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Leão RV, Bernal ECBA, Rodrigues MB, Amaral DT, de Paula Correa MF, Helito PVP. Venous thrombosis: a mimic of musculoskeletal injury on MR imaging. Skeletal Radiol 2022; 52:1263-1276. [PMID: 36534142 DOI: 10.1007/s00256-022-04258-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/24/2022] [Revised: 12/06/2022] [Accepted: 12/09/2022] [Indexed: 12/23/2022]
Abstract
Clinical signs and symptoms of venous thrombosis and musculoskeletal pathologies frequently overlap. Sometimes, patients with venous thrombosis undergo MR examinations under an equivocal suspicion of muscle, tendon or articular injury. A low pretest clinical suspicion and lack of familiarity with the conventional MR imaging signs of venous thrombosis may result in failure to diagnose venous thrombosis, delaying treatment and raising morbimortality. In MR imaging, thrombosis presents as venous ectasia with intraluminal heterogeneous content. Small vein thrombosis is often identified as having a branching aspect. Perivenous edema and inflammatory soft tissue changes may be the most prominent findings. The purpose of this paper is to illustrate MR findings of venous thrombosis in patients who underwent MR examinations due to suspected musculoskeletal pathologies. Cases of venous thrombosis in different sites of the body diagnosed through MR are presented.
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Affiliation(s)
- Renata Vidal Leão
- Department of Radiology, Hospital Sírio-Libanês, R. Adma Jafet, 91, São Paulo, 01308-050, Brazil.
| | | | | | - Denise Tokechi Amaral
- Department of Radiology, Hospital Sírio-Libanês, R. Adma Jafet, 91, São Paulo, 01308-050, Brazil
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Kim KA, Choi SY, Kim R. Endovascular Treatment for Lower Extremity Deep Vein Thrombosis: An Overview. Korean J Radiol 2021; 22:931-943. [PMID: 33660456 PMCID: PMC8154777 DOI: 10.3348/kjr.2020.0675] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2020] [Revised: 09/07/2020] [Accepted: 09/17/2020] [Indexed: 11/17/2022] Open
Abstract
Lower extremity deep vein thrombosis (DVT) is a serious medical condition that can result in local pain and gait disturbance. DVT progression can also lead to death or major disability as a result of pulmonary embolism, postthrombotic syndrome, or limb amputation. However, early thrombus removal can rapidly relieve symptoms and prevent disease progression. Various endovascular procedures have been developed in the recent years to treat DVT, and endovascular treatment has been established as one of the major therapeutic methods to treat lower extremity DVT. However, the treatment of lower extremity DVT varies according to the disease duration, location of affected vessels, and the presence of symptoms. This article reviews and discusses effective endovascular treatment methods for lower extremity DVT.
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Affiliation(s)
- Kyung Ah Kim
- Department of Radiology, St. Vincent's Hospital, College of Medicine, The Catholic University of Korea, Suwon, Korea
| | - Sun Young Choi
- Department of Radiology and Medical Research Institute, School of Medicine, Ewha Womans University, Seoul, Korea.
| | - Ran Kim
- Department of Radiology and Medical Research Institute, School of Medicine, Ewha Womans University, Seoul, Korea
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Mukhtar M, Hamid M, Khan MAA, Ullah W. Sudden death due to pulmonary embolism after minor ankle surgery. BMJ Case Rep 2019; 12:12/3/e227649. [PMID: 30846452 DOI: 10.1136/bcr-2018-227649] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Abstract
Venous thromboembolism prophylaxis guidelines are clear for major orthopaedic surgeries, but data regarding ankle surgery are insufficient. Death from pulmonary embolism (PE) after ankle surgery is rare with the frequency of less than 0.037%. 1 We present a case of a fatal PE after ankle surgery to raise awareness about this rare but potentially fatal complication. Our patient had a left ankle fracture status postsurgical fixation and was discharged without venous thromboembolism (VTE) prophylaxis. Twenty days later, she presented with a sudden onset of dyspnoea and palpitations and was diagnosed to have extensive right-sided PE. Intravenous heparin and thrombolytics were given, but she had multiple pulseless electrical activity arrests, developed disseminated intravascular coagulation and died. Our case depicts an unusual complication of ankle surgery and highlights the importance of considering VTE as one of the complications. Medical personnel should evaluate the need for VTE prophylaxis after ankle surgery on a case to case basis.
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Affiliation(s)
- Maryam Mukhtar
- Internal Medicine, Fauji Foundation Hospital, Rawalpindi, Pakistan
| | - Mohsin Hamid
- Internal Medicine, Abington Jefferson Health, Abington, Pennsylvania, USA
| | | | - Waqas Ullah
- Internal Medicine, Abington Jefferson Health, Abington, Pennsylvania, USA
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4
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Diagnosis and management of pulmonary embolism among pregnant patients. GINECOLOGIA.RO 2019. [DOI: 10.26416/gine.25.3.2019.2494] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022] Open
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Hanley M, Steigner ML, Ahmed O, Azene EM, Bennett SJ, Chandra A, Desjardins B, Gage KL, Ginsburg M, Mauro DM, Oliva IB, Ptak T, Strax R, Verma N, Dill KE. ACR Appropriateness Criteria® Suspected Lower Extremity Deep Vein Thrombosis. J Am Coll Radiol 2018; 15:S413-S417. [DOI: 10.1016/j.jacr.2018.09.028] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2018] [Accepted: 09/07/2018] [Indexed: 10/28/2022]
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Chen H, He X, Xie G, Liang J, Ye Y, Deng W, He Z, Liu D, Li D, Liu X, Fan Z. Cardiovascular magnetic resonance black-blood thrombus imaging for the diagnosis of acute deep vein thrombosis at 1.5 Tesla. J Cardiovasc Magn Reson 2018; 20:42. [PMID: 29936910 PMCID: PMC6016134 DOI: 10.1186/s12968-018-0459-6] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2017] [Accepted: 05/16/2018] [Indexed: 11/15/2022] Open
Abstract
BACKGROUND The aim was to investigate the feasibility of a cardiovascular magnetic resonance (CMR) black-blood thrombus imaging (BBTI) technique, based on delay alternating with nutation for tailored excitation black-blood preparation and a variable flip angle turbo-spin-echo readout, for the diagnosis of acute deep vein thrombosis (DVT) at 1.5 T. METHODS BBTI was conducted in 15 healthy subjects and 30 acute DVT patients. Contrast-enhanced CMR venography (CE-CMRV) was conducted for comparison and only performed in the patients. Apparent contrast-to-noise ratios between the thrombus and the muscle/lumen were calculated to determine whether BBTI could provide an adequate thrombus signal for diagnosis. Two blinded readers assessed the randomized BBTI images from all participants and made independent decisions on the presence or absence of thrombus at the segment level. Images obtained by CE-CMRV were also randomized and assessed by the two readers. Using the consensus CE-CMRV as a reference, the sensitivity, specificity, positive and negative predictive values, and accuracy of BBTI, as well as its diagnostic agreement with CE-CMRV, were calculated. Additionally, diagnostic confidence and interobserver diagnostic agreement were evaluated. RESULTS The thrombi in the acute phase exhibited iso- or hyperintense signals on the BBTI images. All the healthy subjects were correctly identified from the participants based on the segment level. The diagnostic confidence of BBTI was comparable to that of CE-CMRV (3.69 ± 0.52 vs. 3.70 ± 0.47). High overall sensitivity (95.2%), SP (98.6%), positive predictive value (96.0%), negative predictive value (98.3%), and accuracy (97.7%), as well as excellent diagnostic and interobserver agreements, were achieved using BBTI. CONCLUSION BBTI is a reliable, contrast-free technique for the diagnosis of acute DVT at 1.5 T.
