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9 vascular us

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DVT ultrasound evaluation

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.

Transcript

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