Sections

DDx

Diagnostic Considerations

Of patients evaluated for deep venous thrombosis (DVT) of the lower extremity, only a quarter of them have the disease. DVT is characterized by pain and swelling of the limb, which are not specific. Numerous patients with DVT are asymptomatic.

Severe venous congestion produces a clinical appearance that can be indistinguishable from the appearance of cellulitis. Patients with a warm, swollen, tender leg should be evaluated for both cellulitis and DVT because patients with primary DVT often develop a secondary cellulitis, while patients with primary cellulitis often develop a secondary DVT. Superficial thrombophlebitis, likewise, is often associated with a clinically inapparent underlying DVT.

Other problems to be considered include the following:

Achilles tendonitis
Arthritis
Muscle strain or tear
Hematoma
Soft-tissue injury
Stress fracture
Pain
Swelling in a paralyzed limb
Arterial insufficiency
Peripheral occlusive disease
Thromboembolism
Superficial thrombophlebitis
Postphlebitic syndrome
Varicose veins
Dependent edema
Hepatic disease
Renal failure
Nephritic syndrome
Lymphedema

Differential Diagnoses

Workup

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Media Gallery

Deep Venous Thrombosis (DVT). This longitudinal ultrasonographic image reveals a partially recanalized thrombus in the femoral vein at the mid thigh.
Deep Venous Thrombosis (DVT). Note the principal deep veins of the lower extremity.
Deep Venous Thrombosis (DVT). This image demonstrates postphlebitic chronic venous insufficiency with ulceration.
Deep Venous Thrombosis (DVT). This image depicts lipodermatosclerosis caused by DVT.
Deep Venous Thrombosis (DVT). There is a substantial mortality benefit for fibrinolytic therapy compared to anticoagulation in patients with right ventricular strain from pulmonary embolism (Konstantinides, 1997).
Deep Venous Thrombosis (DVT). These sequential images demonstrate treatment of iliofemoral DVT due to May-Thurner (Cockett) syndrome. Far left: View of the entire pelvis reveals iliac occlusion. Middle left: After 12 hours of catheter-directed thrombolysis, an obstruction at the left common iliac vein is evident. Middle right: After 24 hours of thrombolysis, a bandlike obstruction is seen; this is the impression made by the overlying right common iliac artery. Far right: After stent placement, the image shows wide patency and rapid flow through the previously obstructed region. Note that the patient is in the prone position in all views. (Right and left are reversed.)
Deep Venous Thrombosis (DVT). This lower-extremity venogram shows outlining of an DVT in the popliteal vein with contrast enhancement.
Deep Venous Thrombosis (DVT). The lower-extremity venogram reveals a nonocclusive chronic thrombus. The superficial femoral vein (lateral vein) has the appearance of two parallel veins, when in fact it is one lumen containing a chronic linear thrombus. Although the chronic clot is not obstructive after it recanalizes, it effectively causes the venous valves to adhere in an open position, predisposing the patient to reflux in the involved segment.
Deep Venous Thrombosis (DVT). Two views of a commercially available thrombectomy device are shown. The Helix Clot Buster works by creating a vortex with a spinning self-contained propeller that macerates the clot. No thrombolytic agent (ie, tissue plasminogen activator) is necessary when this device is used, but adjunct thrombolytic medications can be useful. Competing devices are available from other manufacturers.
Deep Venous Thrombosis (DVT). Popliteal vein thrombosis with normal compression of the common femoral vein is demonstrated. Image courtesy of Very Special Images with permission from Dr Lennard A Nadalo.
Deep Venous Thrombosis (DVT). Bilateral popliteal vein thrombosis with normal compression of the superficial femoral vein is shown. Image courtesy of Very Special Images with permission from Dr Lennard A Nadalo.
Deep Venous Thrombosis (DVT). Popliteal vein thrombosis is depicted by a Duplex sonogram showing absent flow. Image courtesy of Very Special Images with permission from Dr Lennard A Nadalo.
Deep Venous Thrombosis (DVT). Popliteal vein thrombosis is demonstrated by gray-scale images showing compression failure. Image courtesy of Very Special Images with permission from Dr Lennard A Nadalo.
Deep Venous Thrombosis (DVT). This contrast-enhanced study was obtained through a Mediport placed through the chest wall through the internal jugular vein to facilitate chemotherapy. A thrombus has propagated peripherally from the tip of the catheter in the superior vena cava into both subclavian veins.
Deep Venous Thrombosis (DVT). Superior vena cava syndrome is noted in a patient with lung cancer. The computed tomography scan demonstrates a hypoattenuating thrombus that fills the superior vena cava. The patient was treated with anticoagulation alone.
Deep Venous Thrombosis (DVT). The image shows venous thrombi.
Deep Venous Thrombosis (DVT). A pulmonary embolus is shown.
Deep Venous Thrombosis (DVT). The coagulation pathway is shown.
Deep Venous Thrombosis (DVT). This chart shows postoperative antithrombin III levels.
Deep Venous Thrombosis (DVT). This chart depicts perioperative antithrombin III levels and DVT formation.
Deep Venous Thrombosis (DVT). Lung scans are shown. LPO = left posterior oblique.
Deep Venous Thrombosis (DVT). Spiral computed tomography scan showing a pulmonary thrombus.
Deep Venous Thrombosis (DVT). This is the appearance of a normal pulmonary angiogram.
Deep Venous Thrombosis (DVT). This is a positive pulmonary angiogram.
Deep Venous Thrombosis (DVT). The time course of DVT risk is shown in patients not undergoing treatment for total hip replacement (THR).
Deep Venous Thrombosis (DVT). The computed tomography venogram shows bilateral deep venous thrombosis (arrows).
Deep Venous Thrombosis (DVT). The high-probability perfusion lung scan shows segmental perfusion defects in the right upper lobe and subsegmental perfusion defects in right lower lobe, left upper lobe, and left lower lobe.
Deep Venous Thrombosis (DVT). A normal ventilation scan will make the defects noted in the previous image a mismatch and, hence, a high-probability ventilation-perfusion scan.
Deep Venous Thrombosis (DVT). Anterior views of perfusion and ventilation scans are shown. A perfusion defect is present in the left lower lobe, but perfusion to this lobe is intact, making this a high-probability scan.
Deep Venous Thrombosis (DVT). A segmental ventilation perfusion mismatch is evident in a left anterior oblique projection.
Deep Venous Thrombosis (DVT). This sequence of colored digitized pulmonary angiograms (x-ray) in the front view of the pulmonary arteries in a 43-year-old male patient after a heart attack (cardiac arrest) reveals the presence of a pulmonary embolism with a massive thrombus (clot, dark) in the right and left pulmonary arteries. An outline of the lungs are seen. Image courtesy of Science Source/Zephyr.
Deep Venous Thrombosis (DVT). Hematoxylin and eosin stain. This is a low-power view of a thrombus composed of platelets, fibrin, and leukocytes.

