• Calf-popliteal DVT (> 90 %)
Pain, swelling, warmth & redness in calf of one leg
Increase with ambulation & improve with rest
Symptoms persist 7 days before seek care
• Iliofermoral DVT (< 10 %)
Pain in buttock &/or groin region, extend to medial thigh
If untreated, leg become swollen, painful, & dusky
Phlegmasia cerulea dolens
Causes of isolated iliofemoral DVT
< 10 % of patients with DVT
• Peripartum period ( > 90 % in left leg )
• Pelvic mass
• Recent pelvic surgery
• Oral contraceptive use
• Antiphospholipid antibody syndrome
Phlegmasia Cerulea Dolens (PCD)
Extreme cases of DVT – Surgical emergency
Thrombosis involves deep, superficial, & collateral veins
Thrombosis extends into capillaries in 40 – 60 % of patients
Irreversible ischemia, necrosis, & gangrene
Unilateral & bilateral DVT
• Unilateral DVT
DVT usually develops in only one leg at a given time
• Bilateral DVT
Metastatic adenocarcinoma
Thrombus extends proximally to involve the IVC
Diagnosis of DVT
• Clinical evaluation Positive in only 50%
• D-dimers Sensible – not specific
• Plethysmography Not reliable
• Nuclear medecine Not reliable
• MRI High cost – limited availability
• Contrast venogram Used to be gold standard
Minor & severe adverse effects
• Color Doppler Procedure of choice now
Causes of a positive D-Dimer test
• Thrombogenesis
• Infection
• Inflammation
• Vasculitis
• Pregnancy
• Trauma
• Surgery
Lin EP et al. Ultrasound Clin 2008 ; 3 : 147–158.
US diagnostic criteria of DVT
• Intramural thrombus
• Incompressibility +++
• ↑ in vein diameter
• No flow in pulsed Doppler
• No flow in color Doppler
Direct signs
• Loss of phasicity:
Proximal thrombosis
Venous compression
• Loss of augmentation:
Distal thrombosis
Indirect signs
Incompressibility = Thrombus
Do not compress vein more than necessary in acute thrombus
Fear of detaching thrombus to cause PE
Myers KA & Clough A. Making sense of vascular ultrasound. Arnold, London, 2004.
Transverse compression of veins
Normal vein
Complete collapse
Nonocclusive thrombosed vein
Partial collapse
Completely thrombosed vein
No collapse
Hamper UM et al. Radiol Clin N Am 2007 ; 45 : 525 – 547.
Free-floating thrombus
Free-floating thrombus in LFV extending into CFV
Hamper UM et al. Radiol Clin N Am 2007 ; 45 : 525 – 547.
Long saphenous vein in DVT
High-volume spontaneous flow demonstrated in LSV
of a patient with PV & SFV obstruction
Calf vein thrombosis
Controversy about its clinical significance
• Most resolves spontaneousely with few sequelae
• 10 percent propagate to above-knee veins
• No pulmonary embolism if PV & SFV intact
• Benefit of treatment is uncertain
• If present repeat the exam every 2 – 3 days
• Sensibility of Doppler: 70 %
• Specificity of Doppler: 95 – 100 %
Thrombosis of gastrocnemius vein
Schäberle W. Ultrasonography in vascular diagnosis.
