Doppler ultrasound is the preferred method for diagnosing deep vein thrombosis (DVT). It has high specificity and sensitivity for detecting thrombi in the proximal leg veins. Isolated calf vein thrombi can be missed by Doppler in up to 30% of cases. Clinical evaluation alone is only positive for DVT in about 50% of cases. While D-dimer tests are sensitive, they are not specific for DVT. Doppler ultrasound can directly visualize thrombi as noncompressible segments within veins. Indirect signs of DVT on Doppler include loss of phasicity with respiration and loss of flow augmentation with distal compression. Contrast venography remains the gold standard but is rarely used due to risks of contrast agents and limited
3. 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
5. 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
7. 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
8. 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
9. 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.
10. 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.
11. 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)
13. 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
14. 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
16. 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
17. Compressibility of veins
Do not press too hard since the normal vein collapses
very easily making it difficult to find
19. 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
21. 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
24. 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
29. 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.
34. 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
35. 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.
36. Variations in formation of popliteal vein
Quinlan DJ et al. Radiology 2003 ; 228 : 443 – 448.
True duplication
of PV
At knee jointDistal to
knee joint
Proximal to
knee joint
42. 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
47. 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
48. 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
49. 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.
51. Epidemiology of DVT
Common clinical problem
• 260 000 cases/year of DVT diagnosed in USA
• 50 000 deaths/year due to pulmonary embolism
• 500 000 lower extremity duplex US ordered per year
Difficult to maintain 24-hour coverage, 7 days/week
Useche JN et al. RadioGraphics 2008 ; 28 : 1785 – 1797.
52. Predisposing factors of DVT
Endothelial damage
Flow stasis
Hypercoagulable state
Virchow’s triad (1846) Increased risk
Prolonged immobilization
Oral contraceptives
Congestive heart failure
Trauma & severe burns
Varicosity of lower extremities
Post-partum
Widespread malignancy
53. 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
54. 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
55. 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
56. 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
57. May-Thurner syndrome
Physiologic stenosis – Corrective surgery
• First described by May & Thurner in 1956
• Compression of LCIV by RCIA
• More prone to DVT in LI & lower extremity veins
Varicosities, chronic venous stasis ulcers
PE, phlegmasia cerulea dolens
• Awareness of this entity provide opportunities to pursue
corrective surgery & prevent these complications
Lin EP et al. Ultrasound Clin 2008 ; 3 : 147–158.
58. 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
59. Causes of a positive D-Dimer test
• Thrombogenesis
• Infection
• Inflammation
• Vasculitis
• Pregnancy
• Trauma
• Surgery
Lin EP et al. Ultrasound Clin 2008 ; 3 : 147–158.
60. 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
61. 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.
62. 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.
69. Long saphenous vein in DVT
High-volume spontaneous flow demonstrated in LSV
of a patient with PV & SFV obstruction
70. 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 %
72. Thrombosis of gastrocnemius vein
Schäberle W. Ultrasonography in vascular diagnosis.
Springer-Verlag, Berlin Heidelberg, 2004
Thrombosed GC vein Protrudes into the PV
75. Accuracy of US for diagnosis of
lower extremities DVT
SpecificitySensibilityLocationSymptoms
98%95 %Proximal leg veinsSymptomatic
90 – 100%70 %Isolated calf veins
98 %60 %Proximal leg veinsAsymptomatic
25 %< 60 %Isolated calf veins
76. The ideal patient for US evaluation has
symptoms that extend above the knee
77. 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
78. Diagnostic management of DVT of the leg
Perrier A. Lancet 1999 ; 353 : 190.
Suspected thrombosis
D-dimer test
Compression ultrasound
+
No thrombosis
–
Venography
High risk
Thrombosis
+ –
Low/moderate risk
–
79. 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%
80. 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 reaction-thrombophlebitis
Severe Skin necrosis – allergic reaction
Impaired renal function
Post-injection DVT
Contraindications Renal failure
Severe reaction to contrast agents
81. Asymptomatic DVT
Most postoperative DVT are asymptomatic
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
82. Natural history of DVT
• Spontaneously lyse
• Propagate or embolize
• Recanalize over time
• Permanently occlude the vein
83. 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
84. 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
90. 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
91. 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.