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Author

Kaushal (Kevin) Patel, MD Vascular Surgeon, Kaiser Permanente Los Angeles Medical Center

Disclosure: Nothing to disclose.

Coauthor(s)

Linda Jun Chun, MD Vascular and Endovascular Surgeon, Kaiser Permanente, Los Angeles Medical Center

Disclosure: Nothing to disclose.

Chief Editor

Barry E Brenner, MD, PhD, FACEP Program Director, Emergency Medicine, Einstein Medical Center Montgomery

Barry E Brenner, MD, PhD, FACEP is a member of the following medical societies: Alpha Omega Alpha, American Academy of Emergency Medicine, American College of Chest Physicians, American College of Emergency Physicians, American College of Physicians, American Heart Association, American Thoracic Society, New York Academy of Medicine, New York Academy of Sciences, Society for Academic Emergency Medicine

Disclosure: Nothing to disclose.

Additional Contributors

Jason S Chang, MD Clinical Instructor, Department of Emergency Medicine, University of Pittsburgh Medical Center

Jason S Chang, MD is a member of the following medical societies: American College of Emergency Physicians, American Medical Association, Society for Academic Emergency Medicine, Emergency Medicine Residents' Association

Disclosure: Nothing to disclose.

Acknowledgements

Marc D Basson, MD, PhD, MBA, FACS Professor, Chair, Department of Surgery, Assistant Dean for Faculty Development in Research, Michigan State University College of Human Medicine

Marc D Basson, MD, PhD, MBA, FACS is a member of the following medical societies: Alpha Omega Alpha, American College of Surgeons, American Gastroenterological Association, Phi Beta Kappa, and Sigma Xi

Disclosure: Nothing to disclose.

