Doppler ultrasound in deep vein thrombosis

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  • Please provide download option OR mail to me [suhas8859@rediffmail.com], thank U
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  • Hello Dr. Samir Haffar, I would like to use your image on Doppler ultrasound in DVT in my book "101 Clinical Cases in ER". I will give you full credit for this image. If you have any objections, please let me know. Thanks, Dr. Badar Zaheer. Limramedicaldoc@gmail.com
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  • It's a masterpiece! Can I get this file for self-learning? bell_ms31@ hotmail.com Thanks a lot!
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  • 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.
  • C = calcaneus
  • Doppler ultrasound in deep vein thrombosis

    1. 1. Doppler ultrasound in deep vein thrombosisSamir Haffar M.D.Assistant Professor of internal medicine
    2. 2. Convention in presentation of US
    3. 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
    4. 4.  Anatomy of lower extremity veins
    5. 5. Venous anatomy of lower extremity• Deep Accompanied by artery – larger than arteryCalf veins duplicated or triplicatedPopliteal & femoral may be duplicatedValves: calf (1 every inch) – IVC (no valve)• Superficial Not accompanied by arteriesGSV: Longest vein- 10-20 valves-duplicatedSSV: Anatomy extremely variable• Perforators
    6. 6. Lower extremity veinsDeep systemLin EP et al. Ultrasound Clin 2008 ; 3 : 147–158.
    7. 7. The long saphenous veinThrush 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 SFJ2.5 cm below inguinal ligament
    8. 8. Perforator veinsMyers KA & Clough A. Making sense of vascular ultrasound. Arnold, London, 2004.Flow from superficial to deep veinsDo not connect directly to main trunks of LSV or SSVCommunicate via side branches of main trunks
    9. 9. Major perforators in the LSVCrocket’s perforatorsLower medial calf6, 13 & 18 cm above medial malleolusConnect branches of LSV to PTVBoyd’s perforatorUpper calf – 10 cm below knee jointConnect LSV or its branches to PTVDodd’s perforatorMiddle third of the thighConnect LSV or its branches to SFVThrush A et al. Peripheral vascular ultrasound. Elsevier Churchill Livingstone, 2nd edition, 2005.
    10. 10. Anatomy of the saphenofemoral junctionAt least 6 other tributaries draining to LSV at level of SFJCan be source of primary or recurrent varicose veinsThrush A, Hartshorne T. Peripheral vascular ultrasound: How, why and when.Elsevier Churchill Livingstone, London, 2nd edition, 2005.
    11. 11. The short saphenous veinAnatomy of SSV extremely variableThrush 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 alongposterior thigh (Giacomini vein)
    12. 12.  Normal venous flow
    13. 13. Normal venous flow Spontaneity Spontaneous flow without augmentation Phasicity Flow changes with respiration Compression Transverse plane Augmentation Compression distal to site of examinationPatency below site of examination Valsalva Deep breath, strain while holding breathPatency of abdominal & pelvic veins
    14. 14. Normal venous flow Spontaneity Spontaneous flow without augmentation Phasicity Flow changes with respiration Compression Transverse plane Augmentation Compression distal to site of examinationPatency below site of examination Valsalva Deep breath, strain while holding breathPatency of abdominal & pelvic veins
    15. 15. PhasicityFlow changes with respirationSlow ApneaRapid
    16. 16. Normal venous flow Spontaneity Spontaneous flow without augmentation Phasicity Flow changes with respiration Compression Transverse plane Augmentation Compression distal to site of examinationPatency below site of examination Valsalva Deep breath, strain while holding breathPatency of abdominal & pelvic veins
    17. 17. Compressibility of veinsDo not press too hard since the normal vein collapsesvery easily making it difficult to find
    18. 18. External compression of the veinsCompressionRelaxation
    19. 19. Normal venous flow Spontaneity Spontaneous flow without augmentation Phasicity Flow changes with respiration Compression Transverse plane Augmentation Compression distal to site of examinationPatency below site of examination Valsalva Deep breath, strain while holding breathPatency of abdominal & pelvic veins
    20. 20. Augmented flow in popliteal veinAug Valve closedCompetentvein
    21. 21. Normal venous flow Spontaneity Spontaneous flow without augmentation Phasicity Flow changes with respiration Compression Transverse plane Augmentation Compression distal to site of examinationPatency below site of examination Valsalva Deep breath, strain while holding breathPatency of abdominal & pelvic veins
    22. 22. Valsalva’s maneuverA VAt restA VValsalva
    23. 23. Valsalva’s maneuverEndValsalvaStartValsalvaCompetent vein
    24. 24. Venous valveTwo cups of a valve clearly seenIt is uncommon to see venous valves with this clarityStasis of blood evident behind one of the valve cups
    25. 25. Venous refluxSignificant venous refluxof > 2 sec durationAugmentationor Valsalva
    26. 26. Grading of venous refluxGrade Reflux durationNormal valve function Reflux duration of < 0.5 secRapid closure of venous valvesModerate reflux Reflux duration of 0.5 – 1 secMild to moderate retrograde flowSignificant reflux Reflux duration of > 1 secLarge volume of retrograde flowThrush A, Hartshorne T. Peripheral vascular ultrasound: How, why and when.Elsevier Churchill Livingstone, London, 2nd edition, 2005.