Springer-Verlag, Berlin Heidelberg, 2004
Thrombosed GC vein Protrudes into the PV
Superficial thrombophlebitis
Saphenous-femoral junction
Should be treated if extends to within 2 cm of deep system
Accuracy of US for diagnosis of
lower extremities DVT
Specificity
Sensibility
Location
Symptoms
98%
95 %
Proximal leg veins
Symptomatic
90 – 100%
70 %
Isolated calf veins
98 %
60 %
Proximal leg veins
Asymptomatic
25 %
< 60 %
Isolated calf veins
Predicting pretest probability of thrombosis
Wells 1997
Clinical feature Score
Active cancer + 1
Leg immobilization (cast, paralysis) + 1
Bedridden 3 days, postoperative + 1
Leg swelling (unilateral) + 1
Calf swelling 3 cm + 1
Pain along distribution of veins + 1
Dilated superficial collateral veins + 1
Clinical findings or history of other disease that
explains symptoms or is more likely than thrombosis
– 2
Score 1 to 2: Moderate risk of thrombosis
Score > 2: High risk of thrombosis
Indications of contrast venogram in DVT
• Indications Impossibility to realize quick Doppler
Difficult color Doppler exam
Before position of vena caval filter
• No indications Pulmonary embolism
Difficulty to see upper pole of thrombus
• Frequency Phlebography necessary in only 10%
Diagnosis done by Doppler in 90%
•Il trombo si evidenzia come un difetto di riempimento, visibile in almeno due
immagini successive
•Non è un test diagnostico di prima linea: invasivo, costoso, non sempre agevole o di
facile esecuzione ed interpretazione
Indicazioni
• Se non disponibili altri test
• Se CUS negativa, Dimero D positivo ed alta probabilità clinica
Flebografia con mdc
Contrast venogram in DVT
No longer diagnostic test of choice
Limitations Skilled radiologist – Cooperative patient
Large volume of contrast agents (200 ml)
10% failed to depict segment of venous sys
Adverse effects Minor Pain-skin reactionthrombophlebitis
Severe Skin necrosis – allergic reaction
Impaired renal function
Post-injection DVT
Contraindications Renal failure
Severe reaction to contrast agents
TC mdc •Diagnosi di trombosi venosa addominale
• Panoramicità
• Eventuali anomalie vascolari
• Non operatore-dipendente
RMN
Permette di evidenziare le TVP prossimali con buona accuratezza
Consente di valutare l’eventuale estensione iliaco-cavale della trombosi
Utile per la valutazione del mediastino
Indicata, in alternativa alla flebografia/TC, nei pazienti con allergia o controindicazioni al mezzo di contrasto e/o con insufficienza renale
Asymptomatic DVT
DVT are asymptomatic Most postoperative
Most postoperative DVT isolated to calf veins (50-80%)
Very small thrombi (in some cases < 1 cm in length)
Often do not cause vein occlusion
Don’t follow typical distribution seen in symptomatic pts
Most resolve spontaneously without specific symptoms
Natural history of DVT
• Spontaneously lyse
• Propagate or embolize
• Recanalize over time
• Permanently occlude the vein
Acute & chronic thrombus
Signs interpreted according to clinical history
• Anechoic or hypoechoic Brightly echogenic
• Homogenous Heterogenous
• Poorly attached or floating Well attached
• Smooth borders Irregular borders
• Spongy & deformable More rigid
• Increase in vein diameter Small & contracted vein
• Small collaterals Large collaterals
Acute thrombus Chronic thrombus
Post-thrombotic syndrome
50% within 10 years after a major DVT
• Disabling pain
• Leg swelling
• Skin pigmentation
• Skin ulceration
• Superficial varicose veins
Clinical evaluation
Triplex Doppler
• Wall thickening
• Persistent occlusion
• Collaterals
• Valvular incompetency
• Superficial varicose veins
Differential diagnosis of DVT
• 7 of 10 patients could have a cause other than DVT
• Ancillary finding detected in only 10% of Doppler study
• 90% of incidental findings related to patient symptoms
• Anatomic approach is the most useful strategy for dd
Useche JN et al. RadioGraphics 2008 ; 28 : 1785 – 1797.
Make every effort to establish a diagnosis
when DVT is ruled out
Differential diagnosis of DVT
Anatomic approach
• Groin From inguinal ligament to 10 cm below
• Thigh From this line to Hunter canal
• Popliteal From Hunter canal to 10 cm below pop crease
• Lower leg 10 cm from popliteal crease to ankle
Useche JN et al. RadioGraphics 2008 ; 28 : 1785 – 1797.
Differential diagnosis of DVT
Regions
Differential diagnosis
Inguinal
Hernias: femoral – inguinal
Iliopsoas & ileopectineal bursitis
Adenopathy (inflammatory & neoplastic)
Pseudoaneurysm – AVF – anticoagulation hematoma
Thigh
Sports-related lesions (contusions, muscle tears, hematoma)
Muscle herniation – myositis – abscess
Popliteal
Ruptured Baker’s cyst
Parameniscal cyst – pes anserinus bursitis
Popliteal artery: thrombosis – aneurysm – adventitial cyst
Lower leg
PA entrapment syndrome – thrombophlebitis
Tennis leg
Cardiac and renal failure
Useche JN et al. RadioGraphics 2008 ; 28 : 1785 – 1797.
