Is bilateral ultrasound scanning of the legs necessary for patients with unilateral symptoms of deep vein thrombosis?

Deep Venous Thrombosis and Ulcers of Lower Limbs: Ultrasound Findings in 156 Patients

Venous ulcers (VUs) of lower limbs affect 1% of Western population. In most cases, ultrasounds show only superficial venous insufficiency (SVI), but a deep venous insufficiency (DVI) may also be present without a history of deep vein thrombosis (DVT). To assess SVI and DVI in DVT-positive and DVT-negative patients with VU, a retrospective cohort of 123 patients entered the study (50 male and 73 female, minimum age 29 years and maximum age 90 years, and mean 70.6 years). In 56 patients (45.5%), ulcer was on the right leg, in 52 (42.3%) on the left leg, and in 15 patients (12.2%), ulcer was bilateral, resulting in a total number of 138 limbs in the study. Sixty-six patients suffered DVT, while in 72 anamnesis was negative. Color duplex ultrasound was performed on both limbs, which revealed insufficiencies of superficial and/or deep veins in 18 limbs which had not been affected by an ulcer or a previous DVT. So the study was on 156 limbs. SVI were substantially overlapping in two groups ( p -value = 0.593), while combined SVI and DVI was 72.5% in DVT positive limbs ( p -value = 0.001). In 70% of cases with a femoral vein insufficiency ( p -value = 0.036) or popliteal vein insufficiency (PVI) ( p -value 0,003), a DVT history was present. Of 18 limbs, although not affected by ulcer or previous DVT, eight were positive for DVI (two femoral veins and six popliteal veins). In the patient with VU, the history of DVT is a strong predictor of DVI insufficiency. In DVT-positive patients with ulcer, the number of "combined superficial and deep insufficiencies" appears to be particularly significant and surgical treatment must take this into account. A previous DVT has a low impact on great and small saphenous insufficiencies in ulcer patients; these were substantially overlapping in DVT-positive and DVT-negative patients. The 18 limbs with DVI and SVI without ulcer and DVT history were unexpected result. We think these patients must have a close follow-up to avoid the onset of a VU.

Deep venous thrombosis in patients with chronic spinal cord injury

CONTEXT/OBJECTIVE

Deep venous thrombosis (DVT) is a well-known complication of an acute spinal cord injury (SCI). However, the prevalence of DVT in patients with chronic SCI has only been reported in a limited number of studies. The aim of our study was to examine the prevalence of DVT in patients with SCI beyond three months after injury.

DESIGN

Cross-sectional study.

SETTING

Rehabilitation Department at the Bydgoszcz University Hospital in Poland.

PARTICIPANTS

Sixty-three patients with SCI that were more than 3 months post injury. The patients, ranging in age from 13 to 65 years, consisted of 15 women and 48 men; the mean age of the patients was 32.1 years. The time from injury varied from 4 to 124 months.

OUTCOME MEASURES

Clinical assessment, D-dimer and venous duplex scan.

RESULTS

The venous duplex scan revealed DVT in 5 of the 63 patients. The post-injury time in four of the patients varied between 4 and 5 months; one patient was 42 months post-injury.

CONCLUSION

DVT occurred in patients with chronic SCI, mainly by the 6th post injury month.

The prevalence of and predictors to indicate bilateral venous duplex ultrasound testing to detect contralateral asymptomatic lower extremity deep venous thrombosis in patients with acute symptomatic lower extremity deep venous thrombosis

OBJECTIVE

The goal of this study was to determine the prevalence of and predictors to indicate bilateral venous duplex ultrasound (DU) to detect contralateral asymptomatic deep venous thrombosis (DVT) in patients with acute symptomatic lower extremity DVT.

METHODS

Venous DU reports along with medical records of the patients were collected from February 2005 to April 2012 in a tertiary university hospital in Botucatu, Brazil. All patients with DVT detected in one lower extremity routinely underwent contralateral limb venous DU examination. Exclusion criteria were previous DVT in the contralateral asymptomatic limb, thrombophlebitis, workup for pulmonary embolism, and bilateral symptomatic lower extremities.