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Affiliation(s)
- Hanwei Chen
- Department of Radiology, Guangzhou Panyu Central Hospital, Guangzhou, 511400 Guangdong China
- Medical Imaging Institute of Panyu, Guangzhou, 511400 Guangdong China
| | - Xueping He
- Department of Radiology, Guangzhou Panyu Central Hospital, Guangzhou, 511400 Guangdong China
- Medical Imaging Institute of Panyu, Guangzhou, 511400 Guangdong China
| | - Guoxi Xie
- The Sixth Affiliated Hospital, Guangzhou Medical University, Xinzao, Panyu District, Qingyuan, 511518 Guangdong China
- Department of Biomedical Engineering of Basic Medical School, Guangzhou Medical University, Guangzhou, 511436 Guangdong China
| | - Jianke Liang
- Department of Radiology, Guangzhou Panyu Central Hospital, Guangzhou, 511400 Guangdong China
| | - Yufeng Ye
- Department of Radiology, Guangzhou Panyu Central Hospital, Guangzhou, 511400 Guangdong China
| | - Wei Deng
- Department of Radiology, Guangzhou Panyu Central Hospital, Guangzhou, 511400 Guangdong China
| | - Zhuonan He
- Department of Radiology, Guangzhou Panyu Central Hospital, Guangzhou, 511400 Guangdong China
| | - Dexiang Liu
- Department of Radiology, Guangzhou Panyu Central Hospital, Guangzhou, 511400 Guangdong China
| | - Debiao Li
- Biomedical Imaging Research Institute, Cedars-Sinai Medical Center, Los Angeles, CA 90048 USA
| | - Xin Liu
- Lauterbur Research Center for Biomedical Imaging, Shenzhen Institutes of Advanced Technology, Chinese Academy of Sciences, Shenzhen, 518055 Guangdong China
| | - Zhaoyang Fan
- Biomedical Imaging Research Institute, Cedars-Sinai Medical Center, Los Angeles, CA 90048 USA
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Unenhanced and Contrast-Enhanced MR Angiography and Perfusion Imaging for Suspected Pulmonary Thromboembolism. AJR Am J Roentgenol 2017; 208:517-530. [PMID: 28075625 DOI: 10.2214/ajr.16.17415] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
OBJECTIVE This article discusses the basics of unenhanced MR angiography (MRA) and MR venography (MRV), time-resolved contrast-enhanced (CE) MRA and dynamic first-pass CE perfusion MRI, and unenhanced and CE MRV, in addition to assessing the clinical relevance of these techniques for evaluating patients with suspected pulmonary thromboembolism and deep venous thrombosis. CONCLUSION Since the 1990s, the efficacy of MRA or MRV and dynamic perfusion MRI for patients with suspected pulmonary thromboembolism and deep venous thrombosis has been evaluated. On the basis of the results of single-center trials, comprehensive MRI protocols, including pulmonary unenhanced and CE MRA, perfusion MRI, and MRV, promise to be safe and time effective for assessing patients with suspected pulmonary thromboembolism, although future multicenter trials are required to assess the real clinical value of MRI.
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Min SK, Kim YH, Joh JH, Kang JM, Park UJ, Kim HK, Chang JH, Park SJ, Kim JY, Bae JI, Choi SY, Kim CW, Park SI, Yim NY, Jeon YS, Yoon HK, Park KH. Diagnosis and Treatment of Lower Extremity Deep Vein Thrombosis: Korean Practice Guidelines. Vasc Specialist Int 2016; 32:77-104. [PMID: 27699156 PMCID: PMC5045251 DOI: 10.5758/vsi.2016.32.3.77] [Citation(s) in RCA: 35] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2016] [Accepted: 08/09/2016] [Indexed: 01/28/2023] Open
Abstract
Lower extremity deep vein thrombosis is a serious medical condition that can result in death or major disability due to pulmonary embolism or post-thrombotic syndrome. Appropriate diagnosis and treatment are required to improve symptoms and salvage the affected limb. Early thrombus clearance rapidly resolves symptoms related to venous obstruction, restores valve function and reduces the incidence of post-thrombotic syndrome. Recently, endovascular treatment has been established as a standard method for early thrombus removal. However, there are a variety of views regarding the indications and procedures among medical institutions and operators. Therefore, we intend to provide evidence-based guidelines for diagnosis and treatment of lower extremity deep vein thrombosis by multidisciplinary consensus. These guidelines are the result of a close collaboration between interventional radiologists and vascular surgeons. The goals of these guidelines are to improve treatment, to serve as a guide to the clinician, and consequently to contribute to public health care.
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Affiliation(s)
- Seung-Kee Min
- Department of Surgery, Seoul National University College of Medicine, Seoul,
Korea
| | - Young Hwan Kim
- Department of Radiology, Keimyung University College of Medicine, Daegu,
Korea
| | - Jin Hyun Joh
- Department of Surgery, Kyung Hee University School of Medicine, Seoul,
Korea
| | - Jin Mo Kang
- Department of Surgery, Gachon University College of Medicine, Incheon,
Korea
| | - Ui Jun Park
- Department of Surgery, Keimyung University College of Medicine, Daegu,
Korea
| | - Hyung-Kee Kim
- Department of Surgery, Kyungpook National University School of Medicine, Daegu,
Korea
| | - Jeong-Hwan Chang
- Department of Surgery, Chosun University College of Medicine, Gwangju,
Korea
| | - Sang Jun Park
- Department of Surgery, University of Ulsan College of Medicine, Seoul,
Korea
| | - Jang Yong Kim
- Department of Surgery, Catholic University College of Medicine,
Korea
| | - Jae Ik Bae
- Mint Intervention Clinic, Seongnam,
Korea
| | - Sun Young Choi
- Department of Radiology, Ewha Womans University College of Medicine, Seoul,
Korea
| | - Chang Won Kim
- Department of Radiology, Pusan National University School of Medicine, Yangsan,
Korea
| | - Sung Il Park
- Department of Radiology, Yonsei University College of Medicine, Seoul,
Korea
| | - Nam Yeol Yim
- Department of Radiology, Chonnam National University College of Medicine, Gwangju,
Korea
| | - Yong Sun Jeon
- Department of Radiology, Inha University College of Medicine, Incheon,
Korea
| | - Hyun-Ki Yoon
- Department of Radiology, University of Ulsan College of Medicine, Seoul,
Korea
| | - Ki Hyuk Park
- Department of Surgery, Daegu Catholic University College of Medicine, Daegu,
Korea
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The diagnostic accuracy of magnetic resonance venography in the detection of deep venous thrombosis: a systematic review and meta-analysis. Clin Radiol 2015; 70:858-71. [DOI: 10.1016/j.crad.2015.04.007] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2015] [Revised: 03/26/2015] [Accepted: 04/13/2015] [Indexed: 11/23/2022]
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Steele KE, Canner J, Prokopowicz G, Verde F, Beselman A, Wyse R, Chen J, Streiff M, Magnuson T, Lidor A, Schweitzer M. The EFFORT trial: Preoperative enoxaparin versus postoperative fondaparinux for thromboprophylaxis in bariatric surgical patients: a randomized double-blind pilot trial. Surg Obes Relat Dis 2015; 11:672-83. [DOI: 10.1016/j.soard.2014.10.003] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2014] [Revised: 09/19/2014] [Accepted: 10/04/2014] [Indexed: 11/25/2022]
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11
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DeCosta L, Guthrie JD. Role of B-color and Resolution Sonography Presets for the Diagnosis of Lower Extremity Deep Vein Thrombosis. JOURNAL OF DIAGNOSTIC MEDICAL SONOGRAPHY 2015. [DOI: 10.1177/8756479314563540] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Sonography is an accurate and commonly used method of determining the presence, location, and acuity of deep vein thrombosis (DVT). A retrospective data analysis of 284 venous examinations was performed to determine if imaging presets increase the ability to detect an acute DVT. There were no significant differences between the outcomes of three modalities of sonographic imaging. If a patient had a prior DVT, the likelihood of observing another DVT using only two-dimensional imaging, resolution presets, or the B-color option was approximately nine times greater than for a patient who did not have a prior DVT. Sex, age, body mass index, ethnicity, and comorbidities of diabetes and/or hypertension were not significant predictors of observing a DVT. Using a resolution-enhancing preset that increases the overall frequency range to reduce artifacts and improve border definition and/or using the B-color preset to tint the overall image did not improve the likelihood of detecting an acute DVT during a lower extremity venous duplex sonogram.
