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Doppler ultrasound in deep vein thrombosis
Samir Haffar M.D.
Assistant Professor of internal medicine
Convention in presentation of US
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
 Anatomy of lower extremity veins
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
Lower extremity veins
Deep system
Lin EP et al. Ultrasound Clin 2008 ; 3 : 147–158.
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
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
Phasicity
Flow changes with respiration
Slow ApneaRapid
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
External compression of the veins
CompressionRelaxation
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
Augmented flow in popliteal vein
Aug Valve closed
Competent
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
Valsalva’s maneuver
A V
At rest
A V
Valsalva
Valsalva’s maneuver
End
Valsalva
Start
Valsalva
Competent vein
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
Venous reflux
Significant venous reflux
of > 2 sec duration
Augmentation
or Valsalva
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
 Doppler US techniques in lower
extremities
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.
Head of Mickey mouse
Superficial & deep femoral vessels
Confluence of the SFV & PFV
Normal SFA & SFV
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 jointDistal to
knee joint
Proximal to
knee joint
Calf vein imaging
Calf veins imaging
Posterior tibial & peroneal veins
Normal posterior tibial veins
AugmentationSystoleDiastole
Tripple posterior tibial veins
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
Normal sapheno-femoral junction
Color DopplerBlack & white
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’’
Normal sapheno-popliteal junction
Color DopplerBlack & white
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.
 Doppler US in DVT: acute – chronic
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.
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
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
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.
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.
Types of thrombus
Occlusive Flottant Marginal Recanalisation
Thrombus in the CFV
CompressionRelaxation
Occlusive DVT
Right femoral vein
Lin EP et al. Ultrasound Clin 2008 ; 3 : 147 – 158.
Free-floating thrombus
Free-floating thrombus in LFV extending into CFV
Hamper UM et al. Radiol Clin N Am 2007 ; 45 : 525 – 547.
Partially occluding acute thrombus
Duplicated SFV
Normal Thrombus
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 %
DVT of the PTV & PV
Thrombosis of gastrocnemius vein
Schäberle W. Ultrasonography in vascular diagnosis.
Springer-Verlag, Berlin Heidelberg, 2004
Thrombosed GC vein Protrudes into the PV
Superficial thrombophlebitis
N Engl J Med, 2001 , 344 ; 1214.
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
SpecificitySensibilityLocationSymptoms
98%95 %Proximal leg veinsSymptomatic
90 – 100%70 %Isolated calf veins
98 %60 %Proximal leg veinsAsymptomatic
25 %< 60 %Isolated calf veins
The ideal patient for US evaluation has
symptoms that extend above the knee
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
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
–
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%
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
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
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
Venous webs in the CFV
Post-thrombotic syndrome
Chronic retracted
thrombus
Irregular wall
thickness
Atretic occluded
vein
Collateral veins near popliteal vessels
Chronic calcific thrombus in calf vein
 Differential diagnosis of DVT
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.
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
Normal inguinal anatomy
Jamadar DA et al. AJR 2007; 188 : 1356 – 1364.
Rt inguinal region – Parallel to & cranial to inguinal ligament
Superior
pubic ramus
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
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
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
Enlarged lymph node
Black & white Color Doppler
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 vesselsAbscess
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.
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
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)
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
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
Normal Achilles tendon
Longitudinal sonogram
Linear echogenic pattern
Transverse sonogram
Flat or concave posterior margin
Jamadar DA et al. AJR 2002 ; 179 : 709 – 716.
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
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
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
Thank You

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Doppler ultrasound in deep vein thrombosis

  • 1. Doppler ultrasound in deep vein thrombosis Samir Haffar M.D. Assistant Professor of internal medicine
  • 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.  Anatomy of lower extremity veins
  • 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
  • 6. Lower extremity veins Deep system Lin EP et al. Ultrasound Clin 2008 ; 3 : 147–158.
  • 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
  • 15. Phasicity Flow changes with respiration Slow ApneaRapid
  • 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
  • 18. External compression of the veins CompressionRelaxation
  • 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
  • 20. Augmented flow in popliteal vein Aug Valve closed Competent vein
  • 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
  • 22. Valsalva’s maneuver A V At rest A V Valsalva
  • 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
  • 25. Venous reflux Significant venous reflux of > 2 sec duration Augmentation or Valsalva
  • 26. 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.
  • 27. Venous stasis Echogenic speckle pattern of a deep calf vein Movement of blood is visible in real time Echogenic Blood
  • 28.  Doppler US techniques in lower extremities
  • 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.
  • 30. Head of Mickey mouse
  • 31. Superficial & deep femoral vessels
  • 32. Confluence of the SFV & PFV
  • 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
  • 39. Posterior tibial & peroneal veins
  • 40. Normal posterior tibial veins AugmentationSystoleDiastole
  • 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
  • 44. 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.
  • 45. Normal greater saphenous vein Transverse image Useche JN et al. RadioGraphics 2008 ; 28 : 1785 – 1797. Echogenic elliptical fascial sheath Stylized ‘‘Egyptian eye’’
  • 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.
  • 50.  Doppler US in DVT: acute – chronic
  • 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.
  • 63. Types of thrombus Occlusive Flottant Marginal Recanalisation
  • 64. Thrombus in the CFV CompressionRelaxation
  • 65. Occlusive DVT Right femoral vein Lin EP et al. Ultrasound Clin 2008 ; 3 : 147 – 158.
  • 66. Free-floating thrombus Free-floating thrombus in LFV extending into CFV 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 %
  • 71. DVT of the PTV & PV
  • 72. Thrombosis of gastrocnemius vein Schäberle W. Ultrasonography in vascular diagnosis. Springer-Verlag, Berlin Heidelberg, 2004 Thrombosed GC vein Protrudes into the PV
  • 73. Superficial thrombophlebitis N Engl J Med, 2001 , 344 ; 1214.
  • 74. Superficial thrombophlebitis Saphenous-femoral junction Should be treated if extends to within 2 cm of deep system
  • 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
  • 85. Venous webs in the CFV
  • 87. Collateral veins near popliteal vessels
  • 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.
  • 92. 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.
  • 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
  • 98. Enlarged lymph node Black & white Color Doppler
  • 99. 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.
  • 100. Muscular abscess Useche JN et al. RadioGraphics 2008 ; 28 : 1785 – 1797. Normal femoral vesselsAbscess Staphylococcus aureus infections are the most common
  • 101. Intramuscular hematoma Intramuscular hematoma (*) Edema of the muscle fibers of the gracilis (arrowheads) Useche JN et al. RadioGraphics 2008 ; 28 : 1785 – 1797.
  • 102. 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.
  • 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
  • 107. 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.
  • 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

Editor's Notes

  1. PerforatingFlow from superficial to deep veins Don’t connect directly with saphenous veins Incontinent valves -&gt; 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.
  2. PerforatingFlow from superficial to deep veins Don’t connect directly with saphenous veins Incontinent valves -&gt; 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.
  3. Important to know detailed anatomy of this area
  4. 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.
  5. 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.
  6. 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.
  7. 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.
  8. Symptoms of PE include the following- Sudden breathlessness- Pleuritic chest pain- Coughing up of blood- Right-sided heart failure or cardiovascular collapse- Death
  9. 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.
  10. 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.
  11. D-Dimer is a breakdown product of the cross-linked fibrin blood clot.
  12. dependent on Position &amp; extent of thrombi Patient’s age Physical condition
  13. 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).
  14. 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)
  15. 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.
  16. 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.
  17. 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.
  18. Area around the point of maximal discomfort is always reexamined at completion of the sonographic examination.
  19. 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.
  20. C = calcaneus