RESULTS

Scans were done in 579 patients to rule out contralateral lower extremity DVT whenever DVT was confirmed in the ipsilateral lower extremity; of these, 108 patients (18.6%) had an abnormal finding on DU examination for DVT in the contralateral limb, which was proximal DVT in 71.5%. Age >60 years (odds ratio [OR], 3.33; 95% confidence interval [CI], 1.447-7.670), malignant disease (OR, 5.21; 95% CI, 1.943-14.015), and the association of trauma plus malignant disease (OR, 7.11; 95% CI, 1.640-30.863) were the main predictors.

CONCLUSIONS

Age >60 years, malignant disease, lower extremity trauma, inpatient status, and recent hospitalization are risk factors associated with a high incidence of asymptomatic contralateral lower extremity DVT in patients with ipsilateral lower extremity DVT. Therefore, we recommend routine performance of a venous DU examination on the contralateral lower extremity whenever these risk factors are present in patients with ipsilateral lower extremity DVT.

Controvérsias no diagnóstico e tratamento da trombose venosa profunda pela ecografia vascular

A trombose venosa profunda é uma entidade clínica potencialmente grave, responsável por elevada morbimortalidade. A ecografia vascular representa o método propedêutico de escolha no diagnóstico e acompanhamento dos pacientes com essa doença. Entretanto, várias questões permanecem controversas, tais como a abordagem inicial do paciente com suspeita de trombose venosa profunda, os tipos de protocolo a serem usados, o tempo para a realização do exame e a trombose no plexo de panturrilha. O objetivo dessa revisão é discutir esses assuntos à luz dos conhecimentos atuais.

Incidence and risk factors for bilateral deep venous thrombosis of the lower limbs

The incidence of bilateral deep venous thrombosis in patients with single limb or bilateral symptoms was determined using duplex scan examination. In a prospective study, 157 inpatients with clinical suspicion of deep venous thrombosis underwent duplex scan evaluation of the lower extremities. Demographic characteristics, physical examination data, and risk factor information were collected. In all, 57 (36.3%) patients evaluated presented echographic evidence of acute deep venous thrombosis. Forty-six individuals presented unilateral thrombosis, and 11 patients presented bilateral disease (19.3% of all thrombosis, 7.0% of all patients). Sensitivity and specificity of clinical examination in identifying bilateral thrombosis was 27.2% and 93.3%, respectively. For the risk factors evaluated, active human immunodeficiency virus disease and iliofemoral thrombosis presented an increased risk for bilateral thrombosis (P = .045 and P = .049, respectively). The high incidence of bilateral deep venous thrombosis justifies bilateral duplex scan examination. Active human immunodeficiency virus disease and proximal thrombosis were risk factors for bilateral disease.

[Modern ultrasound diagnostics of deep vein thrombosis in lung embolism of unknown origin]

PURPOSE

We compared innovative ultrasound techniques such as tissue harmonic imaging (THI) and cross-beam technique with speckle reduction imaging (SRI) to conventional fundamental B scan in the diagnosis of deep vein thrombosis.

MATERIAL AND METHODS

We investigated a total number of 185 patients with clinical symptoms of acute vein thrombosis. We documented the thrombosis in the patients using multifrequency ultrasound probes (5-7 MHz, 6-9 MHz, 9-14 MHz, Logig 9, GE) and recorded ultrasound sequences in fundamental B scan, THI, and cross-beam technique with SRI (grade 2). Three blinded ultrasound investigators ranked the marking of the thrombosis in each of these image modalities and graded them with the numbers 5 = weak, 4 = moderate, 3 = satisfactory, 2 = good, and 1 = excellent. We calculated the median and a t-test for each of these image modalities.

RESULTS

We diagnosed 115 thromboses (62%) in 185 investigated patients. This group could be divided as follows: 11 patients (6%) with three-level thrombosis, 37 patients (20%) with two-level thrombosis, and 67 (36%) with one-level thrombosis. The one-level thrombosis group included five (3%) patients with muscle vein thromboses, seven (4%) cases of thrombophlebitis without involvement of the deep vein system, and three (2%) cases of thrombophlebitis with involvement of the deep vein system. The t-test for unconnected samples showed significant differences (p <0.05) in iliac veins and highly significant differences (p <0.001) in the veins of the lower extremity due to the superior capabilities for detection of thrombosis using the cross-beam technique with SRI compared to THI and the fundamental B scan.