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Abdominopelvic and Lower Extremity Deep Venous Thrombosis: Evaluation With Contrast-Enhanced MR Venography With a Blood-Pool Agent. AJR Am J Roentgenol 2013; 201:208-14. [DOI: 10.2214/ajr.12.9611] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
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Bates SM, Jaeschke R, Stevens SM, Goodacre S, Wells PS, Stevenson MD, Kearon C, Schunemann HJ, Crowther M, Pauker SG, Makdissi R, Guyatt GH. Diagnosis of DVT: Antithrombotic Therapy and Prevention of Thrombosis, 9th ed: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines. Chest 2012; 141:e351S-e418S. [PMID: 22315267 DOI: 10.1378/chest.11-2299] [Citation(s) in RCA: 404] [Impact Index Per Article: 33.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022] Open
Abstract
BACKGROUND Objective testing for DVT is crucial because clinical assessment alone is unreliable and the consequences of misdiagnosis are serious. This guideline focuses on the identification of optimal strategies for the diagnosis of DVT in ambulatory adults. METHODS The methods of this guideline follow those described in Methodology for the Development of Antithrombotic Therapy and Prevention of Thrombosis Guidelines: Antithrombotic Therapy and Prevention of Thrombosis, 9th ed: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines. RESULTS We suggest that clinical assessment of pretest probability of DVT, rather than performing the same tests in all patients, should guide the diagnostic process for a first lower extremity DVT (Grade 2B). In patients with a low pretest probability of first lower extremity DVT, we recommend initial testing with D-dimer or ultrasound (US) of the proximal veins over no diagnostic testing (Grade 1B), venography (Grade 1B), or whole-leg US (Grade 2B). In patients with moderate pretest probability, we recommend initial testing with a highly sensitive D-dimer, proximal compression US, or whole-leg US rather than no testing (Grade 1B) or venography (Grade 1B). In patients with a high pretest probability, we recommend proximal compression or whole-leg US over no testing (Grade 1B) or venography (Grade 1B). CONCLUSIONS Favored strategies for diagnosis of first DVT combine use of pretest probability assessment, D-dimer, and US. There is lower-quality evidence available to guide diagnosis of recurrent DVT, upper extremity DVT, and DVT during pregnancy.
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Affiliation(s)
- Shannon M Bates
- Department of Medicine, McMaster University and Thrombosis and Atherosclerosis Research Institute, Hamilton, ON, Canada.
| | - Roman Jaeschke
- Departments of Medicine and Clinical Epidemiology and Biostatistics, McMaster University, Hamilton, ON, Canada
| | - Scott M Stevens
- Department of Medicine, Intermountain Medical Center, Murray, UT
| | - Steven Goodacre
- School of Health and Related Research, University of Sheffield, Sheffield, England
| | - Philip S Wells
- Department of Medicine, University of Ottawa, Ottawa, ON, Canada
| | - Matthew D Stevenson
- School of Health and Related Research, University of Sheffield, Sheffield, England
| | - Clive Kearon
- Departments of Medicine and Clinical Epidemiology and Biostatistics, McMaster University, Hamilton, ON, Canada
| | - Holger J Schunemann
- Departments of Medicine and Clinical Epidemiology and Biostatistics, McMaster University, Hamilton, ON, Canada
| | - Mark Crowther
- Department of Medicine, McMaster University and Thrombosis and Atherosclerosis Research Institute, Hamilton, ON, Canada
| | - Stephen G Pauker
- Department of Medicine, Tufts New England Medical Center, Boston, MA
| | | | - Gordon H Guyatt
- Departments of Medicine and Clinical Epidemiology and Biostatistics, McMaster University, Hamilton, ON, Canada
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James AH. The natural history of pelvic vein thrombosis: the natural history of involution? Am J Obstet Gynecol 2012; 206:276-7. [PMID: 22464065 DOI: 10.1016/j.ajog.2012.01.013] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2011] [Accepted: 01/09/2012] [Indexed: 11/19/2022]
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Khalil H, Avruch L, Olivier A, Walker M, Rodger M. The natural history of pelvic vein thrombosis on magnetic resonance venography after vaginal delivery. Am J Obstet Gynecol 2012; 206:356.e1-4. [PMID: 22310054 DOI: 10.1016/j.ajog.2012.01.006] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2011] [Revised: 10/20/2011] [Accepted: 01/09/2012] [Indexed: 01/10/2023]
Abstract
OBJECTIVE Venous thromboembolism constitutes the leading cause of direct maternal mortality in the developed world. To date, there are no studies using magnetic resonance venography (MRV) to delineate the incidence and natural history of intraluminal filling defects in the postpartum period in patients with low thrombosis risk. STUDY DESIGN This was a prospective cohort study of women at low thrombosis risk postvaginal delivery undergoing MRV in the early postpartum period. RESULTS In 30 eligible and consenting participants, independently adjudicated MRV, conducted on a median of postpartum day 1, identified definite thrombosis in 30% (95% confidence interval [CI], 13.6-46.4%) of study participants. All episodes of definite thrombosis were identified in the iliac and ovarian veins. Probable thrombosis was identified in an additional 27% of study participants (95% CI, 10.3-41.7%), and possible thrombosis in an additional 10% (95% CI, 0-20.7%). CONCLUSION In this group of low-risk postpartum patients, we identified a high prevalence of definite pelvic vein intraluminal filling defects of uncertain clinical significance. This study suggests that some degree of pelvic vein intraluminal filling defect may be a normal finding after uncomplicated vaginal delivery.
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ACR Appropriateness Criteria(®) on suspected lower extremity deep vein thrombosis. J Am Coll Radiol 2012; 8:383-7. [PMID: 21636051 DOI: 10.1016/j.jacr.2011.02.016] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2011] [Accepted: 02/16/2011] [Indexed: 11/22/2022]
Abstract
Lower extremity deep vein thrombosis (DVT) is a common clinical concern, with an incidence that increases with advanced age. DVT typically begins below the knee but may extend proximally and result in pulmonary embolism. Pulmonary embolism can occur in 50% to 60% of patients with untreated DVT and can be fatal. Although clinical examination and plasma d-dimer blood evaluation can often predict the presence of DVT, imaging remains critical for the diagnostic confirmation and treatment planning of DVT. Patients with above-the-knee or proximal DVT have a high risk for pulmonary embolism and are recommended to receive anticoagulation therapy. On the other hand, patients with below-the-knee or distal DVT rarely experience pulmonary embolism, and anticoagulation therapy in these patients remains controversial. However, one sixth of patients with distal DVT may experience extension of their thrombus above the knee and therefore are recommended to undergo serial imaging assessment at 1 week to exclude proximal DVT extension if anticoagulation therapy is not initiated. Ultrasound is the preferred imaging method for evaluation of patients with newly suspected lower extremity DVT. Magnetic resonance and CT venography can be especially helpful for the evaluation of suspected DVT in the pelvis and thigh. Contrast x-ray venography, the historic gold standard for DVT assessment, is now less commonly performed and primarily reserved for patients with more complex presentations such as those with suspected recurrent acute DVT.
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Thromboembolic disorders in obstetrics. Best Pract Res Clin Obstet Gynaecol 2012; 26:53-64. [DOI: 10.1016/j.bpobgyn.2011.10.003] [Citation(s) in RCA: 33] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2011] [Accepted: 10/09/2011] [Indexed: 01/08/2023]
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van Langevelde K, Tan M, Srámek A, Huisman MV, de Roos A. Magnetic resonance imaging and computed tomography developments in imaging of venous thromboembolism. J Magn Reson Imaging 2011; 32:1302-12. [PMID: 21105136 DOI: 10.1002/jmri.22379] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022] Open
Abstract
Venous thromboembolism (VTE) is a disease that causes high morbidity and mortality in the population. At present the first-line imaging test for a suspected pulmonary embolism (PE) is computed tomography (CT) pulmonary angiography, and ultrasonography is widely used for the diagnosis of deep-vein thrombosis (DVT). Although these modalities are proven to be safe and accurate, unresolved issues remain, such as whether CT scanning in patients with a suspected PE should be extended to the legs. Another issue is the diagnosis of recurrent DVT. Magnetic resonance imaging (MRI) offers a number of advantages in the imaging of VTE. Recent developments of scanning protocols with shorter acquisition times, sometimes complemented by navigator gating or making use of endogenous contrast, offer new perspectives for the use of MRI. This review provides an overview of state of the art MRI techniques for the diagnosis of PE and DVT. Furthermore, the use of new contrast agents such as fibrin labeling to detect thrombi are addressed.