    27. 27. Venous stasisEchogenic speckle pattern of a deep calf veinMovement of blood is visible in real timeEchogenicBlood
    28. 28.  Doppler US techniques in lowerextremities
    29. 29. Examining femoral veins & popliteal fossaLeg bent at the knee & rotated outwardBest exposure of the femoral veins & the popliteal fossaMa OJ, Mateer JR, Blaivas M. Emergency Ultrasound, 2nd edition.
    30. 30. Head of Mickey mouse
    31. 31. Superficial & deep femoral vessels
    32. 32. Confluence of the SFV & PFV
    33. 33. Normal SFA & SFV
    34. 34. Compression test at level of adductor canalCompression test inadequate at level of adductor canalRather, examiner additionally presses the vein againsttransducer from below with flat handSchäberle W. Ultrasonography in vascular diagnosis.Springer-Verlag, Berlin Heidelberg, 2004
    35. 35. Examining popliteal & leg veinsLeg allowed to hang over the edge of the bed with theprobe positioned in the popliteal fossaMa OJ, Mateer JR, Blaivas M. Emergency Ultrasound, 2nd edition.
    36. 36. Variations in formation of popliteal veinQuinlan DJ et al. Radiology 2003 ; 228 : 443 – 448.True duplicationof PVAt knee jointDistal toknee jointProximal toknee joint
    37. 37. Calf vein imaging
    38. 38. Calf veins imaging
    39. 39. Posterior tibial & peroneal veins
    40. 40. Normal posterior tibial veinsAugmentationSystoleDiastole
    41. 41. Tripple posterior tibial veins
    42. 42. Evaluating valve competence of saphenous veinsCompression-decompression testSchäberle W. Ultrasonography in vascular diagnosis.Springer-Verlag, Berlin Heidelberg, 2004Long saphenous vein Short saphenous vein
    43. 43. Normal sapheno-femoral junctionColor DopplerBlack & white
    44. 44. Sapheno-femoral junctionSFJLSVSuperiortributaryThrush A, Hartshorne T. Peripheral vascular ultrasound: How, why and when.Elsevier Churchill Livingstone, London, 2nd edition, 2005.
    45. 45. Normal greater saphenous veinTransverse imageUseche JN et al. RadioGraphics 2008 ; 28 : 1785 – 1797.Echogenic elliptical fascial sheathStylized ‘‘Egyptian eye’’
    46. 46. Normal sapheno-popliteal junctionColor DopplerBlack & white
    47. 47. The Giacomini veinGiacomini V SSVPVGVSPJThrush 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 LSVwith Giacomini vein
    48. 48. Sapheno-popliteal junction incompetenceThrush A, Hartshorne T. Peripheral vascular ultrasound: How, why and when.Elsevier Churchill Livingstone, London, 2nd edition, 2005.Distal augmentationFlow toward the heartPVSSVSPJFollowing squeeze releaseRetrograde flow in SSVPVSSVSPJ
    49. 49. Vein scan reportUse of diagrams makes it easier for clinician to interpretfindings of a venous duplex examinationThrush A et al. Peripheral vascular ultrasound. Elsevier Churchill Livingstone, London, 2005.