CONCLUSION

The use of high-resolution linear ultrasound probes with the concomitant application of THI and cross-beam technique with SRI facilitates the diagnosis of deep vein thrombosis. The employment of these new ultrasound modalities is an advantage in distinguishing the veins from the surrounding tissue structures and helps in evaluating the compressibility of venous vessels.

Case report: bilateral calf (tibial) deep venous thrombosis following air travel

OBJECTIVES

To describe an interesting case of bilateral calf (tibial) deep venous thrombosis (DVT) in a traveller.

METHODS

Clinical case notes and reports of further investigations were analysed in the light of the existing literature concerning DVT and travellers.

RESULTS

A 56-year-old university lecturer presented within 48 h of a return to New Zealand from international travel abroad. An otherwise fit and healthy man he developed bilateral calf pains most notable on arising the day of presentation, although he reported some mild pain in the lower legs within 5 h of landing at Auckland. He reported no other complaints. Physical examination was unremarkable, except for the bilateral calf tenderness and being overweight. An urgent outpatient ultrasound to both lower limbs was reported as follows: 'There is evidence of extensive thrombus involving the paired posterior tibial veins of both calves'. He was admitted to hospital for 24 h and started on low-molecular weight heparin. On completion of the course of heparin, he was further treated orally with warfarin. A follow-up assessment with a Clinical Haematologist occurred one month after hospitalisation.

CONCLUSIONS

The present case illustrates bilateral calf (tibial) DVT in an otherwise fit male traveller following extensive long haul travel. It also illustrates the need to consider the possible diagnosis and the need for bilateral ultrasound scanning of the legs, particularly in travellers undertaking long haul air travel, who are symptomatic. All travellers undertaking extensive, long-haul air travel need to be warned of the risks of DVT and venous thromboembolism (VTE) and advised of appropriate preventive measures as have been outlined. In addition, all travellers should be aware of the signs and symptoms of DVT/VTE and of the need to seek medical advice should they develop them; in order to help prevent progression of a DVT to a VTE.

Site and clinical outcome of deep vein thrombosis of the lower limbs: an epidemiological study

Clinical outcomes of patients diagnosed with venous thromboembolic disease (VTED) have rarely been assessed on large series of patients from single institutions. This was work based on our practice to routinely screen all suspected pulmonary embolism (PE) and deep venous thrombosis (DVT) patients with bilateral proximal and distal venous US was designed to evaluate survival, recurrence and cancer occurrence in patients diagnosed with symptomatic or asymptomatic DVT and to assess their relationship with the site of the DVT (proximal vs. distal, bilateral vs. unilateral). Our study is based on the cross-matching of the VTED register of the Grenoble University Hospital with the local Cancer Register and community mortality data. Survival analyses were performed with the Kaplan-Meier method; prognostic variables were tested using the log-rank test. A total of 1913 patients with a DVT of the lower limbs from 1993 to 1998 were included (57% women; mean age, 69 years). Of these, 1018 patients were diagnosed with proximal DVT (156 bilateral) and 895 distal DVT (112 bilateral). PE was associated in 760 patients. Patients with PE and no detected DVT were not included. At 2 years, adjusted survival rates were 80% in patients with unilateral-distal DVT, 67% in bilateral-distal, 72% in unilateral-proximal and 65% in bilateral-proximal DVT patients. The cumulated VTED recurrence rates were 7.7% in unilateral-distal DVT, 13.3% when DVT was bilateral-distal, 14% when unilateral-proximal and 13.2% when bilateral-proximal. The rate of new cancer was 6.4% in unilateral-distal DVT, 10.8% when it was bilateral-distal, 6.5% when unilateral-proximal and 6.1% when bilateral-proximal. Based on a large series of unselected patients, our results show that the site of the DVT and principally the bilaterality provides important prognostic information that may be used in the setting up of medical strategies.

Is bilateral duplex scanning necessary in patients with symptoms of deep venous thrombosis?

