Clinical Role of the “Venous” Ultrasound to Identify Lower Extremity Pathology

Popliteal cysts are not a risk factor for lower extremity deep vein thrombosis

BACKGROUND

Popliteal cysts (PC) result from distension of the gastrocnemio-semimembranosous bursa. Published reports indicate coincident PC and deep vein thrombosis (DVT). Whether the presence of PC increase the risk of deep vein thrombosis (DVT) remains unclear.

METHODS

Lower extremity venous Duplex ultrasound (DUS) reports were evaluated across the Mayo Clinic Enterprise (Rochester, Minnesota, Jacksonville, Florida, Scottsdale, Arizona, and the Mayo Clinic Health System) in patients ≥ 18 years of age. Natural language processing (NLP) algorithms were created and validated to identify acute lower extremity DVT and PC from these reports. To determine whether there is a link between PC and lower extremity DVT, the frequency of PC among cases (ultrasounds with acute DVT) were compared to controls (ultrasounds without acute DVT).

RESULTS

A total of 357,703 lower extremities venous DUS were performed in 237,052 patients (mean age 63.3 ± 16.6, 54.4% were female) between 1992 and 2021. Acute DVT was identified in 32,572 (9.1%) DUS, and PC in 32,448 (9.1%). PC were seen in a lower frequency (8.0%) of ultrasounds with acute DVT than those without (9.2%) acute DVT (OR: 0.85, 95% CI: 0.82 to 0.89, p < 0.001). In a multivariate logistic regression model after adjusting for age, sex, and race, PCs were not positively associated with acute DVT (adjusted OR: 0.84, 95% CI: 0.81 to 0.88).

CONCLUSIONS

PC are an incidental finding or an alternative diagnosis on lower extremity venous DUS, a finding that increases significantly with age. PC were not a risk factor in the development of lower extremity DVT.

Prevalence and associations of incidental nonvenous duplex findings discovered during lower extremity venous imaging

OBJECTIVE

Venous duplex imaging defines venous pathology (VP). Unexpected clinically relevant findings are also found but rarely mentioned in the literature. This study aims to define the prevalence of ancillary findings (nonvenous duplex) by study type and venous outcome and subgroup associations with primary study indication and risk factors.

METHODS

Our vascular laboratory database was queried for lower extremity venous duplex studies with comments regarding ancillary findings and associated patient demographics, primary study indication, associated conditions, and venous study outcome.

RESULTS

There were 52,215 venous studies performed, 48,425 to evaluate for venous occlusion (acute/chronic) and 3790 for venous reflux. Of these studies, 15,810 found VP and 36,405 found no venous disease. There were 875 studies with venous disease that had ancillary duplex findings (5.5%) noted as 559 (3.5%) with prominent lymph node(s) (LN), 179 (1.1%) Baker's cyst (BC), 44 (0.3%) hematoma/mass (HM), 31 (0.2%) arterial aneurysm, and 16 (0.1%) arterial occlusion. There were 3130 studies free of VP with ancillary findings (8.6%) noted as 2258 (6.2%) prominent LN(s), 626 (1.7%) BC, 156 (0.4%) HM, 37 (0.1%) arterial aneurysm, and 22 (0.06%) arterial occlusion. The overall prevalence of ancillary findings was 8.62%. Analysis demonstrated statistically more ancillary findings in venous occlusion (odds ratio [OR], 1.25) studies, which was the largest group at 13 to 1. Studies free of venous disease had more ancillary findings (P < .001) with an OR of 1.88 and similar results were noted for LN(s), BC, and hematoma. Studies with VP favored a finding of aneurysm (OR, 0.52). Subgroup analyses demonstrated that those with prominent LN(s) were statistically older and male and BC statistically older in those with coexistent venous disease. BC subgroup analysis showed that studies free of venous disease were 2.5 times more likely to report pain as the primary study indication (P < .0001). In general, within ancillary subgroups, leg symptoms were statistically more prominent on the side with ancillary pathology and free of venous disease.

CONCLUSIONS

Ancillary findings are not uncommon and are more common in studies found free of VP. The most common are LNs, BC and HM and, within subgroups, significant leg symptoms favors the presence of ancillary findings without coexisting venous disease. Ancillary findings should be an integral part of a quality report.

Extended-Duration Treatment of Superficial Vein Thrombosis of the Lower Limbs with Tinzaparin

PURPOSE

To identify risk factors for recurrent thromboembolic events (RTEs) and define the optimum duration of treatment with tinzaparin in patients with superficial vein thrombosis (SVT) of the lower limbs.

MATERIALS AND METHODS

A total of 147 consecutive patients with significant SVT were treated with subcutaneously administered tinzaparin. The composite primary endpoint of the study was RTE, deep-vein thrombosis (DVT) and/or pulmonary embolism (PE) at 120 days. Patients were stratified into group A, where patients received a variable dose of tinzaparin for up to 60 days (n=98), and a subsequent group B-ext, where patients received a standardized intermediate dose of tinzaparin (n=49) for 90 days.

RESULTS

RTEs occurred in 15/147 patients (10.2%), including recurrent SVT (n=10), DVT (n=4) and fatal PE (n=1). RTEs were less frequent in group B-ext (0% vs. 15.3% for group A, P=0.004), a difference that remained significant at the one-year follow-up. Clinically extensive SVT was an independent predictor for RTEs (hazard ratio, 5.94; 95% confidence interval, 2.05-17.23; P=0.001, Cox regression). Predictors or DVT or PE in group A included clinically extensive SVT (P=0.004), absence of local pain (P=0.023) and the ultrasound findings of superficial axial vein thrombosis (any, P=0.006 or isolated, P=0.036) and multiple thrombosed superficial venous sites (P<0.001).

CONCLUSION

An extended three-month regimen of tinzaparin in patients with SVT of the lower limbs is more effective than a shorter course and may be desirable in patients with risk factors.