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Affiliation(s)
- Kirsten van Langevelde
- Department of Clinical Epidemiology, Leiden University Medical Center, Leiden, The Netherlands.
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Durán-Mendicuti A, Sodickson A. Imaging evaluation of the pregnant patient with suspected pulmonary embolism. Int J Obstet Anesth 2010; 20:51-9. [PMID: 21036031 DOI: 10.1016/j.ijoa.2010.07.018] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/04/2009] [Revised: 02/17/2010] [Accepted: 07/23/2010] [Indexed: 11/24/2022]
Abstract
Pulmonary embolism is the leading cause of maternal death in the developed world. The clinical diagnosis of pulmonary embolism is particularly challenging in pregnant patients as physiologic changes of pregnancy can mimic symptoms of pulmonary embolism or deep venous thrombosis. Clinical decision and imaging algorithms for venous thromboembolic disease have been proposed in the literature for the general population, but have not undergone wide-scale validation in pregnant patients. Laboratory evaluation of D-dimer levels has likewise been established as a viable screening method in the general population but remains controversial in pregnant patients. Regardless of whether D-dimer levels are used in this population, the clinician must often rely on imaging tests to confirm or exclude a clinical suspicion of pulmonary embolism. Additional factors beyond test performance must be weighed during pregnancy: radiation exposure to the fetus and maternal breast tissue, the safety of intravenous contrast administration and the diagnostic accuracy of the various testing options so that diagnosis and proper management are not delayed. The epidemiology of pregnancy-related venous thromboembolic disease and the different diagnostic methods are reviewed, with emphasis on the pregnant patient. Finally, a diagnostic imaging algorithm is proposed for the evaluation of the pregnant patient when a clinical suspicion of pulmonary embolism exists.
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Affiliation(s)
- A Durán-Mendicuti
- Emergency Radiology Division, Radiology Department, Brigham and Women's Hospital, Boston, MA, USA
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Hundley WG, Bluemke DA, Finn JP, Flamm SD, Fogel MA, Friedrich MG, Ho VB, Jerosch-Herold M, Kramer CM, Manning WJ, Patel M, Pohost GM, Stillman AE, White RD, Woodard PK. ACCF/ACR/AHA/NASCI/SCMR 2010 expert consensus document on cardiovascular magnetic resonance: a report of the American College of Cardiology Foundation Task Force on Expert Consensus Documents. J Am Coll Cardiol 2010; 55:2614-62. [PMID: 20513610 PMCID: PMC3042771 DOI: 10.1016/j.jacc.2009.11.011] [Citation(s) in RCA: 450] [Impact Index Per Article: 32.1] [Reference Citation Analysis] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
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Hundley WG, Bluemke DA, Finn JP, Flamm SD, Fogel MA, Friedrich MG, Ho VB, Jerosch-Herold M, Kramer CM, Manning WJ, Patel M, Pohost GM, Stillman AE, White RD, Woodard PK. ACCF/ACR/AHA/NASCI/SCMR 2010 expert consensus document on cardiovascular magnetic resonance: a report of the American College of Cardiology Foundation Task Force on Expert Consensus Documents. Circulation 2010; 121:2462-508. [PMID: 20479157 PMCID: PMC3034132 DOI: 10.1161/cir.0b013e3181d44a8f] [Citation(s) in RCA: 232] [Impact Index Per Article: 16.6] [Reference Citation Analysis] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
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[Thromboembolic disease in orthopedic surgery]. Med Clin (Barc) 2009; 131 Suppl 2:18-24. [PMID: 19087846 DOI: 10.1016/s0025-7753(08)76444-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
Thromboembolic complications are frequent after orthopaedic surgery of the limbs. Strategies to minimize these complications go from recognize the risk factors of the patient to introduce new antithrombotic drugs, and including general medical care, regional anaesthesia and early mobilization. Based in epidemiological studies, prophylaxis must be extended 4-6 weeks in total hip and knee arthroplasty and in surgery of the hip fracture.
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Gjesdal KI, Storaas T, Geitung JT. A noncontrast-enhanced pulse sequence optimized to visualize human peripheral vessels. Eur Radiol 2008; 19:110-20. [PMID: 18704438 DOI: 10.1007/s00330-008-1113-8] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2007] [Revised: 06/13/2008] [Accepted: 06/22/2008] [Indexed: 11/25/2022]
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Remy-Jardin M, Pistolesi M, Goodman LR, Gefter WB, Gottschalk A, Mayo JR, Sostman HD. Management of suspected acute pulmonary embolism in the era of CT angiography: a statement from the Fleischner Society. Radiology 2007; 245:315-29. [PMID: 17848685 DOI: 10.1148/radiol.2452070397] [Citation(s) in RCA: 397] [Impact Index Per Article: 23.4] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/27/2023]
Affiliation(s)
- Martine Remy-Jardin
- Department of Thoracic Imaging, Hospital Calmette, University Center of Lille, Boulevard Jules Leclerc, 59037, Lille, France.
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Cantwell CP, Cradock A, Bruzzi J, Fitzpatrick P, Eustace S, Murray JG. MR venography with true fast imaging with steady-state precession for suspected lower-limb deep vein thrombosis. J Vasc Interv Radiol 2007; 17:1763-9. [PMID: 17142706 DOI: 10.1097/01.rvi.0000242502.40626.53] [Citation(s) in RCA: 50] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
PURPOSE To compare true fast imaging with steady-state precession (FISP) magnetic resonance (MR) venography for suspected deep vein thrombosis (DVT) with contrast agent-enhanced venography. MATERIALS AND METHODS This was a prospective study of randomly selected patients with a clinical suspicion of DVT of the lower limb. Standard contrast venography was performed and compared with MR venography from the inferior vena cava to the feet in 24 patients with use of true FISP sequences (repetition time, 3.74 msec; echo time, 1.8 msec). Two radiologists independently read the MR venography and contrast venography studies. Segment visibility, secondary signs of DVT, and additional diagnoses were noted. RESULTS MR venography demonstrated all venous segments in the pelvis and thigh. When results were analyzed on a per-patient basis, there was good agreement between contrast venography and MR venography (kappa = 0.64; 95% CI, 0.33-0.94; P = .0001). When the venous system was analyzed on a segmental basis, there was very good agreement between contrast venography and MR venography (kappa = 0.81; 95% CI, 0.68-0.94; P = .0001). The sensitivity and specificity for DVT detection were 100% for the iliac and popliteal segments and 100% and 98%, 68% and 94%, and 87% and 98%, respectively, for the femoral, below-knee, and all veins. Eleven of 14 patients without DVT had an alternative diagnosis suggested by MR venography. CONCLUSIONS MR venography with axial true FISP allows noninvasive rapid diagnosis of acute DVT in the iliac, femoral, popliteal, and calf muscle veins. MR venography is much less reliable in the tibial or peroneal veins. It may demonstrate a nonvenous cause of a patient's symptoms.
