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(Radiographics. 2000;20:1195-1200.)
© RSNA, 2000

PLENARY SESSION

1999 Plenary Session: Friday Imaging Symposium 1

Venous US of Lower-Extremity Deep Venous Thrombosis: When Is US Insufficient?

Damian E. Dupuy, MD

1 From the Department of Diagnostic Imaging, Brown University School of Medicine, Rhode Island Hospital, 593 Eddy St, Providence, RI 02903. From the Plenary Session, Friday Imaging Symposium: Algorithmic Controversies, at the 1999 RSNA scientific assembly. Received March 3, 2000; revision requested March 17 and received April 12; accepted April 14. Address correspondence to the author (e-mail: ddupuy@lifespan.org).

Index Terms: Extremities, thrombosis, 93.751 • Veins, thrombosis, 93.751 • Veins, US, 93.1298

Learning Objective

Recognize the US appearances of acute and chronic deep venous thrombosis in the lower extremity and identify situations in which Tc-99m apcitide may be useful.

Introduction

The diagnosis of acute lower-extremity deep venous thrombosis (DVT) in symptomatic patients is routinely established with venous ultrasonography (US). Compression venous US is the venous procedure of choice in patients with suspected DVT due to its noninvasive nature, high sensitivity and specificity in the symptomatic patient, wide availability 24 hours a day, portability, and low cost (1–3).

Diagnosis of lower-extremity DVT is important not only in evaluation of suspected pulmonary embolism but also in local venous evaluation. Long-term deleterious effects from damaged venous valves cause the postphlebitic syndrome. In patients with a history of DVT who present with recurrent symptoms due to postphlebitic syndrome or recurrent DVT, the US findings often do not allow differentiation of acute thrombus from prior or chronic thrombus (4,5). In addition, a nonocclusive clot may go undetected because of its location, small size, and nonocclusive nature (6,7).

New scintigraphic techniques play an assisting role in these specific clinical circumstances. The new commercially available radiopharmaceutical technetium-99m apcitide (AcuTect; Diatide, Londonderry, NH) is a complex of the radionuclide Tc-99m and the small synthetic peptide apcitide (8). Apcitide binds to glycoprotein IIb/IIIa receptors, which are expressed on the surface of activated platelets, making the radiopharmaceutical specific for acute thrombi but not chronic thrombi. Tc-99m apcitide allows imaging of the entire lower extremities, including the calf (9). These attributes may make Tc-99m apcitide imaging a potential complementary test for differentiation of acute from chronic DVT and detection of segmental DVT that is occult at US in certain selected patient populations.

In this article, venous US of DVT is reviewed and situations in which US is insufficient are discussed.

Venous US of DVT

Most patients with acute DVT involving the deep venous system below the inguinal ligament present with an acutely swollen and painful extremity. This clinical scenario occurs in approximately 90% of patients with symptomatic DVT. The thrombosis usually starts in the calf veins and propagates into the popliteal vein. The remaining 10% of patients have isolated iliofemoral DVT; if left untreated, this entity can lead to the syndrome of phlegmasia cerulea dolens, which is characterized by a painful, completely swollen, cyanotic-appearing lower extremity with prominent superficial collateral veins.

US performed with the proper technique, whereby the entire deep venous system from the common femoral vein to the popliteal trifurcation is compressed every 1–2 cm in the transverse and longitudinal planes with a linear high-frequency transducer (5–10 MHz), has been proved to be an accurate test, with a sensitivity and specificity exceeding 95% and 98%, respectively (3) (Fig 1). Lack of venous wall coaptation with compression is the contemporary US standard, and this finding is largely responsible for the success of US in evaluation of lower-extremity DVT. Secondary signs with Doppler techniques (ie, lack of spontaneous flow, lack of phasic variation with respiration, and lack of flow during augmentation) are helpful, particularly in the deeper veins above the inguinal ligament. Doppler techniques—whether color, power, or spectral—have helped improve the ease of examination but have not improved the specificity and sensitivity (10,11).



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  		Figure 1a.   Normal finding in a patient with suspected DVT. Transverse gray-scale US images of the common femoral vein (V) just below the inguinal ligament, obtained without (a) and with (b) direct compression with the transducer, show complete coaptation of the venous walls (arrow in b), which indicates a lack of thrombus at this level. A = common femoral artery.

 


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  		Figure 1b.   Normal finding in a patient with suspected DVT. Transverse gray-scale US images of the common femoral vein (V) just below the inguinal ligament, obtained without (a) and with (b) direct compression with the transducer, show complete coaptation of the venous walls (arrow in b), which indicates a lack of thrombus at this level. A = common femoral artery.