    50. 50.  Doppler US in DVT: acute – chronic
    51. 51. Epidemiology of DVTCommon 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 yearDifficult to maintain 24-hour coverage, 7 days/weekUseche JN et al. RadioGraphics 2008 ; 28 : 1785 – 1797.
    52. 52. Predisposing factors of DVTEndothelial damageFlow stasisHypercoagulable stateVirchow’s triad (1846) Increased riskProlonged immobilizationOral contraceptivesCongestive heart failureTrauma & severe burnsVaricosity of lower extremitiesPost-partumWidespread malignancy
    53. 53. Clinical presentation of symptomatic DVT• Calf-popliteal DVT (> 90 %)Pain, swelling, warmth & redness in calf of one legIncrease with ambulation & improve with restSymptoms persist 7 days before seek care• Iliofermoral DVT (< 10 %)Pain in buttock &/or groin region, extend to medial thighIf untreated, leg become swollen, painful, & duskyPhlegmasia cerulea dolens
    54. 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. 55. Phlegmasia Cerulea Dolens (PCD)Extreme cases of DVT – Surgical emergencyThrombosis involves deep, superficial, & collateral veinsThrombosis extends into capillaries in 40 – 60 % of patientsIrreversible ischemia, necrosis, & gangrene
    56. 56. Unilateral & bilateral DVT• Unilateral DVTDVT usually develops in only one leg at a given time• Bilateral DVTMetastatic adenocarcinomaThrombus extends proximally to involve the IVC
    57. 57. May-Thurner syndromePhysiologic stenosis – Corrective surgery• First described by May & Thurner in 1956• Compression of LCIV by RCIA• More prone to DVT in LI & lower extremity veinsVaricosities, chronic venous stasis ulcersPE, phlegmasia cerulea dolens• Awareness of this entity provide opportunities to pursuecorrective surgery & prevent these complicationsLin EP et al. Ultrasound Clin 2008 ; 3 : 147–158.
    58. 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 standardMinor & severe adverse effects• Color Doppler Procedure of choice now
    59. 59. Causes of a positive D-Dimer test• Thrombogenesis• Infection• Inflammation• Vasculitis• Pregnancy• Trauma• SurgeryLin EP et al. Ultrasound Clin 2008 ; 3 : 147–158.
    60. 60. US diagnostic criteria of DVT• Intramural thrombus• Incompressibility +++• ↑ in vein diameter• No flow in pulsed Doppler• No flow in color DopplerDirect signs• Loss of phasicity:Proximal thrombosisVenous compression• Loss of augmentation:Distal thrombosisIndirect signs
    61. 61. Incompressibility = ThrombusDo not compress vein more than necessary in acute thrombusFear of detaching thrombus to cause PEMyers KA & Clough A. Making sense of vascular ultrasound. Arnold, London, 2004.
    62. 62. Transverse compression of veinsNormal veinComplete collapseNonocclusive thrombosed veinPartial collapseCompletely thrombosed veinNo collapseHamper UM et al. Radiol Clin N Am 2007 ; 45 : 525 – 547.
    63. 63. Types of thrombusOcclusive Flottant Marginal Recanalisation
    64. 64. Thrombus in the CFVCompressionRelaxation
    65. 65. Occlusive DVTRight femoral veinLin EP et al. Ultrasound Clin 2008 ; 3 : 147 – 158.
    66. 66. Free-floating thrombusFree-floating thrombus in LFV extending into CFVHamper UM et al. Radiol Clin N Am 2007 ; 45 : 525 – 547.
    67. 67. Partially occluding acute thrombus
    68. 68. Duplicated SFVNormal Thrombus
    69. 69. Long saphenous vein in DVTHigh-volume spontaneous flow demonstrated in LSVof a patient with PV & SFV obstruction
    70. 70. Calf vein thrombosisControversy 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 %
    71. 71. DVT of the PTV & PV
    72. 72. Thrombosis of gastrocnemius veinSchäberle W. Ultrasonography in vascular diagnosis.Springer-Verlag, Berlin Heidelberg, 2004Thrombosed GC vein Protrudes into the PV
    73. 73. Superficial thrombophlebitisN Engl J Med, 2001 , 344 ; 1214.