BACKGROUND

Venous duplex ultrasound scanning (VDUS) has been shown to be an accurate non-invasive means to diagnose symptomatic deep venous thrombosis (DVT). The aim of our study was to determine whether bilateral VDUS is necessary in patients who present with symptoms of DVT.

METHODS

We retrospectively reviewed the results of bilateral lower extremity VDUS performed on 1029 inpatients at Royal Prince Alfred Hospital in the 24 months from 1 January 1998 to 31 December 1999.

RESULTS

Of the 1029 patients, 705 (69%) presented with unilateral symptoms and 324 (31%) with bilateral symptoms. The overall incidence of DVT was 168 (16% of 1029 patients). In 705 patients with unilateral symptoms the diagnosis of DVT was confirmed in 120 (17.0%), of whom 20 (16.7%) had unsuspected bilateral DVT. There were 12 patients (1.7% of the 705 patients) who had DVT in the asymptomatic limb, without DVT identified in the symptomatic limb. Overall there were 32 (5% of 705) patients with unilateral symptoms who had unsuspected DVT in the asymptomatic limb. Of the 20 patients with bilateral DVT, only one patient had more extensive DVT in the asymptomatic limb than in the symptomatic limb, that was therefore likely to alter treatment. Bilateral symptoms of DVT were present in 324 (31.5%) patients, 48 (14.8%) of whom were found to have DVT. Nineteen (39.6%) of these DVTs were bilateral.

CONCLUSION

Overall the diagnostic yield of VDUS was low in this study, with an incidence of 16% of DVT detected in symptomatic patients. Techniques that improve the diagnostic yield of VDUS in symptomatic patients are required. A significant proportion (23%) of the DVT detected in this study were bilateral, and a small but significant proportion (10%) of DVT found in patients presenting with unilateral symptoms were only in the asymptomatic contralateral limb. Our study supports bilateral VDUS in symptomatic inpatients, as the detection of DVT in asymptomatic limbs aids future patient management if symptoms develop in the asymptomatic limb.

Resident-performed compression ultrasonography for the detection of proximal deep vein thrombosis: fast and accurate

OBJECTIVES

To assess whether emergency medicine residents (EMRs) could quickly perform accurate compression ultrasonography (CUS) for the detection of proximal lower extremity deep vein thromboses (PLEDVTs) with minimal training.

METHODS

A prospective, observational study using a convenience sample of patients presenting with signs and/or symptoms for PLEDVT. Vascular laboratory and department of radiology studies were considered the criterion standard. CUS of the femoral vessels was performed. Incompressibility or visualized thrombus was considered "positive."

RESULTS

Eight residents with limited ultrasound (US) experience and no prior experience with deep vein thrombosis (DVT) US volunteered to participate in this study, enrolling 72 patients. Their average scan time was 11.7 minutes (95% CI = 9.4 to 14). There were 23 true positives, 4 false positives, 45 true negatives, and 0 false negatives. The test characteristics for PLEDVT gave a sensitivity of 100% (95% CI = 82.2 to 100) and a specificity of 91.8% (95% CI = 79.5 to 97.4).

CONCLUSION

Emergency medicine residents with limited US experience were able to quickly perform CUS after minimal training for the detection of PLEDVT in a select group of patients.

Deep venous thrombosis caused by congenital absence of inferior vena cava, combined with hyperhomocysteinemia

We present a case of suprarenal and infrarenal absence of the inferior vena cava, combined with hyperhomocysteinemia in a 39-year-old woman who presented with symptoms of deep venous thrombosis. The patient also had a homozygous mutation of C677T methylenetetrahydrofolate reductase. Deep vein thrombosis has a multifactorial etiology involving both genetic and acquired factors. Absence of the inferior vena cava is a rare congenital anomaly, but recently it was confirmed as an important risk factor for the development of deep vein thrombosis, especially in young persons. Hypercoagulability due to hyperhomocysteinemia with a tendency toward venous stasis, mediated by congenital absence of the inferior vena cava is thought to have caused deep vein thrombosis in our patient. To our knowledge, this association has not yet been reported. The clinical features and prognosis of the entity are discussed.