John J Borsa, MD Consulting Staff, Department of Radiology, St Joseph Medical Center

John J Borsa, MD is a member of the following medical societies: American College of Radiology, American Society of Neuroradiology, Cardiovascular and Interventional Radiological Society of Europe, Radiological Society of North America, Royal College of Physicians and Surgeons of Canada, and Society of Interventional Radiology

Disclosure: Nothing to disclose.

Hearns W Charles, MD Assistant Professor of Radiology, New York University School of Medicine; Attending Physician, Division of Vascular and Interventional Radiology, Department of Radiology, New York University Medical Center

Hearns W Charles, MD is a member of the following medical societies: American College of Radiology, American Roentgen Ray Society, Radiological Society of North America, and Society of Cardiovascular and Interventional Radiology

Disclosure: Nothing to disclose.

Kyung J Cho, MD, FACR William Martel Professor of Radiology, Interventional Radiology Fellowship Director, University of Michigan Health System

Kyung J Cho, MD, FACR is a member of the following medical societies: American College of Radiology, American Heart Association, American Medical Association, American Roentgen Ray Society, Association of University Radiologists, and Radiological Society of North America

Disclosure: Nothing to disclose.

Douglas M Coldwell, MD, PhD Professor of Radiology, Director, Division of Vascular and Interventional Radiology, University of Louisville School of Medicine

Douglas M Coldwell, MD, PhD is a member of the following medical societies: American Association for Cancer Research, American College of Radiology, American Heart Association, American Physical Society, American Roentgen Ray Society, Society of Cardiovascular and Interventional Radiology, Southwest Oncology Group, and Special Operations Medical Association

Disclosure: Sirtex, Inc. Consulting fee Speaking and teaching; DFINE, Inc. Honoraria Consulting

Francis Counselman, MD, FACEP Chair, Professor, Department of Emergency Medicine, Eastern Virginia Medical School

Francis Counselman, MD, FACEP is a member of the following medical societies: Alpha Omega Alpha, American College of Emergency Physicians, Association of Academic Chairs of Emergency Medicine (AACEM), Norfolk Academy of Medicine, and Society for Academic Emergency Medicine

Disclosure: Nothing to disclose.

Paul E Di Cesare, MD, FACS Professor and Chair, Department of Orthopedic Sugery, University of California, Davis, School of Medicine

Paul E Di Cesare, MD, FACS is a member of the following medical societies: American Academy of Orthopaedic Surgeons, American College of Surgeons, and Sigma Xi

Disclosure: Stryker Consulting fee Consulting

Robert S Ennis, MD, FACS Associate Professor, Department of Orthopedic Surgery, University of Miami School of Medicine; President, OrthoMed Consulting Services, Inc

Robert S Ennis, MD, FACS is a member of the following medical societies: American Academy of Orthopaedic Surgeons, American College of Surgeons, and Florida Orthopaedic Society

Disclosure: Nothing to disclose.

Craig F Feied, MD, FACEP, FAAEM, FACPh Professor of Emergency Medicine, Georgetown University School of Medicine; General Manager, Microsoft Enterprise Health Solutions Group

Disclosure: Nothing to disclose.

Luis G Fernandez, MD, KHS, FACS, FASAS, FCCP, FCCM, FICS Assistant Clinical Professor of Surgery and Family Practice, University of Texas Health Science Center; Adjunct Clinical Professor of Medicine and Nursing, University of Texas, Arlington; Chairman, Division of Trauma Surgery and Surgical Critical Care, Chief of Trauma Surgical Critical Care Unit, Trinity Mother Francis Health System; Brigadier General, Texas Medical Rangers, TXSG/MB

Luis G Fernandez, MD, KHS, FACS, FASAS, FCCP, FCCM, FICS is a member of the following medical societies: American Association for the Surgery of Trauma, American College of Chest Physicians, American College of Legal Medicine, American College of Surgeons, American Society of Abdominal Surgeons, American Society of General Surgeons, American Society of General Surgeons, American Society of Law, Medicine & Ethics, American Trauma Society, Association for SurgicalEducation, Association of Military Surgeons of the US, Chicago Medical Society, Illinois State Medical Society, International College of Surgeons, New York Academy of Sciences, Pan American Trauma Society, Society of Critical Care Medicine, Society of Laparoendoscopic Surgeons, Southeastern Surgical Congress, Texas Medical Association, and Undersea and Hyperbaric Medical Society

Disclosure: Nothing to disclose.