    74. 74. Superficial thrombophlebitisSaphenous-femoral junctionShould be treated if extends to within 2 cm of deep system
    75. 75. Accuracy of US for diagnosis oflower extremities DVTSpecificitySensibilityLocationSymptoms98%95 %Proximal leg veinsSymptomatic90 – 100%70 %Isolated calf veins98 %60 %Proximal leg veinsAsymptomatic25 %< 60 %Isolated calf veins
    76. 76. The ideal patient for US evaluation hassymptoms that extend above the knee
    77. 77. Predicting pretest probability of thrombosisWells 1997Clinical feature ScoreActive cancer + 1Leg immobilization (cast, paralysis) + 1Bedridden 3 days, postoperative + 1Leg swelling (unilateral) + 1Calf swelling 3 cm + 1Pain along distribution of veins + 1Dilated superficial collateral veins + 1Clinical findings or history of other disease thatexplains symptoms or is more likely than thrombosis– 2Score 1 to 2: Moderate risk of thrombosisScore > 2: High risk of thrombosis
    78. 78. Diagnostic management of DVT of the legPerrier A. Lancet 1999 ; 353 : 190.Suspected thrombosisD-dimer testCompression ultrasound+No thrombosis–VenographyHigh riskThrombosis+ –Low/moderate risk–
    79. 79. Indications of contrast venogram in DVT• Indications Impossibility to realize quick DopplerDifficult color Doppler examBefore position of vena caval filter• No indications Pulmonary embolismDifficulty to see upper pole of thrombus• Frequency Phlebography necessary in only 10%Diagnosis done by Doppler in 90%
    80. 80. Contrast venogram in DVTNo longer diagnostic test of choiceLimitations Skilled radiologist – Cooperative patientLarge volume of contrast agents (200 ml)10% failed to depict segment of venous sysAdverse effects Minor Pain-skin reaction-thrombophlebitisSevere Skin necrosis – allergic reactionImpaired renal functionPost-injection DVTContraindications Renal failureSevere reaction to contrast agents
    81. 81. Asymptomatic DVTMost postoperative DVT are asymptomaticMost postoperative DVT isolated to calf veins (50-80%)Very small thrombi (in some cases < 1 cm in length)Often do not cause vein occlusionDon’t follow typical distribution seen in symptomatic ptsMost resolve spontaneously without specific symptoms
    82. 82. Natural history of DVT• Spontaneously lyse• Propagate or embolize• Recanalize over time• Permanently occlude the vein
    83. 83. Acute & chronic thrombusSigns 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 collateralsAcute thrombus Chronic thrombus
    84. 84. Post-thrombotic syndrome50% within 10 years after a major DVT• Disabling pain• Leg swelling• Skin pigmentation• Skin ulceration• Superficial varicose veinsClinical evaluation Triplex Doppler• Wall thickening• Persistent occlusion• Collaterals• Valvular incompetency• Superficial varicose veins
    85. 85. Venous webs in the CFV
    86. 86. Post-thrombotic syndromeChronic retractedthrombusIrregular wallthicknessAtretic occludedvein
    87. 87. Collateral veins near popliteal vessels
    88. 88. Chronic calcific thrombus in calf vein
    89. 89.  Differential diagnosis of DVT
    90. 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 ddUseche JN et al. RadioGraphics 2008 ; 28 : 1785 – 1797.Make every effort to establish a diagnosiswhen DVT is ruled out
    91. 91. Differential diagnosis of DVTAnatomic 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 ankleUseche JN et al. RadioGraphics 2008 ; 28 : 1785 – 1797.