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Du J, Thornton FJ, Mistretta CA, Grist TM. Dynamic MR venography: An intrinsic benefit of time-resolved MR angiography. J Magn Reson Imaging 2006; 24:922-7. [PMID: 16958067 DOI: 10.1002/jmri.20716] [Citation(s) in RCA: 16] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Abstract
PURPOSE To investigate the possibility of obtaining dynamic contrast-enhanced magnetic resonance venography (DCE-MRV) images of the lower extremities. MATERIALS AND METHODS Peripheral contrast-enhanced magnetic resonance angiography (CE-MRA) was performed on 20 patients using a time-resolved sequence that combined undersampled projection reconstruction (PR) in-plane and Cartesian slice encoding through-plane. The contrast dynamics of distal vessels were depicted. An automated segmentation algorithm based on a contrast arrival time (CAT) threshold was used to generate contrast dynamics in the venous system. The signal difference between the vein and artery was measured to evaluate the effectiveness of this technique in isolating the venous contrast dynamics. RESULTS The automatically generated image series depicted the contrast dynamics of both the arterial and venous systems, including asymmetric venous enhancement and background tissue enhancement. Quantitative measurement showed a mean venous/arterial signal ratio increase from 1.58 to 4.82 for the peak venous frame after arterial signal suppression. CONCLUSION DCE-MRV is a minimally invasive technique for evaluating the venous side of the systemic vascular anatomy. Time-resolved MRA has the potential clinical benefit of enabling both arterial and venous disease to be detected in patients undergoing CE-MRA.
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Affiliation(s)
- Jiang Du
- Department of Medical Physics, University of Wisconsin-Madison, Wisconsin, USA.
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Sampson FC, Goodacre SW, Thomas SM, van Beek EJR. The accuracy of MRI in diagnosis of suspected deep vein thrombosis: systematic review and meta-analysis. Eur Radiol 2006; 17:175-81. [PMID: 16628439 DOI: 10.1007/s00330-006-0178-5] [Citation(s) in RCA: 86] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2005] [Revised: 01/04/2006] [Accepted: 01/24/2006] [Indexed: 10/24/2022]
Abstract
Magnetic resonance imaging (MRI) may be used to diagnose deep vein thrombosis (DVT) in patients for whom ultrasound examination is inappropriate or unfeasible. We undertook a systematic review of the literature and meta-analysis to estimate the diagnostic accuracy of MRI for DVT. We searched databases of medical literature and citation lists of retrieved articles. We selected studies that compared MRI with a reference standard in patients with suspected DVT or suspected pulmonary embolus, or high-risk asymptomatic patients. Data were analysed by random effects meta-analysis. We included 14 articles in the meta-analysis. Most compared MRI with venography in patients with clinically suspected DVT. The pooled estimate of sensitivity was 91.5% (95% CI: 87.5-94.5%) and the pooled estimate of specificity was 94.8% (95% CI: 92.6-96.5%). Sensitivity for proximal DVT was higher than sensitivity for distal DVT (93.9% versus 62.1%). However, pooled estimates should be interpreted with caution as estimates of both sensitivity and specificity were subject to significant heterogeneity (P<0.001). Individual studies reported sensitivity ranging from zero to 100%, while specificity ranged from 43 to 100%. MRI has equivalent sensitivity and specificity to ultrasound for diagnosis of DVT, but has been evaluated in many fewer studies, using a variety of different techniques.
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Affiliation(s)
- Fiona C Sampson
- Health Services Research Section, ScHARR, University of Sheffield, 30 Regent Street, Sheffield, S1 4DA, UK.
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29
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Abstract
Acute pulmonary embolism (PE) is a life-threatening condition that requires accurate diagnostic imaging. Morbidity and mortality that result from PE can be reduced significantly if appropriate treatment is initiated early; this makes timely diagnosis imperative. Historically, the gold standard for the imaging of PE has been pulmonary angiography. Rapid advances in radiology and nuclear medicine have led to this modality largely being replaced by noninvasive techniques, most frequently multidetector helical CT pulmonary angiography (CTPA). In cases in which CTPA is contraindicated, other modalities for diagnosis of PE include nuclear ventilation perfusion scanning, magnetic resonance pulmonary angiography, duplex Doppler ultrasonography for deep venous thrombosis, and echocardiography. This article reviews the literature on the role of these imaging modalities in the diagnosis of PE.
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Affiliation(s)
- Paul G Kluetz
- Department of Internal Medicine, University of Maryland, Baltimore, MD 21201, USA
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Fink AM, Herzog N, Borst-Krafek B, Jurecka W, Steiner A. Long-term Mortality in Patients with Thrombosis of the Inferior Vena Cava, Iliac and Femoral Veins. Eur J Vasc Endovasc Surg 2006; 31:200-3. [PMID: 16125982 DOI: 10.1016/j.ejvs.2005.07.013] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2005] [Accepted: 07/03/2005] [Indexed: 11/21/2022]
Abstract
OBJECTIVES To assess the long-term mortality in patients with thrombosis of the vena cava, iliac and femoral veins. DESIGN Registry study. MATERIALS Between 1992 and 2000, 212 consecutive patients with acute pelvic vein thrombosis diagnosed by duplex sonography were examined by magnetic resonance imaging (MRI) to determine the most proximal extent of the thrombus. MRI revealed a thrombosis in the inferior vena cava in 46 patients (22%), in the iliac vein in 142 patients (67%), and in the femoral vein in 24 patients (11%). METHODS The vital status of the patients was investigated in April 2004 using the Austrian National Registry and the Cause of Death Register. RESULTS A total of 211 patients of the original 212 patients were monitored over a mean follow-up period of 91 months. Seventy-two of 211 patients (34%) had died. There was no significant difference in the long-term mortality, the survival period or the occurrence of fatal pulmonary embolism (PE) between previously diagnosed vena cava, iliac vein, or femoral vein thrombosis. CONCLUSIONS Extension of a thrombus into the inferior caval vein in patients considered to have a pelvic vein thrombosis has no impact on long-term mortality or the development of fatal PE compared to those patients with thrombus limited to more distal veins.
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Affiliation(s)
- A M Fink
- Department of Dermatology, Wilhelminenspital, Montleartstr. 37, 1160 Vienna, Austria.
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Stannard JP, Lopez-Ben RR, Volgas DA, Anderson ER, Busbee M, Karr DK, McGwin GR, Alonso JE. Prophylaxis against deep-vein thrombosis following trauma: a prospective, randomized comparison of mechanical and pharmacologic prophylaxis. J Bone Joint Surg Am 2006; 88:261-6. [PMID: 16452735 DOI: 10.2106/jbjs.d.02932] [Citation(s) in RCA: 35] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND Deep-vein thrombosis following skeletal trauma is an important yet poorly studied issue. The purpose of the present study was to evaluate the efficacy of two different strategies for prophylaxis against deep-vein thrombosis and pulmonary embolus following blunt skeletal trauma. METHODS Two hundred and twenty-four inpatients were enrolled in a prospective, randomized study investigating venous thromboembolic disease following trauma. Two hundred patients completed the study, which compared two different regimens of prophylaxis. The patients in Group A received enoxaparin (30 mg, administered subcutaneously twice a day) starting twenty-four to forty-eight hours after blunt trauma. The patients in Group B were managed with pulsatile foot pumps at the time of admission combined with enoxaparin on a delayed basis. All patients were screened with magnetic resonance venography and ultrasonography before discharge. RESULTS There were ninety-seven patients in Group A and 103 patients in Group B. Twenty-two patients (including thirteen in Group A and nine in Group B) had development of deep-vein thrombosis, with two (both in Group A) also having development of pulmonary embolism. The prevalence of deep-vein thrombosis was 11% for the whole series, 13.4% for Group A, and 8.7% for Group B; the difference between Groups A and B was not significant. There were eleven large or occlusive clots (prevalence, 11.3%) in Group A, compared with only three (prevalence, 2.9%) in Group B (p = 0.025). The prevalence of pulmonary embolism was 2.1% in Group A and 0% in Group B. Wound complications occurred in twenty-one patients in Group A, compared with twenty patients in Group B. Patients who had development of deep-vein thrombosis during the inpatient portion of the study required a mean of 7.4 units of blood during hospitalization, compared with 3.9 units of blood for those who did not (p < 0.05). CONCLUSIONS Our results indicate that early mechanical prophylaxis with foot pumps and the addition of enoxaparin on a delayed basis is a very successful strategy for prophylaxis against venous thromboembolic disease following serious musculoskeletal injury. The prevalence of large or occlusive deep-vein thromboses among patients who had been managed with this protocol was significantly less than that among patients who had been managed with enoxaparin alone.
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Affiliation(s)
- James P Stannard
- Division of Orthopaedic Surgery, University of Alabama at Birmingham, 509 Medical Education Building, 619 South 19th Street, Birmingham, AL 35294-3295, USA.
