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Age: 57

Sex: Male

Indication: Left lower extremity swelling

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Case #23


Findings

  • Internal echogenicity within the popliteal and gastrocnemius veins with noncompressibility
  • Internal echogenicity in the proximal portion of the peroneal vein with maintained compressibility distally
  • Patent common femoral, femoral, profunda femoral, greater saphenous, anterior tibial, and posterior tibial veins with normal compressibility and waveform response to augmentation


Diagnosis

Deep venous thrombosis

Sample Report

Deep venous thrombosis involving the popliteal and gastrocnemius veins in addition to nonocclusive thrombus in the proximal peroneal vein.


Discussion

  • Deep venous thrombosis (DVT) is a commonly considered diagnosis in patients presenting with extremity pain and/or swelling
  • For lower extremity DVT, treatment with anticoagulation is generally accepted when there is involvement above the knee (including the popliteal vein) and more controversial for calf veins and superficial veins
  • Ultrasound findings supportive of a diagnosis of DVT include:
    • Echogenic material within the lumen of a vessel on grayscale imaging with vessel expansion – acute thrombus is often centrally located within the vessel whereas chronic thrombus often becomes more stringy and retracts eccentrically toward the vessel wall
    • Absence of Doppler flow within the vessel (in the setting of occlusive thrombosis)
    • Incomplete (or absent in the case of occlusive thrombus) vessel compressibility – the superficial and deep walls of the vein should touch when pressure is applied with the ultrasound probe, creating a “winking” appearance
  • Other indirect clues include:
    • Distal augmentation – squeezing the calf while imaging proximally – should result in transient increased flow velocity in the imaged vein. If this maneuver does not change flow within the vein being imaged, it raises concern from thrombus somewhere between the vein being imaged and the calf
      • The presence of DVT on grayscale assessment may be seen as a contraindication for augmentation due to the theoretical risk for mobilizing thrombus by transiently increasing intravenous pressure
    • Phasicity – venous flow should normally vary with respiration (remember that intrathoracic pressure decreases during inspiration, which not only causes air to rush in but increases systemic blood return to the heart) – if absent, this raises concern for more proximal thrombus (e.g. in the iliac veins or IVC)



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