    92. 92. Differential diagnosis of DVTRegions Differential diagnosis Inguinal Hernias: femoral – inguinalIliopsoas & ileopectineal bursitisAdenopathy (inflammatory & neoplastic)Pseudoaneurysm – AVF – anticoagulation hematoma Thigh Sports-related lesions (contusions, muscle tears, hematoma)Muscle herniation – myositis – abscess Popliteal Ruptured Baker’s cystParameniscal cyst – pes anserinus bursitisPopliteal artery: thrombosis – aneurysm – adventitial cyst Lower leg PA entrapment syndrome – thrombophlebitisTennis legCardiac and renal failureUseche JN et al. RadioGraphics 2008 ; 28 : 1785 – 1797.
    93. 93. Location of anterior abdominal wall herniasJamadar DA et al. AJR 2007; 188 : 1356 – 1364.Direct inguinal herniaIndirect inguinal herniaFemoral herniaInferior epigastric artery
    94. 94. Normal inguinal anatomyJamadar DA et al. AJR 2007; 188 : 1356 – 1364.Rt inguinal region – Parallel to & cranial to inguinal ligamentSuperiorpubic ramus
    95. 95. Indirect inguinal herniaJamadar DA et al. AJR 2007; 188 : 1356 – 1364.Rt inguinal region – Parallel to & cranial to inguinal ligamentPre-Valsalva maneuverSuperiorpubic ramusPost-Valsalva maneuverSuperiorpubic ramus
    96. 96. Direct inguinal herniaJamadar DA et al. AJR 2007; 188 : 1356 – 1364.Rt inguinal region – Parallel & cranial to inguinal ligamentInferior epigastricarteryPre-Valsalva maneuverFat stripePost-Valsalva maneuverInferior epigastricartery
    97. 97. Femoral herniaSuperior pubicramusPre-Valsalva maneuverSuperior pubicramusPost-Valsalva maneuverJamadar DA et al. AJR 2007; 188 : 1356 – 1364.Rt inguinal region – Parallel & caudad to inguinal ligament
    98. 98. Enlarged lymph nodeBlack & white Color Doppler
    99. 99. Differential diagnosis of DVTRegions Differential diagnosis Inguinal Hernias: femoral – inguinalIliopsoas & ileopectineal bursitisAdenopathy (inflammatory & neoplastic)Pseudoaneurysm – AVF – anticoagulation hematoma Thigh Sports-related lesions (contusions, muscle tears, hematoma)Muscle herniation – myositis – abscess Popliteal Ruptured Baker’s cystParameniscal cyst – pes anserinus bursitisPopliteal artery: thrombosis – aneurysm – adventitial cyst Lower leg PA entrapment syndrome – thrombophlebitisTennis legCardiac and renal failureUseche JN et al. RadioGraphics 2008 ; 28 : 1785 – 1797.
    100. 100. Muscular abscessUseche JN et al. RadioGraphics 2008 ; 28 : 1785 – 1797.Normal femoral vesselsAbscessStaphylococcus aureus infections are the most common
    101. 101. Intramuscular hematomaIntramuscular hematoma (*)Edema of the muscle fibers ofthe gracilis (arrowheads)Useche JN et al. RadioGraphics 2008 ; 28 : 1785 – 1797.
    102. 102. Differential diagnosis of DVTRegions Differential diagnosis Inguinal Hernias: femoral – inguinalIliopsoas & ileopectineal bursitisAdenopathy (inflammatory & neoplastic)Pseudoaneurysm – AVF – anticoagulation hematoma Thigh Sports-related lesions (contusions, muscle tears, hematoma)Muscle herniation – myositis – abscess Popliteal Ruptured Baker’s cystParameniscal cyst – pes anserinus bursitisPopliteal artery: thrombosis – aneurysm – adventitial cyst Lower leg PA entrapment syndrome – thrombophlebitisTennis legCardiac and renal failureUseche JN et al. RadioGraphics 2008 ; 28 : 1785 – 1797.