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Affiliation(s)
- Juan F Agudelo
- Department of Orthopedic Surgery, Denver Health Medical Center, Colorado, USA
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Stannard JP, Singhania AK, Lopez-Ben RR, Anderson ER, Farris RC, Volgas DA, McGwin GR, Alonso JE. Deep-vein thrombosis in high-energy skeletal trauma despite thromboprophylaxis. ACTA ACUST UNITED AC 2005; 87:965-8. [PMID: 15972912 DOI: 10.1302/0301-620x.87b7.15989] [Citation(s) in RCA: 39] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
We report the incidence and location of deep-vein thrombosis in 312 patients who had sustained high-energy, skeletal trauma. They were investigated using magnetic resonance venography and Duplex ultrasound. Despite thromboprophylaxis, 36 (11.5%) developed venous thromboembolic disease with an incidence of 10% in those with non-pelvic trauma and 12.2% in the group with pelvic trauma. Of patients who developed deep-vein thrombosis, 13 of 27 in the pelvic group (48%) and only one of nine in the non-pelvic group (11%) had a definite pelvic deep-vein thrombosis. When compared with magnetic resonance venography, ultrasound had a false-negative rate of 77% in diagnosing pelvic deep-vein thrombosis. Its value in the pelvis was limited, although it was more accurate than magnetic resonance venography in diagnosing clots in the lower limbs. Additional screening may be needed to detect pelvic deep-vein thrombosis in patients with pelvic or acetabular fractures.
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Affiliation(s)
- J P Stannard
- University of Alabama at Birmingham Hospitals, 510 S 20th St., FOT 960 Birmingham, Alabama 35294-3409, USA.
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Foley BS, Buschbacher RM, Grossart E. Deep Venous Thrombosis Seen on Magnetic Resonance Imaging After Ankle Sprain. Am J Phys Med Rehabil 2004; 83:784. [PMID: 15385788 DOI: 10.1097/01.phm.0000140791.12344.2e] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Affiliation(s)
- Brian S Foley
- Department of Physical Medicine and Rehabilitation, Indiana University School of Medicine, Indianapolis, Indiana 46202-5111, USA
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Abstract
MRA and MRI have become increasingly important diagnostic modalities in vascular surgery. The ability to obtain cross-sectional and angiographic images by these noninvasive and non-nephrotoxic modalities represents one of the most significant advances in vascular surgery over the past decade. We review the current status of MRI and MRA in vascular surgical practice.
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Affiliation(s)
- Erik K Insko
- Department of Radiology, University of Pennsylvania, Philadelphia, PA 19104, USA
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Kanne JP, Lalani TA. Role of computed tomography and magnetic resonance imaging for deep venous thrombosis and pulmonary embolism. Circulation 2004; 109:I15-21. [PMID: 15051664 DOI: 10.1161/01.cir.0000122871.86662.72] [Citation(s) in RCA: 103] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
During the 1990s, computed tomography (CT) and magnetic resonance (MR) imaging underwent extensive technological advancement and expanded clinical use in patients with venous thromboembolic disease, particularly with regard to evaluation of the pulmonary vasculature. In many institutions, helical (spiral) CT pulmonary angiography has become the initial imaging study of choice to evaluate patients with suspected pulmonary embolism, supplanting ventilation/perfusion scintigraphy. In addition, CT venography of the pelvis and lower extremities is often incorporated into the CT angiography protocol to identify or exclude concurrent deep venous thrombosis. MR pulmonary angiography and MR venography are second-line diagnostic tools because of their higher cost, limited availability, and other logistical constraints. As the technology improves and becomes more widely available, MR imaging may play a greater role in the evaluation of patients with venous thromboembolic disease.
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Affiliation(s)
- Jeffrey P Kanne
- Department of Radiology, University of Washington School of Medicine, Seattle, WA 98195, USA
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Abstract
Venous thromboembolism (VTE) consists of two related conditions: pulmonary embolism (PE) and deep vein thrombosis (DVT). Objective testing for VTE is crucial because the clinical diagnosis is nonspecific and insensitive, and the consequences of a missed diagnosis are serious. The purpose of this review is to discuss the utility of venous ultrasonography as the foundation for diagnosis of acute lower extremity DVT. The effectiveness and practicality of venous ultrasonography as a stand-alone examination versus theoretically attractive, but perhaps less practical, combined approaches of ultrasonography with clinical probability assessment and D-dimer testing in the diagnosis of acute DVT is also addressed. Finally, the role of venous ultrasonography in a diagnostic algorithm for suspected PE is discussed.
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Affiliation(s)
- Brenda K Zierler
- Department of Biobehavioral Nursing and Health Systems, School of Nursing, University of Washington, Seattle, WA 98195, USA.
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Stein PD, Woodard PK, Hull RD, Kayali F, Weg JG, Olson RE, Fowler SE. Gadolinium-enhanced magnetic resonance angiography for detection of acute pulmonary embolism: an in-depth review. Chest 2004; 124:2324-8. [PMID: 14665516 DOI: 10.1016/s0012-3692(15)31694-9] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022] Open
Abstract
STUDY OBJECTIVE To review the published experience with gadolinium-enhanced magnetic resonance angiography (MRA) for the detection of acute pulmonary embolism (PE) in order to test the hypothesis that gadolinium-enhanced MRA may be potentially sensitive and specific enough to include it among diagnostic alternatives in the evaluation of patients with suspected PE. METHODS Studies were identified by searching MEDLINE for trials that used gadolinium-enhanced MRA to diagnose acute PE based on the visualization of an intraluminal filling defect or a cutoff vessel, using pulmonary angiography as a reference standard. RESULTS Twenty-eight investigations were identified in which MRA was used to diagnose PE. Only three studies, however, met the criteria for inclusion in the analysis. In these three case series, the sensitivity of gadolinium-enhanced MRA ranged from 77 to 100%, and the specificity ranged from 95 to 98%. CONCLUSION Gadolinium-enhanced MRA may be a useful diagnostic alternative in some patients with suspected acute PE, particularly if they have an elevated creatinine level, have an allergy to radiographic contrast material, or should, if possible, avoid exposure to ionizing radiation.
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Affiliation(s)
- Paul D Stein
- St. Joseph Mercy Oakland Hospital, 44555 Woodward Avenue, Suite 107, Pontiac, MI 48341-2985, USA.
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Gallix BP, Achard-Lichère C, Dauzat M, Bruel JM, Lopez FM. Flow-independent magnetic resonance venography of the calf. J Magn Reson Imaging 2003; 17:421-6. [PMID: 12655580 DOI: 10.1002/jmri.10273] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
Abstract
PURPOSE To show that flow-independent venography that exploit the intrinsic MR properties of blood to isolate vessels from surrounding structures can be used for depiction of peripheral veins and for detection of deep venous thrombosis (DVT). MATERIALS AND METHODS Sequence and parameters were first determined on a theoretical basis. The sequence was then optimized in volunteers (N = 4) for the depiction of the peripheral venous vessels. Qualitative evaluation of the normal venous anatomy was performed in five volunteers. The feasibility of diagnosing DVT of the calf with this method was evaluated with preliminary clinical studies. RESULTS Excellent depiction of the venous anatomy was achieved in all volunteers with the optimized technique. Very small venous structures, such as superficial, muscular, and perforator veins, were clearly depicted because of the high spatial and contrast resolution capacities of the sequences. In all six patients, DVT findings diagnosed by duplex sonography were also seen on MR venography. CONCLUSION Venous anatomy mapping and detection of lower-limb DVT appear feasible using flow-independent MR venograms.
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Affiliation(s)
- Benoît P Gallix
- Service d'Imagerie Médicale, Hôpital Saint-Eloi, Faculté de Médecine de Montpellier-Nîmes, Montpellier, France.