 
The likelihood that a patient with a history of DVT will present with repeat symptoms within 1 year is reported to be as high as 20% (5,12), and the prevalence of true recurrent DVT is reported to be as high as 8% (13). Repeat symptoms are largely determined by the extent of venous reflux, the presence of persistent popliteal obstruction, and the rate of recanalization, all of which may determine the presence of postphlebitic syndrome. Postphlebitic syndrome is caused by impaired venous valve function from prior thrombus. Particularly in the erect position, the retrograde venous flow leads to chronic venous hypertension, which induces superficial varicosities, chronic swelling, hyperpigmentation from stagnant red blood cell breakdown, and in severe cases ulceration.

With knowledge of the natural history of acute thrombus resolution, it is possible to recognize the US manifestations of chronic venous changes after acute DVT. Within the 1st week, an acute thrombus is entirely composed of red blood cells, platelets, and white blood cells in a network of fibrin. The acute thrombus distends the vein wall. The thrombus is loosely attached to the vein wall, and the risk of embolization is at its highest. Over the ensuing 2–8 weeks, the thrombus becomes adherent to the vein wall and capillaries grow into the thrombus. Thrombus fragmentation and fibrinolysis cause new endothelium-lined sinuses to form, which when completely joined lead to restoration of the venous lumen. Complete restoration of the lumen takes 5–24 weeks, occurs in about 50%–68% of patients, and is likely related to thrombus size and location, local blood flow, and the adequacy of anticoagulation (14,15). Venous diameter decreases after DVT but returns to normal after complete recanalization and is not associated with chronic changes in venous compliance (16). Fibroblasts, histiocytes, and capillaries that infiltrate the thrombus may persist as fibroelastic tissue and cause focal or diffuse thickening of the venous wall. In summary, the patterns of resolution can be categorized into persistent occlusion, complete resolution with no residual wall abnormalities, partial resolution with recanalization and residual neointimal thickening, and partial resolution with focal wall abnormalities. The three latter patterns can be recognized as chronic with venous US.

Situations in Which US Is Insufficient

When a venous valve has been destroyed by thrombus, US can be used to detect venous regurgitation by examining the patient in the erect position and using the Valsalva maneuver and spectral Doppler techniques (17). The presence of venous valvular regurgitation in conjunction with chronic wall changes and the absence of a distended, noncompressible vein wall usually ensure that the patient's symptoms are not due to acute DVT (Fig 2). Difficulty arises when a prior DVT did not resolve and the patient does not have signs of venous regurgitation or prior US documentation of persistent occlusion during follow-up of prior DVT. In this setting, US images of a lower-extremity vein can be equivocal. At this point, one could elect to repeat US in 3 days to look for propagation of thrombus in the abnormal region, which would imply that the thrombus is acute. Tc-99m apcitide could also be used to determine the acuity of the abnormality (Figs 3, 4). In addition, administration of low-molecular-weight heparin in the outpatient setting may be a safe alternative prior to repeat confirmatory testing (18) (Fig 5).



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  		Figure 2a.   Venous valvular insufficiency in a 68-year-old man with a history of DVT in the left lower extremity who presented with a chronically swollen left lower extremity. (a, b) Longitudinal gray-scale US images obtained without (a) and with (b) compression show an echogenic focal wall defect (arrow) that is incompletely compressible. (c) Longitudinal spectral Doppler US image of the popliteal vein obtained by using erect patient positioning and the Valsalva maneuver shows significant retrograde venous flow (arrow), which is indicative of venous valvular insufficiency.

 


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  		Figure 2b.   Venous valvular insufficiency in a 68-year-old man with a history of DVT in the left lower extremity who presented with a chronically swollen left lower extremity. (a, b) Longitudinal gray-scale US images obtained without (a) and with (b) compression show an echogenic focal wall defect (arrow) that is incompletely compressible. (c) Longitudinal spectral Doppler US image of the popliteal vein obtained by using erect patient positioning and the Valsalva maneuver shows significant retrograde venous flow (arrow), which is indicative of venous valvular insufficiency.

 


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  		Figure 2c.   Venous valvular insufficiency in a 68-year-old man with a history of DVT in the left lower extremity who presented with a chronically swollen left lower extremity. (a, b) Longitudinal gray-scale US images obtained without (a) and with (b) compression show an echogenic focal wall defect (arrow) that is incompletely compressible. (c) Longitudinal spectral Doppler US image of the popliteal vein obtained by using erect patient positioning and the Valsalva maneuver shows significant retrograde venous flow (arrow), which is indicative of venous valvular insufficiency.