    103. 103. Baker’s cystJamadar DA et al. AJR 2002 ; 179 : 709 – 716.Anechoic fluid distends SM – GC bursaCharacteristic neck between SM tendon & medial GC muscle & tendonSemimembranosustendonMedial gastrocnemiustendonMedial gastrocnemiusmuscle
    104. 104. Ruptured Baker’s cystPseudo-thrombophlebitisJamadar DA et al. AJR 2002 ; 179 : 709 – 716.Debris in inferiorportion of cystAnechoic fluid trackingdistally in subcutaneoustissuesLongitudinal scan through distal aspect of Baker’s cyst
    105. 105. Popliteal artery aneurysmPartial thrombosisTransverse color Doppler US Sagittal color Doppler USHamper UM et al. Radiol Clin N Am 2007 ; 45 : 525 – 547.
    106. 106. Popliteal artery aneurysmComplete thrombosisUseche JN et al. RadioGraphics 2008 ; 28 : 1785 – 1797.Thrombosed popliteal aneurysm occluding PAPatency of the vein clearly demonstrated
    107. 107. Differential diagnosis of DVTRegions Differential diagnosis Inguinal Hernias: femoral – inguinalIliopsoas & ileopectineal bursitisAdenopathy (inflammatory & neoplastic)Pseudoaneurysm – AVF – anticoagulation hematoma Thigh Sports-related lesions (contusions, muscle tears, hematoma)Muscle herniation – myositis – abscess Popliteal Ruptured Baker’s cystParameniscal cyst – pes anserinus bursitisPopliteal artery: thrombosis – aneurysm – adventitial cyst Lower leg PA entrapment syndrome – thrombophlebitisTennis legCardiac and renal failureUseche JN et al. RadioGraphics 2008 ; 28 : 1785 – 1797.
    108. 108. Position of US probe in painful calfJamadar DA et al. AJR 2002 ; 179 : 709 – 716.Baker’s cystTransverse scanPlantaris tendonLongitudinal scanMedial head of GC insertionLongitudinal scanAchilles tendonLongitudinal scan
    109. 109. Normal medial head of gastrocnemius muscleJamadar DA et al. AJR 2002 ; 179 : 709 – 716.Longitudinal sonogramTriangular insertion of GC medial headLinear hyperechoic plantaris tendonTransverse sonogramMedial head of GC muscle (G)Plantaris tendon (arrow)
    110. 110. Plantaris tendon tearAnechoic fluid collection betweenmedial GC & soleus musclesNonvisualization of plantaris tendonLongitudinal sonogramJamadar DA et al. AJR 2002 ; 179 : 709 – 716.Fluid collection (F) in expectedlocation of plantaris tendonTransverse sonogram
    111. 111. Medial gastrocnemius muscle tearTennis legJamadar DA et al. AJR 2002 ; 179 : 709 – 716.Anechoic collectionat distal insertionof GCMBlunting of expectedtriangular configurationIntact plantarisTendonLongitudinal sonogram
    112. 112. Normal Achilles tendonLongitudinal sonogramLinear echogenic patternTransverse sonogramFlat or concave posterior marginJamadar DA et al. AJR 2002 ; 179 : 709 – 716.
    113. 113. Achilles tendinosisJamadar DA et al. AJR 2002 ; 179 : 709 – 716.Transverse sonogramSwollen & hypoechoic tendonAbnormal convex posterior marginLongitudinal sonogramHypoechoic swellingNo disruption of tendon fibers
    114. 114. Full-thickness tear – ShadowingAnkle in dorsal flexionApproximated tendon endsAnkle in plantar flexionAcute full-thickness Achilles tendon tearDynamic examinationJamadar DA et al. AJR 2002 ; 179 : 709 – 716.Conservative management : placing plantar-flexed ankle in a cast
    115. 115. Calf neoplasmLongitudinal sonogram of medial calfJamadar DA et al. AJR 2002 ; 179 : 709 – 716.Heterogeneous soleus muscle mass with indistinct marginsg = gastrocnemius muscle
    116. 116. Congestive heart failureVenous flow signals recorded in a patient withCHF demonstrate a pulsatile flow patternCommon femoral veinInverted W wave
    117. 117. Interstitiel edemaFluid edema demonstrated in subcutaneous tissuesas numerous anechoic channels (arrows) splaying the tissue
    118. 118. LymphedemaGrainy appearance in subcutaneous tissuesSuperficial tissue relatively thickDegraded image quality typical of this disorder
    119. 119. Thank You

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