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Borst-Krafek B, Fink AM, Lipp C, Umek H, Köhn H, Steiner A. Proximal extent of pelvic vein thrombosis and its association with pulmonary embolism. J Vasc Surg 2003; 37:518-22. [PMID: 12618685 DOI: 10.1067/mva.2003.151] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
OBJECTIVE Conventional methods such as duplex ultrasound scanning do not provide accurate information about proximal extension of pelvic vein thrombosis. We evaluated proximal extent of thrombus toward pelvic veins with magnetic resonance imaging in patients with suspected deep vein thrombosis (DVT) proximal to the inguinal ligament on the basis of duplex ultrasound scans. In addition, frequency of pulmonary embolism (PE) and early (4 weeks) clinical outcome were evaluated. METHODS Two hundred twelve patients with acute symptomatic DVT proximal to the inguinal ligament, diagnosed at duplex ultrasound scanning, were enrolled in this prospective study. All patients underwent magnetic resonance imaging of the abdominal and pelvic veins, as well as lung scintigraphy to detect the presence of pulmonary embolism. RESULTS In 24 of 212 patients (11%), thrombus was restricted to the femoral vein. The thrombus extended into iliac veins in 142 patients (67%) and into the inferior vena cava in 46 patients (22%). The frequency of PE was not associated with the most proximal extension of thrombus (P =.61). No patients died as a consequence of thromboembolic events. CONCLUSIONS Extension of DVT into the inferior vena cava occurs relatively frequently. In our patients this finding was not associated with higher risk for PE compared with DVT of the femoral or iliac veins.
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Affiliation(s)
- Barbara Borst-Krafek
- Department of Dermatology, Wilhelminen Hospital, Montleartstrasse 37, A-1171 Vienna, Austria
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Abstract
Venous thromboembolism frequently complicates the management of patients with severe medical and surgical illnesses. Because the diagnosis of VTE is especially challenging in critically ill patients, the focus of intensivists should be on characterization of risk factors and the appropriate choice of VTE prophylaxis. LDUH or LMHW is the preferred choice for VTE prophylaxis in ICU patients. Mechanical methods of prophylaxis should be reserved for patients with a high risk for bleeding. The effectiveness of mechanical methods and of combined strategies of prevention and the clinically important outcomes of therapy need to be explored further in critically ill patients. Few diagnostic strategies have been assessed in ICU patients with suspected PE. Ventilation-perfusion lung scans remain a pivotal diagnostic test but retain the same limitations in critically ill patients as seen in other patient populations. Newer noninvasive techniques, such as spiral CT associated with imaging of the extremities, are gaining more wide-spread use, but, thus far, pulmonary angiography remains the most reliable technique to confirm or exclude PE in patients with respiratory failure. A consensus must be reached regarding the most appropriate combination of tests for adequate and cost-effective diagnosis of VTE. Further investigation of diagnostic strategies that include adequate consideration of clinical diagnosis using standardized models and noninvasive imaging are warranted.
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Affiliation(s)
- Ana T Rocha
- Division of Pulmonary and Critical Care Medicine, Duke University Medical Center, Box 3221, Durham, NC 27710, USA.
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Stover MD, Morgan SJ, Bosse MJ, Sims SH, Howard BJ, Stackhouse D, Weresh MJ, Kellam JF. Prospective comparison of contrast-enhanced computed tomography versus magnetic resonance venography in the detection of occult deep pelvic vein thrombosis in patients with pelvic and acetabular fractures. J Orthop Trauma 2002; 16:613-21. [PMID: 12368640 DOI: 10.1097/00005131-200210000-00001] [Citation(s) in RCA: 34] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
OBJECTIVE To determine the rate of pelvic vein thrombosis following acetabular or pelvic fracture identified by enhanced computed tomography venography or magnetic resonance venography. DESIGN Prospective evaluation of computed tomography venography and magnetic resonance venography in patients with pelvic and acetabular trauma as a screening tool for deep vein thrombosis. SETTING Level I trauma center. RESULTS Thirty patients with pelvic or acetabular fractures and who met the study criteria were prospectively screened with magnetic resonance venography and computed tomography venography to determine preoperative presence of pelvic venous thrombosis. Pelvic deep vein thrombosis was detected by computed tomography venography in two patients (7%) and by magnetic resonance venography in four patients (13%). Invasive selective pelvic venographies were performed on the five subjects who tested positive on either one or both screening tests. Only one computed tomography venography case was validated by invasive pelvic venography. The false-positive rate for computed tomography venography was 50%, and the false-positive rate for magnetic resonance venography was 100%. CONCLUSIONS We cannot recommend the sole use of either computed tomography venography or magnetic resonance venography to screen and direct the treatment of asymptomatic thrombi in patients with fracture of the pelvic ring because of the high false positive rates. If these studies are used as screening tools, confirmation of the presence of thrombosis with selective venography should be performed prior to initiating invasive treatment with a vena cava filter. Clinical decisions based solely on one of these imaging techniques may result in inappropriate aggressive treatment due to the high false-positive rate.
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Affiliation(s)
- Michael D Stover
- Department of Orthopaedic Surgery, Loyola University Medical Center, Maywood, Illinois 20153, USA
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Stern JB, Abehsera M, Grenet D, Friard S, Couderc LJ, Scherrer A, Stern M. Detection of pelvic vein thrombosis by magnetic resonance angiography in patients with acute pulmonary embolism and normal lower limb compression ultrasonography. Chest 2002; 122:115-21. [PMID: 12114346 DOI: 10.1378/chest.122.1.115] [Citation(s) in RCA: 52] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022] Open
Abstract
STUDY OBJECTIVE In patients with proven acute pulmonary embolism (PE), a systematic search for "residual" deep vein thrombosis (DVT) using venography or compression duplex ultrasonography (CDUS) of the lower limbs is negative in 20 to 50% of patients. We hypothesized that undetectable pelvic vein thrombosis (from the external iliac vein to the inferior vena cava) could account for a substantial proportion of patients with negative CDUS findings. Using a noninvasive test, magnetic resonance angiography (MRA), the objective of the study was to assess the prevalence of pelvic DVT in patients with acute PEs and normal findings on lower limb CDUS. DESIGN Prospective study. SETTING A 35-bed respiratory unit in a 680-bed Parisian teaching hospital. PATIENTS From June 1995 to October 1996, 24 patients (mean age, 49 years; age range, 18 to 83 years) with acute PEs and normal findings on lower limb CDUS underwent pelvic MRA. MEASUREMENTS AND RESULTS MRA disclosed pelvic DVT in seven patients (29%). The common iliac vein was involved in five patients. Internal iliac vein (hypogastric) thrombosis was imaged in two patients, but no patients had DVT limited to this vein. Three patients underwent subsequent venography studies that confirmed the MRA findings. In three other patients, a new MRA at the end of anticoagulant therapy showed the resolution of the DVT. CONCLUSIONS Our data support the view that, among patients with negative findings on CDUS, a substantial proportion of the DVTs that are responsible for PE originates in the pelvic veins. This study provides additional arguments to suggest that MRA might become the reference test for the exploration of pelvic DVT.
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Hatabu H, Uematsu H, Nguyen B, Miller WT, Hasegawa I, Gefter WB. CT and MR in pulmonary embolism: A changing role for nuclear medicine in diagnostic strategy. Semin Nucl Med 2002; 32:183-92. [PMID: 12105799 DOI: 10.1053/snuc.2002.125973] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
The goal of this article is to summarize current data on computed tomography (CT) and magnetic resonance (MR) in the diagnosis of acute pulmonary embolism (PE) in relation to the radionuclide ventilation perfusion scan. It is important for the nuclear medicine, CT, and MR communities to develop a shared approach to this disorder. Triage using chest radiographs appears to be a practical method for enhancing both nuclear medicine and CT/MR performance. The realization that there is no clinically available gold standard for the diagnosis of PE suggests that the imaging community should replace impractical and idealistic discussions with more realistic outcome-oriented approaches. A simplified one-step evaluation of the pulmonary arteries and the lower extremity veins for deep venous thrombus can provide a comprehensive examination for PE. CT is currently a more practical diagnostic tool, whereas MR offers a scientific probe for pulmonary physiology including the regional mapping of ventilation-perfusion relationships. Nuclear medicine, CT, and MR thus form an imaging triad for the diagnosis of acute PE.