 


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  		Figure 3a.   Acute DVT in a 58-year-old man with metastatic adenocarcinoma and a history of DVT 2 months earlier who presented with worsening pain and swelling in the right lower extremity. (a, b) Transverse gray-scale US images obtained without (a) and with (b) compression show noncompressible echogenic material in the venous lumen (arrow). It was unclear whether this material represented acute on chronic DVT or chronic DVT only. A = artery. (c) Anterior 2-hour delayed image from a Tc-99m apcitide study shows linear radionuclide activity along the right superficial femoral vein (arrow), a finding consistent with acute DVT.

 


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  		Figure 3b.   Acute DVT in a 58-year-old man with metastatic adenocarcinoma and a history of DVT 2 months earlier who presented with worsening pain and swelling in the right lower extremity. (a, b) Transverse gray-scale US images obtained without (a) and with (b) compression show noncompressible echogenic material in the venous lumen (arrow). It was unclear whether this material represented acute on chronic DVT or chronic DVT only. A = artery. (c) Anterior 2-hour delayed image from a Tc-99m apcitide study shows linear radionuclide activity along the right superficial femoral vein (arrow), a finding consistent with acute DVT.

 


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  		Figure 3c.   Acute DVT in a 58-year-old man with metastatic adenocarcinoma and a history of DVT 2 months earlier who presented with worsening pain and swelling in the right lower extremity. (a, b) Transverse gray-scale US images obtained without (a) and with (b) compression show noncompressible echogenic material in the venous lumen (arrow). It was unclear whether this material represented acute on chronic DVT or chronic DVT only. A = artery. (c) Anterior 2-hour delayed image from a Tc-99m apcitide study shows linear radionuclide activity along the right superficial femoral vein (arrow), a finding consistent with acute DVT.

 


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  		Figure 4a.   Acute thrombus in a 68-year-old man with acute shortness of breath and a positive ventilation-perfusion scan. (a) Longitudinal color Doppler image of the popliteal vein shows focal lack of color flow adjacent to a valve (arrow). (b) Posterior planar image from a Tc-99m apcitide study shows focal tracer accumulation (arrow), a finding consistent with acute thrombus.

 


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  		Figure 4b.   Acute thrombus in a 68-year-old man with acute shortness of breath and a positive ventilation-perfusion scan. (a) Longitudinal color Doppler image of the popliteal vein shows focal lack of color flow adjacent to a valve (arrow). (b) Posterior planar image from a Tc-99m apcitide study shows focal tracer accumulation (arrow), a finding consistent with acute thrombus.

 


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  		Figure 5.   Imaging algorithm for patients with a history of DVT who present with symptoms suggestive of recurrent DVT. LMW = low-molecular-weight.

 
The prevalence of postoperative DVT has been reported to be as high as 60% in patients who have undergone arthroplasty (19–21). This high prevalence has led to prophylaxis with postoperative anticoagulation therapy, pneumatic leg compression, and early physical therapy. US has been used for detection of asymptomatic DVT in this population with variable results (22–24), which are largely due to incomplete visualization of the entire deep venous system, the high prevalence of calf clots, and the existence of segmental, hypoechoic, compressible thrombi, which are more difficult to detect. Administration of heparin, warfarin, or low-molecular-weight heparin may make visualization of a thrombus more difficult because the thrombus may be segmental, hypo-echoic, and less likely to occlude the lumen (25). In fact, in patients who are receiving 4–8 weeks of prolonged postoperative anticoagulation therapy, screening US might be considered unnecessary on the basis of published data (24).

Despite these shortcomings of US, very few institutions perform routine postoperative venography and some continue to perform US. This fact is likely related to the low frequency of significant pulmonary embolism in the setting of contemporary venous prophylaxis (25,26). If Tc-99m apcitide could provide a more accurate means of determining which patients need longer anticoagulation therapy, then its use may be justified. However, the timing of this study is still unknown, since some patients develop DVT as late as 2–4 weeks after surgery (25). With no meaningful clinical data or cost analysis available in this patient group, to my knowledge, the role of Tc-99m apcitide remains speculative at best.

Another situation in which diagnosis of acute DVT is problematic is isolated calf thrombus. Eighty-eight percent of calf thrombi occur in the asymptomatic population, and this entity accounts for 50% of the clots in the asymptomatic population (7). Isolated calf thrombus is rarely a cause of pulmonary embolism (27). US can be used for direct detection of calf thrombi or for assessment of propagation into the femoral-popliteal system, which occurs in approximately 20% of patients (28). In high-risk patients in whom imaging is difficult or follow-up examinations are not desirable, Tc-99m apcitide could be used to identify acute thrombus. These high-risk patients may then receive anticoagulation that is aggressive compared with that used to treat calf thrombus in low-risk patients.