Differential diagnosis of DVT
Regions
Differential diagnosis
Inguinal
Hernias: femoral – inguinal
Iliopsoas & ileopectineal bursitis
Adenopathy (inflammatory & neoplastic)
Pseudoaneurysm – AVF – anticoagulation hematoma
Thigh
Sports-related lesions (contusions, muscle tears, hematoma)
Muscle herniation – myositis – abscess
Popliteal
Ruptured Baker’s cyst
Parameniscal cyst – pes anserinus bursitis
Popliteal artery: thrombosis – aneurysm – adventitial cyst
Lower leg
PA entrapment syndrome – thrombophlebitis
Tennis leg
Cardiac and renal failure
Useche JN et al. RadioGraphics 2008 ; 28 : 1785 – 1797.
Muscular abscess
Useche JN et al. RadioGraphics 2008 ; 28 : 1785 – 1797.
Normal femoral vessels Abscess
Staphylococcus aureus infections are the most common
Intramuscular hematoma
Intramuscular hematoma (*)
Edema of the muscle fibers of
the gracilis (arrowheads)
Useche JN et al. RadioGraphics 2008 ; 28 : 1785 – 1797.
Differential diagnosis of DVT
Regions
Differential diagnosis
Inguinal
Hernias: femoral – inguinal
Iliopsoas & ileopectineal bursitis
Adenopathy (inflammatory & neoplastic)
Pseudoaneurysm – AVF – anticoagulation hematoma
Thigh
Sports-related lesions (contusions, muscle tears, hematoma)
Muscle herniation – myositis – abscess
Popliteal
Ruptured Baker’s cyst
Parameniscal cyst – pes anserinus bursitis
Popliteal artery: thrombosis – aneurysm – adventitial cyst
Lower leg
PA entrapment syndrome – thrombophlebitis
Tennis leg
Cardiac and renal failure
Useche JN et al. RadioGraphics 2008 ; 28 : 1785 – 1797.
Baker’s cyst
Jamadar DA et al. AJR 2002 ; 179 : 709 – 716.
Anechoic fluid distends SM – GC bursa
Characteristic neck between SM tendon & medial GC muscle & tendon
Semimembranosus
tendon
Medial gastrocnemius
tendon
Medial gastrocnemius
muscle
Ruptured Baker’s cyst
Pseudo-thrombophlebitis
Jamadar DA et al. AJR 2002 ; 179 : 709 – 716.
Debris in inferior
portion of cyst
Anechoic fluid tracking
distally in subcutaneous
tissues
Longitudinal scan through distal aspect of Baker’s cyst
Popliteal artery aneurysm
Partial thrombosis
Transverse color Doppler US Sagittal color Doppler US
Hamper UM et al. Radiol Clin N Am 2007 ; 45 : 525 – 547.
Popliteal artery aneurysm
Complete thrombosis
Useche JN et al. RadioGraphics 2008 ; 28 : 1785 – 1797.
Thrombosed popliteal aneurysm occluding PA
Patency of the vein clearly demonstrated
Differential diagnosis of DVT
Regions
Differential diagnosis
Inguinal
Hernias: femoral – inguinal
Iliopsoas & ileopectineal bursitis
Adenopathy (inflammatory & neoplastic)
Pseudoaneurysm – AVF – anticoagulation hematoma
Thigh
Sports-related lesions (contusions, muscle tears, hematoma)
Muscle herniation – myositis – abscess
Popliteal
Ruptured Baker’s cyst
Parameniscal cyst – pes anserinus bursitis
Popliteal artery: thrombosis – aneurysm – adventitial cyst
Lower leg
PA entrapment syndrome – thrombophlebitis
Tennis leg
Cardiac and renal failure
Useche JN et al. RadioGraphics 2008 ; 28 : 1785 – 1797.
Calf neoplasm
Longitudinal sonogram of medial calf
Jamadar DA et al. AJR 2002 ; 179 : 709 – 716.
Heterogeneous soleus muscle mass with indistinct margins
g = gastrocnemius muscle
Congestive heart failure
Venous flow signals recorded in a patient with
CHF demonstrate a pulsatile flow pattern
Common femoral vein
Inverted W wave
Interstitiel edema
Fluid edema demonstrated in subcutaneous tissues
as numerous anechoic channels (arrows) splaying the tissue
Lymphedema
Grainy appearance in subcutaneous tissues
Superficial tissue relatively thick
Degraded image quality typical of this disorder