93. Location of anterior abdominal wall hernias
Jamadar DA et al. AJR 2007; 188 : 1356 – 1364.
Direct inguinal hernia
Indirect inguinal hernia
Femoral hernia
Inferior epigastric artery
94. Normal inguinal anatomy
Jamadar DA et al. AJR 2007; 188 : 1356 – 1364.
Rt inguinal region – Parallel to & cranial to inguinal ligament
Superior
pubic ramus
95. Indirect inguinal hernia
Jamadar DA et al. AJR 2007; 188 : 1356 – 1364.
Rt inguinal region – Parallel to & cranial to inguinal ligament
Pre-Valsalva maneuver
Superior
pubic ramus
Post-Valsalva maneuver
Superior
pubic ramus
96. Direct inguinal hernia
Jamadar DA et al. AJR 2007; 188 : 1356 – 1364.
Rt inguinal region – Parallel & cranial to inguinal ligament
Inferior epigastric
artery
Pre-Valsalva maneuver
Fat stripe
Post-Valsalva maneuver
Inferior epigastric
artery
97. Femoral hernia
Superior pubic
ramus
Pre-Valsalva maneuver
Superior pubic
ramus
Post-Valsalva maneuver
Jamadar DA et al. AJR 2007; 188 : 1356 – 1364.
Rt inguinal region – Parallel & caudad to inguinal ligament
100. Muscular abscess
Useche JN et al. RadioGraphics 2008 ; 28 : 1785 – 1797.
Normal femoral vesselsAbscess
Staphylococcus aureus infections are the most common
103. 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
104. 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
105. 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.
106. 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
108. Position of US probe in painful calf
Jamadar DA et al. AJR 2002 ; 179 : 709 – 716.
Baker’s cyst
Transverse scan
Plantaris tendon
Longitudinal scan
Medial head of GC insertion
Longitudinal scan
Achilles tendon
Longitudinal scan
109. Normal medial head of gastrocnemius muscle
Jamadar DA et al. AJR 2002 ; 179 : 709 – 716.
Longitudinal sonogram
Triangular insertion of GC medial head
Linear hyperechoic plantaris tendon
Transverse sonogram
Medial head of GC muscle (G)
Plantaris tendon (arrow)
110. Plantaris tendon tear
Anechoic fluid collection between
medial GC & soleus muscles
Nonvisualization of plantaris tendon
Longitudinal sonogram
Jamadar DA et al. AJR 2002 ; 179 : 709 – 716.
Fluid collection (F) in expected
location of plantaris tendon
Transverse sonogram
111. Medial gastrocnemius muscle tear
Tennis leg
Jamadar DA et al. AJR 2002 ; 179 : 709 – 716.
Anechoic collection
at distal insertion
of GCM
Blunting of expected
triangular configuration
Intact plantaris
Tendon
Longitudinal sonogram
112. Normal Achilles tendon
Longitudinal sonogram
Linear echogenic pattern
Transverse sonogram
Flat or concave posterior margin
Jamadar DA et al. AJR 2002 ; 179 : 709 – 716.
113. Achilles tendinosis
Jamadar DA et al. AJR 2002 ; 179 : 709 – 716.
Transverse sonogram
Swollen & hypoechoic tendon
Abnormal convex posterior margin
Longitudinal sonogram
Hypoechoic swelling
No disruption of tendon fibers
114. Full-thickness tear – Shadowing
Ankle in dorsal flexion
Approximated tendon ends
Ankle in plantar flexion
Acute full-thickness Achilles tendon tear
Dynamic examination
Jamadar DA et al. AJR 2002 ; 179 : 709 – 716.
Conservative management : placing plantar-flexed ankle in a cast
115. 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
116. Congestive heart failure
Venous flow signals recorded in a patient with
CHF demonstrate a pulsatile flow pattern
Common femoral vein
Inverted W wave
117. Interstitiel edema
Fluid edema demonstrated in subcutaneous tissues
as numerous anechoic channels (arrows) splaying the tissue
118. Lymphedema
Grainy appearance in subcutaneous tissues
Superficial tissue relatively thick
Degraded image quality typical of this disorder
PerforatingFlow from superficial to deep veins Don’t connect directly with saphenous veins Incontinent valves -> superficial varicositiesIt is worth noting that many perforators do not connect directly to the main trunks of the LSV or SSV, but communicate via side branches of the main trunks.