Douglas M Geehan, MD Associate Professor, Department of Surgery, University of Missouri at Kansas City

Douglas M Geehan, MD is a member of the following medical societies: American College of Surgeons, American Institute of Ultrasound in Medicine, American Medical Association, Association for Academic Surgery, Phi Beta Kappa, Society of American Gastrointestinal and Endoscopic Surgeons, and Society of Critical Care Medicine

Disclosure: Nothing to disclose.

John Geibel, MD, DSc, MA Vice Chair and Professor, Department of Surgery, Section of Gastrointestinal Medicine, and Department of Cellular and Molecular Physiology, Yale University School of Medicine; Director, Surgical Research, Department of Surgery, Yale-New Haven Hospital

John Geibel, MD, DSc, MA is a member of the following medical societies: American Gastroenterological Association, American Physiological Society, American Society of Nephrology, Association for Academic Surgery, International Society of Nephrology, New York Academy of Sciences, and Society for Surgery of the Alimentary Tract

Disclosure: AMGEN Royalty Consulting; ARdelyx Ownership interest Board membership

Harris Gellman, MD Consulting Surgeon, Broward Hand Center; Voluntary Clinical Professor of Orthopedic Surgery and Plastic Surgery, Departments of Orthopedic Surgery and Surgery, University of Miami, Leonard M Miller School of Medicine

Harris Gellman, MD is a member of the following medical societies: American Academy of Medical Acupuncture, American Academy of Orthopaedic Surgeons, American Orthopaedic Association, American Society for Surgery of the Hand, and Arkansas Medical Society

Disclosure: Nothing to disclose.

Craig Greben, MD Assistant Professor of Radiology, Hofstra University School of Medicine; Chief, Division of Vascular and Interventional Radiology, North Shore University Hospital

Craig Greben, MD is a member of the following medical societies: Society of Cardiovascular and Interventional Radiology

Disclosure: Nothing to disclose.

Lars Grimm, MD, MHS House Staff, Department of Diagnostic Radiology, Duke University Medical Center

Disclosure: Nothing to disclose.

Michael A Grosso, MD Consulting Staff, Department of Cardiothoracic Surgery, St Francis Hospital

Michael A Grosso, MD is a member of the following medical societies: American College of Surgeons, Society of Thoracic Surgeons, and Society of University Surgeons

Disclosure: Nothing to disclose.

George Hartnell, MBChB Professor of Radiology, Tufts University School of Medicine; Director of Cardiovascular and Interventional Radiology, Department of Radiology, Baystate Medical Center

George Hartnell, MBChB is a member of the following medical societies: American College of Cardiology, American College of Radiology, American Heart Association, Association of University Radiologists, British Institute of Radiology, British Medical Association, Massachusetts Medical Society, Radiological Society of North America, Royal College of Physicians, Royal College of Radiologists, andSociety of Cardiovascular and Interventional Radiology

Disclosure: Nothing to disclose.

Eric K Hoffer, MD Director, Vascular and Interventional Radiology, Associate Professor of Radiology, Section of Angiography and Interventional Radiology, Dartmouth-Hitchcock Medical Center

Eric K Hoffer, MD is a member of the following medical societies: American Heart Association, Radiological Society of North America, Society for Cardiac Angiography and Interventions, and Society of Interventional Radiology

Disclosure: Nothing to disclose.

James Quan-Yu Hwang, MD, RDMS, RDCS, FACEP Staff Physician, Emergency Department, Kaiser Permanente

James Quan-Yu Hwang, MD, RDMS, RDCS, FACEP is a member of the following medical societies: American Academy of Emergency Medicine, American College of Emergency Physicians, American Institute of Ultrasound in Medicine, and Society for Academic Emergency Medicine

Disclosure: 3rd Rock Ultrasound, LLC Salary Speaking and teaching; Schlesinger Associates Consulting fee Consulting; Philips Ultrasound Consulting fee Consulting

Bartholomew Kwan, MBBS, FRCPC, FRCR Staff Radiologist, Department of Medical Imaging, WOHC Brampton Civic Hospital

Bartholomew Kwan, MBBS, FRCPC, FRCR is a member of the following medical societies: American Roentgen Ray Society, Cardiovascular and Interventional Radiological Society of Europe, Radiological Society of North America, Royal College of Physicians and Surgeons of Canada, Royal College of Radiologists, and Society of Interventional Radiology

Disclosure: Nothing to disclose.