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Affiliation(s)
- Hiroto Hatabu
- Department of Radiology, University of Pennsylvania Medical Center, Philadelphia, PA 19104, USA
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Yang DC, Ratani RS, Kalani J, Joyce Chen YW, Huang YF, Magzadeh P, Ilkhanizadeh R. Subcutaneous Whole-Body Radionuclide Venography Using Tc-99m In Vivo Tagged Red Blood Cells. Clin Nucl Med 2001; 26:491-4. [PMID: 11353292 DOI: 10.1097/00003072-200106000-00001] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
PURPOSE The accurate diagnosis of deep vein thrombosis (DVT) is essential to prevent its complications and to initiate appropriate treatment. Doppler ultrasound (DUS), contrast venography, and intravenous radionuclide venography have been used for many years to detect DVT. However, obtaining venous access in the foot for injection of contrast agent can be difficult. METHODS The authors introduce the technique of subcutaneous radionuclide venography using Tc-99m in vivo tagged red blood cells and compare it with DUS, a widely used method. Sixty patients (120 lower extremities) underwent subcutaneous radionuclide venography and DUS. RESULTS The concordance rate was 94% in the femoral veins and 95% in the popliteal veins. Subcutaneous radionuclide venography revealed 10 iliac vein thromboses and 2 inferior vena cava thromboses that were not detected by DUS. CONCLUSIONS Subcutaneous radionuclide venography is a useful alternative method for detecting DVT. It is particularly valuable for evaluating DVT in the iliac veins and in the inferior vena cava.
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Affiliation(s)
- D C Yang
- Department of Radiology, New York Methodist Hospital and Weill Medical College of Cornell University, New York, New York, USA.
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Tanios MA, Simon AR, Hassoun PM. Management of venous thromboembolic disease in the chronically critically ill patient. Clin Chest Med 2001; 22:105-22. [PMID: 11315449 DOI: 10.1016/s0272-5231(05)70028-9] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
Although PE is the most common preventable cause of death among U.S. hospital patients, proper treatment of thromboembolism and adequate prophylaxis in high-risk patients have been shown to be effective in saving lives. Because clinical symptoms and signs of thromboembolic disease are often nonspecific, early diagnosis and treatment rely on the capacity of physicians to adequately identify a patient at risk, choose the appropriate diagnostic modalities in a cost-effective fashion, and promptly initiate treatment. The diagnosis of VTE is particularly challenging in patients who are in the post acute period of a complex medical or surgical illness. Avenues that need to be further explored include various diagnostic tests such as spiral CT, MR imaging, and transesophageal echocardiography, which are less invasive than the present gold standard of pulmonary angiography. Also needed are better clinical data regarding the optimal choice of preventive therapy (e.g., unfragmented heparin or LMWH or mechanical devices) and clinical outcome of such therapy in patients with prolonged illness.
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Affiliation(s)
- M A Tanios
- Department of Medicine, Division of Pulmonary and Critical Care, New England Medical Center, Tufts University School of Medicine, Boston, Massachusetts, USA
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Cham MD, Yankelevitz DF, Shaham D, Shah AA, Sherman L, Lewis A, Rademaker J, Pearson G, Choi J, Wolff W, Prabhu PM, Galanski M, Clark RA, Sostman HD, Henschke CI. Deep venous thrombosis: detection by using indirect CT venography. The Pulmonary Angiography-Indirect CT Venography Cooperative Group. Radiology 2000; 216:744-51. [PMID: 10966705 DOI: 10.1148/radiology.216.3.r00se44744] [Citation(s) in RCA: 196] [Impact Index Per Article: 8.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
PURPOSE To assess the clinical benefits of performing indirect computed tomographic (CT) venography after pulmonary CT angiography to detect deep venous thrombosis (DVT) in patients suspected of having a pulmonary embolism. MATERIALS AND METHODS The authors prospectively enrolled 541 consecutive patients who underwent pulmonary CT angiography for suspected pulmonary embolism at seven institutions. Using a protocol that optimizes venous enhancement without additional contrast material injection, the authors obtained contiguous images from the pelvis to the popliteal fossa. Ultrasonography (US) also was performed in 116 patients. RESULTS DVT was found at indirect CT venography in 45 (8%), and pulmonary embolism was found at pulmonary CT angiography in 91 (17%) of 541 patients. Among the 45 patients with DVT, DVT occurred in 16 patients who had no pulmonary embolism at pulmonary CT angiography, which increased the diagnosis of thromboembolic disease by 18%. Among 116 patients who underwent US and indirect CT venography, 15 had DVT at US, and in all 15, DVT also was seen at indirect CT venography. In four additional cases, DVT was seen at only indirect CT venography. CONCLUSION Among patients suspected to have pulmonary embolism, a substantial number had DVT in the absence of pulmonary embolism. Combined pulmonary CT angiography-indirect CT venography can depict these cases with accuracy comparable to that of US and thus could have a significant effect on patient care.
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Affiliation(s)
- M D Cham
- New York Presbyterian Hospital/Weill Medical College of Cornell University, New York, NY 10021, USA
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Amundsen T, Torheim G, Waage A, Bjermer L, Steen PA, Haraldseth O. Perfusion magnetic resonance imaging of the lung: characterization of pneumonia and chronic obstructive pulmonary disease. A feasibility study. J Magn Reson Imaging 2000; 12:224-31. [PMID: 10931584 DOI: 10.1002/1522-2586(200008)12:2<224::aid-jmri3>3.0.co;2-e] [Citation(s) in RCA: 38] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
Abstract
Perfusion magnetic resonance (MR) imaging is a promising new method for detection of perfusion defects in the diagnosis of pulmonary embolism. In the present study we evaluated the first-pass characteristics of perfusion MR imaging in patients with pneumonia or chronic obstructive pulmonary disease (COPD), frequent differential diagnoses to pulmonary embolism. Dynamic contrast-enhanced MR images of 12 patients with acute pneumonia and 13 patients with exacerbation of COPD were acquired in both the coronal and transaxial planes (an inversion recovery prepared gradient-echo sequence using 0.05 mmol/kg gadodiamide/injection). The MR images and the signal intensity (SI) versus time curves were characterized for each disease entity and compared with normal lung and the findings in pulmonary embolism from our previous study. The perfusion MR images of pneumonia showed distinct regions of increased contrast enhancement; in COPD with signs of emphysema (11 of the 13 COPD patients), the images showed a coarse pattern of reduced contrast enhancement. The SI versus time curves of pneumonia, COPD with signs of emphysema, and normal lung were statistically different, the respective pooled SI values (+/-95% CI) being as follows: mean baseline SI, 20.7 (1.1), 7.4 (0.4), and 8.5 (0.3); mean peak SI, no peak, 12.9 (1.5), and 27 (4.6); and mean max change of SI in percent, 110 (27), 79 (22), and 205 (52). Perfusion MR imaging of pneumonia and COPD with signs of emphysema showed first-pass that were characteristics promising for diagnostic use. Both the MR images and the SI versus time curves were different from the perfusion characteristics in normal lung and pulmonary embolism shown previously.
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Affiliation(s)
- T Amundsen
- Department of Medicine, University Hospital of Trondheim, Norwegian University of Science and Technology.
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Abstract
Recent years have witnessed an explosion in imaging technology applicable to chest medicine. These include CT and magnetic resonance angiography (MRA) for the diagnosis of pulmonary embolism, and high-resolution CT for the detection and characterization of diffuse lung diseases and the quantification of emphysema. Newly developed approaches to pulmonary functional imaging using CT and MRI have been applied to the evaluation of pulmonary ventilation and perfusion and to the detection of small airways disease. Volumetric CT imaging techniques together with advanced image processing have made possible "virtual bronchoscopy." Positron emission tomography provides an important new approach to the accurate detection and staging of chest malignancies and to the evaluation of pulmonary nodules. Finally, new digital imaging techniques, which are rapidly replacing conventional x-ray film, offer the possibility of computer-aided diagnosis.
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Affiliation(s)
- D D Maki
- Department of Radiology, University of Pennsylvania Medical Center, Philadelphia, PA 19104, USA
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