PerforatingFlow from superficial to deep veins Don’t connect directly with saphenous veins Incontinent valves -> superficial varicositiesIt is worth noting that many perforators do not connect directly to the main trunks of the LSV or SSV, but communicate via side branches of the main trunks.
Important to know detailed anatomy of this area
It can be difficult to compress the distal SFV when imaging through the anteromedial window. If so, place your free hand behind the thigh and push the limb into the transducer rather than trying to compress the vein through the adductor muscle.
The popliteal vein is described as a single vessel formed by the confluence of the anterior and posterior tibial veins, often at the distal border of the popliteus muscle, which become the SFV proximal to the adductor opening.
Carlo Giacomini (1840–1898)Professor of Anatomy at University of Turin, Italy. An anatomical variation involving the proximal SSV In this image the SSV (S) continued to run up the posterior thigh as the Giacomini vein (G). A gastrocnemius vein (GV) also drains to the SSV just proximal to the saphenopopliteal junction (J). The popliteal vein (PV) is demonstrated in this image.
In this color flow image of the saphenopopliteal junction, flow in the SSV (S) and popliteal vein (coded blue) is toward the heart during distal augmentation. Following squeeze release there is significant retrograde flow (coded red) in the SSV and popliteal vein above the junction, due to saphenopopliteal junction incompetence. However, no retrograde flow is demonstrated in the popliteal vein below the level of the saphenopopliteal junction, indicating popliteal vein competency at this level.
Symptoms of PE include the following- Sudden breathlessness- Pleuritic chest pain- Coughing up of blood- Right-sided heart failure or cardiovascular collapse- Death
Less than one third of symptomatic patients who have a DVT exhibit Homan’s sign.In addition, one half of patients who have Homan’s sign do not have a DVT.
PCD occurs when thrombosis involves the deep, superficial, and collateral veins of the lower extremity, resulting in outflow obstruction, arterial insufficiency, massive extravascular fluid sequestration, and edema.Thrombosis extends into the capillaries in 40% to 60% of patients who have PCD, leading to irreversible ischemia, necrosis, and gangrene. PCD is a surgical emergency, and early diagnosis by ultrasound may expedite appropriate management.
D-Dimer is a breakdown product of the cross-linked fibrin blood clot.
dependent on Position & extent of thrombi Patient’s age Physical condition
Sonogram of inguinal region parallel and cranial to inguinal ligament Spermatic cord (C), external iliac artery (A), inferior epigastric artery (E), femoral vein (V), and superior pubic ramus (curved arrow).
Pre-Valsalva maneuver sonogramHernia not visible, external iliac artery (A), inferior epigastric artery (E), and superior pubic ramus (curved arrow).Post-Valsalva maneuver sonogram External iliac artery (A), inferior epigastric artery (E), dilated external iliac vein (V), superior pubic ramus (curved arrow), and indirect inguinal hernia (H) originating from lateral to external iliac artery (arrowhead) and traversing inguinal canal from lateral to medial. (Left = lateral)
Pre-Valsalva maneuver sonogram Hernia not visible, peritoneal fat stripe (straight arrows) medial to inferior epigastric artery (curved arrow).Post-Valsalva maneuver sonogramDirect inguinal hernia deforming peritoneal reflection (straight arrows) medial to inferior epigastric artery (curved arrow). Left is lateral, right is medial.
Pre-Valsalva maneuver sonogram Hernia not visible, femoral artery (A), femoral vein (V), and superior pubic ramus (curved arrow).Post-Valsalva maneuver sonogram Dilated femoral vein (V) lateral to femoral hernia (arrows). Superior pubic ramus (curved arrow) is also seen.
Rupture of a Baker’s cyst frequently presents with the sudden onset of pain in the calf and must be differentiatedfrom a deep venous thrombosis or other traumatic injuries of the calf.
Area around the point of maximal discomfort is always reexamined at completion of the sonographic examination.
Typically seen in middle-aged patients. It is caused by dorsiflexion of the ankle with full knee extension.The patient typically points directly over the musculotendinous junction when asked to show the point of maximal discomfort.