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Bedside Ultrasonography, Deep Vein Thrombosis

Author: Lars Grimm, MD, Yale University Medical School
Coauthor(s): William C Manson, MD, Associate Director of Emergency Ultrasound, Department of Emergency Medicine, Emory University School of Medicine
Contributor Information and Disclosures

Updated: Jul 28, 2009

Introduction

Venous thrombosis is a major cause of morbidity and mortality in the United States and a frequent cause of presentation in many emergency departments (EDs). The sequelae of deep vein thromboses (DVTs) range from the more common chronic venous stasis to the most serious pulmonary emboli (PEs).1 PEs have been described as one of the most common preventable causes of death, and approximately two thirds of PEs are estimated to originate in the lower extremities as DVTs. The rate of propagation from DVT to PE is estimated to range from 10-50%.2,3,4 Treatments with anticoagulation or Greenfield filter placement are extremely effective if used early, thus underscoring the need for rapid diagnosis.

Compression ultrasonography has proven to be a highly sensitive and specific modality for the recognition of lower extremity DVTs without the need for radiation or contrast exposure.5,6 Traditional lower extremity studies interrogate and review the entire lower extremity vasculature, are performed by an ultrasound technologist, and are read by a radiologist.7,8 These factors are not always available and have been shown to delay the time to diagnosis and potential treatment of a DVT by up to 2 hours.9,10

EDs now use a modified 2-point compression technique that focuses on the highest probability areas, decreases the study time to less than 5 minutes, and provides similar sensitivity and specificity.11,12 In patients with a clinically suspected DVT, a negative compression ultrasound may safely delay the need for anticoagulation therapy.13 The 2-point DVT compression examination has been assessed in multiple randomized controlled studies and is well accepted when used properly with pretest probability assessments.11,14,15

The safety, ease of use, rapid time to diagnosis, low cost, and accessibility make bedside ultrasonography for DVT especially useful for emergency and critical care clinicians.

Indications

Patients who have risk factors for deep vein thrombosis (DVT) or pulmonary embolism (PE), and in whom clinician suspect DVT or PE, should have workups that include, but are not necessarily limited to, bedside compression ultrasonography.

Contraindications

  • Absolute contraindications: No absolute contraindications exist.
  • Relative contraindications: If the clinical suspicion and pretest probability for a pulmonary embolism (PE) are high enough that a spiral CT with intravenous contrast or V/Q (ventilation/perfusion) scan is warranted, then ultrasonography should not delay such studies or any further treatment goals.

More on Bedside Ultrasonography, Deep Vein Thrombosis

Overview: Bedside Ultrasonography, Deep Vein Thrombosis
Treatment & Medication: Bedside Ultrasonography, Deep Vein Thrombosis
Multimedia: Bedside Ultrasonography, Deep Vein Thrombosis
References
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References

  1. Lund F, Diener L, Ericsson JL. Postmortem intraosseous phlebography as an aid in studies of venous thromboembolism. With application on a geriatric clientele. Angiology. Mar 1969;20(3):155-76. [Medline].

  2. Anderson FA Jr, Wheeler HB, Goldberg RJ, Hosmer DW, Patwardhan NA, Jovanovic B. A population-based perspective of the hospital incidence and case-fatality rates of deep vein thrombosis and pulmonary embolism. The Worcester DVT Study. Arch Intern Med. May 1991;151(5):933-8. [Medline].

  3. Gillum RF. Pulmonary embolism and thrombophlebitis in the United States, 1970-1985. Am Heart J. Nov 1987;114(5):1262-4. [Medline].

  4. Yamaki T, Nozaki M, Sakurai H, Takeuchi M, Soejima K, Kono T. Presence of lower limb deep vein thrombosis and prognosis in patients with symptomatic pulmonary embolism: preliminary report. Eur J Vasc Endovasc Surg. Feb 2009;37(2):225-31. [Medline].

  5. Lensing AW, Prandoni P, Brandjes D, Huisman PM, Vigo M, Tomasella G. Detection of deep-vein thrombosis by real-time B-mode ultrasonography. N Engl J Med. Feb 9 1989;320(6):342-5. [Medline].

  6. Heijboer H, Buller HR, Lensing AW, Turpie AG, Colly LP, ten Cate JW. A comparison of real-time compression ultrasonography with impedance plethysmography for the diagnosis of deep-vein thrombosis in symptomatic outpatients. N Engl J Med. Nov 4 1993;329(19):1365-9. [Medline].

  7. Seidel AC, Cavalheri G Jr, Miranda F Jr. The role of duplex ultrasonography in the diagnosis of lower-extremity deep vein thrombosis in non-hospitalized patients. Int Angiol. Oct 2008;27(5):377-84. [Medline].

