9 vascular us
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DEEP VENOUS ULTRASOUNDPetra Duran-Gehring, M.D.
University of Florida-Jacksonville
Department of Emergency Medicine
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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
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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
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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
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Physical Exam
Unilateral leg swelling Tenderness to palpation Redness Warmth Palpable cords- rare Homann’s sign- rare Pratt’s sign
Poor sensitivity and Specificity
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Lower Extremity DVT
Popliteal 10%
Popliteal + Superficial Femoral 42%
Popliteal + Superficial Femoral + Common Femoral 5%
All proximal vessels 35%
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DVT Diagnostics
Contrast Venography Former gold standard Time consuming IV dye exposure
Plethysmography CT MRI Ultrasound
Low cost Portable Non-invasive
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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
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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
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Lower Extremity Venous Anatomy
Common Femoral Superficial
(saphenous) Deep
Deep Femoral (Profunda)
Superficial Femoral Popliteal
Anterior Tibial Peroneal Posterior Tibial
Common Femoral Deep
Femoral
Superficial Femoral
Popliteal
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Common Femoral Anatomy
Common Femoral Vein
Femoral Artery
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Femoral Junction Anatomy
Common Femoral Vein
Femoral Artery
Saphenous Vein
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Femoral Bifurcation Anatomy
Common Femoral Vein Femor
al Artery
Profunda Femoris
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Superficial Femoral Anatomy
Superficial Femoral Vein
Femoral Artery
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Popliteal Anatomy
Popliteal Vein
Popliteal Artery
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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
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Ultrasonic DVT Findings
Non-compressibility Echogenic material with lumen Decreased blood flow
Despite augmentation
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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
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Common Femoral
Pt placed in supine position
Leg externally rotated
Probe indicator to pt’s right
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Femoral Vein
Place probe in inguinal crease
Use color flow doppler to distinguish vessels
Scan from CFV through the SFV
Compress as you go
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Femoral Vein DVT
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Popliteal
Position Prone Decubitus Seated on edge of
gurney Knee bent to
increase venous filling
Reverse trendelenburg
Probe indicator to pt’s right
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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
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Popliteal Vein DVT
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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
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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
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Questions???