9 vascular us

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DVT ultrasound evaluation

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  • You will notice again how large the vein is in comparison to the artery here in the femoral triangle. Note that the vein and artery lie side by side, but please note that this relationship may not occur in all your patients. It is common for the vein to reside under the artery, making your ability to distinguish artery from vein essential.
  • You will notice again how large the vein is in comparison to the artery here in the femoral triangle. Note that the vein and artery lie side by side, but please note that this relationship may not occur in all your patients. It is common for the vein to reside under the artery, making your ability to distinguish artery from vein essential.
  • You will notice again how large the vein is in comparison to the artery here in the femoral triangle. Note that the vein and artery lie side by side, but please note that this relationship may not occur in all your patients. It is common for the vein to reside under the artery, making your ability to distinguish artery from vein essential.
  • You will notice again how large the vein is in comparison to the artery here in the femoral triangle. Note that the vein and artery lie side by side, but please note that this relationship may not occur in all your patients. It is common for the vein to reside under the artery, making your ability to distinguish artery from vein essential.
  • 9 vascular us

    1. 1. Deep Venous Ultrasound<br />University of Florida-Jacksonville<br />Department of Emergency Medicine<br />Petra Duran-Gehring, M.D.<br />
    2. 2. Objectives<br />Describe the indications and limitations of focused ultrasound for the detection of deep venous thrombosis<br />Understand the standard ultrasound protocol when performing a focused exam<br />Define the relevant local anatomy<br />Develop an understanding of doppler physics and instrumentation<br />Recognize the relevant focused findings and pitfalls when evaluation for deep vein thrombosis<br />
    3. 3. Deep Venous Thromboembolism <br />Incidence in U.S.: 1 in 1000 people/year<br />10% of proximal DVTs will lead to PE<br />50% of untreated proximal DVTs will lead to PE within 3 months<br />>80% of PEs due to DVTs<br />
    4. 4. DVT Risk Factors<br />Recent Trauma<br />Recent Surgery<br />Immobility<br />Cancer<br />Estrogen <br />Pregnancy<br />OCPs<br />Prior DVT/PE<br />Family history of hypercoagulabity<br />Protein C or S deficiency<br />Factor V lieden or Antithrombin III deficiency<br />Antiphospholipin or anticardiolipin antibody<br />Homocysteine<br />Lupus anticoagulant<br />
    5. 5. Physical Exam<br />Unilateral leg swelling<br />Tenderness to palpation<br />Redness<br />Warmth<br />Palpable cords- rare<br />Homann’s sign- rare<br />Pratt’s sign<br />Poor sensitivity and Specificity<br />
    6. 6. Lower Extremity DVT<br />Popliteal<br />10%<br />Popliteal + Superficial Femoral<br />42%<br />Popliteal + Superficial Femoral + Common Femoral<br />5%<br />All proximal vessels<br />35%<br />
    7. 7. DVT Diagnostics<br />Contrast Venography<br />Former gold standard<br />Time consuming<br />IV dye exposure<br />Plethysmography<br />CT<br />MRI<br />Ultrasound<br />Low cost<br />Portable<br />Non-invasive<br />
    8. 8. Ultrasound Protocols<br />Duplex<br />Comprehensive<br />Color flow<br />Doppler<br />Time consuming (about 45 mins)<br />Limited Compression<br />Focused technique<br />Bedside exam<br />Look for clot only in<br />Common femoral vein<br />Popliteal vein<br />
    9. 9. Limited Compression Ultrasound<br />Focus on proximal veins<br />Thrombi distal to popliteal rarely embolize<br />Distal thrombi may propagate to popliteal<br />Therefore, if DVT suspected, must rescan in 3-5 days<br />Clot is identified by the lack of normal compressibility of the vein<br />Proven to be as accurate as Duplex US and better than plethysmography in finding proximal clots<br />
    10. 10. Lower Extremity Venous Anatomy<br />Common Femoral<br />Common Femoral<br />Superficial (saphenous)<br />Deep<br />Deep Femoral (Profunda)<br />Superficial Femoral<br />Popliteal<br />Anterior Tibial<br />Peroneal<br />Posterior Tibial<br />Deep Femoral <br />Superficial Femoral<br />Popliteal<br />
    11. 11. Common Femoral Anatomy<br />Common Femoral Vein<br />Femoral Artery<br />
    12. 12. Femoral Junction Anatomy<br />Common Femoral Vein<br />Saphenous Vein<br />Femoral Artery<br />
    13. 13. Femoral Bifurcation Anatomy<br />Common Femoral Vein<br />Femoral Artery<br />ProfundaFemoris<br />
    14. 14. Superficial Femoral Anatomy<br />Superficial Femoral Vein<br />Femoral Artery<br />
    15. 15. Popliteal Anatomy<br />Popliteal Vein<br />Popliteal Artery<br />
    16. 16. Scanning Technique<br />Linear array probe <br />6-10 mHz<br />Medium footprint<br />If pt is obese, may need to use a lower frequency sector probe<br />Positioning<br />Reverse trendelenberg<br />Semi-sitting with hips in 30 degrees flexion<br />
    17. 17. Ultrasonic DVT Findings<br />Non-compressibility<br />Echogenic material with lumen<br />Decreased blood flow<br />Despite augmentation<br />
    18. 18. Compression<br />Compress vein using transducer<br />Complete apposition of the vein walls needed to rule out DVT<br />If compression is not achieved with pressure sufficient to deform adjacent artery, thrombus present <br />
    19. 19. Common Femoral<br />Pt placed in supine position<br />Leg externally rotated<br />Probe indicator to pt’s right<br />
    20. 20. Femoral Vein<br />Place probe in inguinal crease<br />Use color flow doppler to distinguish vessels<br />Scan from CFV through the SFV<br />Compress as you go<br />
    21. 21. Femoral Vein DVT<br />
    22. 22. Popliteal<br />Position<br />Prone<br />Decubitus<br />Seated on edge of gurney<br />Knee bent to increase venous filling<br />Reverse trendelenburg<br />Probe indicator to pt’s right<br />
    23. 23. Popliteal<br />Place probe 10-12 cm above bend in knee<br />Use color flow doppler to distinguish vessels<br />Scan through to the trifurcation of the popliteal<br />Compress as you go<br />
    24. 24. Popliteal Vein DVT<br />
    25. 25. Scan Protocol<br />Begin by palpating femoral pulse<br />Place transducer over inguinal ligament with probe indicator to pt’s right<br />Scan through the common femoral to the bifurcation (about 10 cm)<br />Move to posterior knee bend<br />Scan through popliteal to the trifurcation<br />Take clips to illustrate compressibility<br />May need to image the contralateral side if results questionable<br />
    26. 26. Pearls<br />Augmentation of flow by compressing the calf can help distinguish the vein from artery<br />Optimize gain to best see the vascular system<br />If case equivocal, scan other side and compare<br />May scan through the superficial femoral vein is clinical suspicion is high<br />
    27. 27. Questions???<br />

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