William C Manson, MD 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

Girish R Mood, MBBS, MD, MRCS Fellow, Department of Vascular Medicine, Cleveland Clinic Foundation

Disclosure: Nothing to disclose.

James Naidich, MD Residency Director, North Shore University Hospital; Professor, Department of Radiology, New York University School of Medicine

Disclosure: Nothing to disclose.

Jason J Naidich, MD Assistant Professor of Radiology, New York University School of Medicine; Attending Physician, Division of Vascular and Interventional Radiology, North Shore University Hospital

Disclosure: Nothing to disclose.

Vincent Lopez Rowe, MD Associate Professor of Surgery, Department of Surgery, Division of Vascular Surgery, University of Southern California Medical Center

Vincent Lopez Rowe, MD is a member of the following medical societies: American College of Surgeons, American Heart Association, Pacific Coast Surgical Association, Peripheral Vascular Surgery Society, Society for Clinical Vascular Surgery, Society for Vascular Surgery, and Western Vascular Surgical Society

Disclosure: Nothing to disclose.

Miguel A Schmitz, MD Consulting Surgeon, Department of Orthopedics, Klamath Orthopedic and Sports Medicine Clinic

Miguel A Schmitz, MD is a member of the following medical societies: American Academy of Orthopaedic Surgeons, American Orthopaedic Society for Sports Medicine, Arthroscopy Association of North America, and North American Spine Society

Disclosure: Nothing to disclose.

Donald Schreiber, MD, CM Associate Professor of Surgery (Emergency Medicine), Stanford University School of Medicine

Donald Schreiber, MD, CM is a member of the following medical societies: American College of Emergency Physicians

Disclosure: Abbott Point of Care Inc Research Grant and Speakers Bureau Speaking and teaching; Nanosphere Inc Grant/research funds Research; Singulex Inc Grant/research funds Research; Abbott Diagnostics Inc Grant/research funds None

William A Schwer, MD Professor, Department of Family Medicine, Rush Medical College; Chairman, Department of Family Medicine, Rush-Presbyterian-St Luke's Medical Center

William A Schwer, MD is a member of the following medical societies: American Academy of Family Physicians

Disclosure: Nothing to disclose.

Gary Setnik, MD Chair, Department of Emergency Medicine, Mount Auburn Hospital; Assistant Professor, Division of Emergency Medicine, Harvard Medical School

Gary Setnik, MD is a member of the following medical societies: American College of Emergency Physicians, National Association of EMS Physicians, and Society for Academic Emergency Medicine

Disclosure: SironaHealth Salary Management position; South Middlesex EMS Consortium Salary Management position; ProceduresConsult.com Royalty Other

Gary P Siskin, MD Professor and Chairman, Department of Radiology, Albany Medical College

Gary P Siskin, MD is a member of the following medical societies: American College of Radiology, Cardiovascular and Interventional Radiological Society of Europe, Radiological Society of North America, and Society of Interventional Radiology

Disclosure: Nothing to disclose.

Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Medscape Salary Employment

Wai Hong Wilson Tang, MD Associate Professor of Medicine, Section of Heart Failure and Cardiac Transplantation Medicine, Cleveland Clinic Foundation

Wai Hong Wilson Tang, MD is a member of the following medical societies: American College of Cardiology, American Heart Association, Heart Failure Society of America, and International Society for Heart and Lung Transplantation

Disclosure: Abbott Laboratories Grant/research funds Research Supplies; Medtronic Inc Consulting fee Consulting; St Jude Medical Consulting fee Consulting

Anthony Watkinson, MD Professor of Interventional Radiology, The Peninsula Medical School; Consultant and Senior Lecturer, Department of Radiology, The Royal Devon and Exeter Hospital, UK

Anthony Watkinson, MD is a member of the following medical societies: Radiological Society of North America, Royal College of Radiologists, and Royal College of Surgeons of England

Disclosure: Nothing to disclose.

Study and Number of Patients	Patent Iliac Vein
Delin (13)	85%
Plate (31)	87%
Piquet (92)	80%
Einarsson (51)	88%
Juhan (42)	93%
Vollmar (93)	82%
Kniemeyer (185)	96%
Neglen (48)	89%

Total (555)	88%

Deep Venous Thrombosis (DVT) Differential Diagnoses

Diagnostic Considerations

Differential Diagnoses

References

Tables

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