  8. de Oliveira A, Franca GJ, Vidal EA, Stalke PS, Baroncini LA. Duplex scan in patients with clinical suspicion of deep venous thrombosis. Cardiovasc Ultrasound. Oct 20 2008;6:53. [Medline].

  9. Frederick MG, Hertzberg BS, Kliewer MA, Paulson EK, Bowie JD, Lalouche KJ. Can the US examination for lower extremity deep venous thrombosis be abbreviated? A prospective study of 755 examinations. Radiology. Apr 1996;199(1):45-7. [Medline].

  10. Theodoro D, Blaivas M, Duggal S, Snyder G, Lucas M. Real-time B-mode ultrasound in the ED saves time in the diagnosis of deep vein thrombosis (DVT). Am J Emerg Med. May 2004;22(3):197-200. [Medline].

  11. Blaivas M, Lambert MJ, Harwood RA, Wood JP, Konicki J. Lower-extremity Doppler for deep venous thrombosis--can emergency physicians be accurate and fast?. Acad Emerg Med. Feb 2000;7(2):120-6. [Medline].

  12. Nunn KP, Thompson PK. Towards evidence based emergency medicine: best BETs from the Manchester Royal Infirmary. Using the ultrasound compression test for deep vein thrombosis will not precipitate a thromboembolic event. Emerg Med J. Jul 2007;24(7):494-5. [Medline].

  13. Cogo A, Lensing AW, Koopman MM, Piovella F, Siragusa S, Wells PS. Compression ultrasonography for diagnostic management of patients with clinically suspected deep vein thrombosis: prospective cohort study. BMJ. Jan 3 1998;316(7124):17-20. [Medline].

  14. Frazee BW, Snoey ER, Levitt MA, Wilbur LC. Negative emergency department compression ultrasound reliably excludes proximal deep vein thrombosis. Acad Emerg Med. 1998;5:406-7.

  15. [Best Evidence] Bernardi E, Camporese G, Büller HR, Siragusa S, Imberti D, Berchio A, et al. Serial 2-point ultrasonography plus D-dimer vs whole-leg color-coded Doppler ultrasonography for diagnosing suspected symptomatic deep vein thrombosis: a randomized controlled trial. JAMA. Oct 8 2008;300(14):1653-9. [Medline].

  16. Useche JN, de Castro AM, Galvis GE, Mantilla RA, Ariza A. Use of US in the evaluation of patients with symptoms of deep venous thrombosis of the lower extremities. Radiographics. Oct 2008;28(6):1785-97. [Medline].

  17. Dona E, Fletcher JP, Hughes TM, Saker K, Batiste P, Ramanathan I. Duplicated popliteal and superficial femoral veins: incidence and potential significance. Aust N Z J Surg. Jun 2000;70(6):438-40. [Medline].

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Further Reading

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Keywords

DVT, deep vein thrombosis, emergency ultrasound, emergency medicine, US, ultrasound examination, ultrasound exam, DVT exam, DVT examination, DVT ultrasound, deep vein thrombi, venous thromboembolism, deep venous thrombosis, blood clot, thrombus, U/S, ultrasound, lower extremity ultrasound, Doppler, PE, pulmonary embolism, pulmonary emboli

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Contributor Information and Disclosures

Author

Lars Grimm, MD, Yale University Medical School
Disclosure: Nothing to disclose.

Coauthor(s)

William C Manson, MD, Associate Director of Emergency Ultrasound, Department of Emergency Medicine, Emory University School of Medicine
William C Manson, MD is a member of the following medical societies: American College of Emergency Physicians, American Institute of Ultrasound in Medicine, Emergency Medicine Residents Association, and Society for Academic Emergency Medicine
Disclosure: The Emergency Ultrasound Course Honoraria Speaking and teaching

Medical Editor

James Quan-Yu Hwang, MD, Attending Physician, Department of Emergency Medicine, Brigham & Women's Hospital; Clinical Instructor, Harvard Medical School
James Quan-Yu Hwang, MD is a member of the following medical societies: American Academy of Emergency Medicine, American College of Emergency Physicians, and American Institute of Ultrasound in Medicine
Disclosure: 3rd Rock Ultrasound, LLC Salary Speaking and teaching; Schlesinger Associates Consulting fee Consulting

Pharmacy Editor

Mary L Windle, PharmD, Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy, Pharmacy Editor, eMedicine
Disclosure: Pfizer Inc Stock Investment from financial planner; Avanir Pharma Stock Investment from financial planner ; WebMD Salary and stock Employment and investment from financial planner

Chief Editor

Rick Kulkarni, MD, Medical Director, Assistant Professor of Surgery, Section of Emergency Medicine, Yale-New Haven Hospital
Rick Kulkarni, MD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Emergency Medicine, American College of Emergency Physicians, American Medical Association, American Medical Informatics Association, Phi Beta Kappa, and Society for Academic Emergency Medicine
Disclosure: WebMD Salary Employment

 
 
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