Conclusions

As newer imaging tests become available, it is important that controlled scientific studies are performed before decisions are made regarding implementation of these tests. Venous US has been used clinically for almost 2 decades, and hundreds of published studies have investigated its role in various clinical scenarios. Despite the shortcomings of venous US in cases of chronic DVT and in patients who have undergone arthroplasty, no body of knowledge exists that unequivocally points to replacing venous US in day-to-day clinical practice. Although Tc-99m apcitide imaging has some theoretical advantages that have been described and has been approved for clinical use, many unanswered questions remain regarding its role.

Acknowledgments

I thank John J. Cronan, MD, for his intellectual assistance.

Footnotes

Abbreviation: DVT = deep venous thrombosis

References

  1. Cronan JJ, Dorfman GS, Scola FH, Schepps B, Alexander J. Deep venous thrombosis: US assessment using vein compression. Radiology 1987; 162:191-194.[Abstract/Free Full Text]
  2. Cronan JJ. Venous thromboembolic disease: the role of US. Radiology 1993; 186:619-630.[Abstract/Free Full Text]
  3. Fraser JD, Anderson DR. Deep venous thrombosis: recent advances and optimal investigation with US. Radiology 1999; 211:9-24.[Free Full Text]
  4. Cronan JJ, Leen V. Recurrent deep venous thrombosis: limitations of US. Radiology 1989; 170:739-742.[Abstract/Free Full Text]
  5. Heijboer H, Jongbloets LMM, Buller HR, Lensing AWA, Ten Cate JW. Clinical utility of real-time compression ultrasonography for diagnostic management of patients with recurrent venous thrombosis. Acta Radiol 1992; 33:297-300.[Medline]
  6. Davidson BL, Elliott CG, Lensing AW. Low accuracy of color Doppler ultrasound in the detection of proximal leg vein thrombosis in asymptomatic high-risk patients: the RD Heparin Arthroplasty Group. Ann Intern Med 1992; 117:735-738.
  7. Rose SC, Zwiebel WJ, Miller FJ. Distribution of acute lower extremity deep venous thrombosis in symptomatic and asymptomatic patients: imaging implications. J Ultrasound Med 1994; 13:243-250.[Abstract]
  8. Lister-James J, Knight LC, Maurer AH, et al. Thrombus imaging with a technetium-99m-labeled activated platelet receptor-binding peptide. J Nucl Med 1996; 37:775-781.[Abstract/Free Full Text]
  9. Taillefer R, Therasse E, Turpin S, et al. Comparison of early and delayed scintigraphy with 99mTc-apcitide and correlation with contrast-enhanced venography in detection of acute deep vein thrombosis. J Nucl Med 1999; 40:2029-2035.[Abstract/Free Full Text]
  10. Lensing AW, Doris CI, McGrath FP, et al. A comparison of compression ultrasound with color Doppler ultrasound for the diagnosis of symptomless postoperative deep venous thrombosis. Arch Intern Med 1997; 157:765-768.[Abstract/Free Full Text]
  11. Cogo A, Lensing AWA, Wells P, Prandoni P, Buller HR. Noninvasive objective tests for the diagnosis of clinically suspected deep-vein thrombosis. Haemostasis 1995; 25:27-39.[Medline]
  12. Meissner MH, Caps MT, Zierler BK, et al. Determinants of chronic venous disease after acute deep venous thrombosis. Radiology 1994; 192:651-655.[Abstract/Free Full Text]
  13. Huisman MV, Buller HR, Ten Cate JW. Utility of impedance plethysmography in the diagnosis of recurrent deep-vein thrombosis. Arch Intern Med 1988; 148:681-684.[Abstract/Free Full Text]
  14. Murphy TM, Cronan JJ. Evolution of deep venous thrombosis: a prospective evaluation with US. Radiology 1990; 177:543-548.[Abstract/Free Full Text]
  15. Caprini JA, Arcelus JI, Reyna JJ, et al. Deep vein thrombosis outcome and the level of oral anticoagulation therapy. J Vasc Surg 1999; 30:805-811.[Medline]
  16. Meissner MH, Manzo RA, Bergelin RO, Strandness DE, Jr. Venous diameter and compliance after deep venous thrombosis. Radiology 1993; 186:619-630.
  17. Araki CT, Back TL, Padberg FT, et al. Refinements in the ultrasonic detection of popliteal vein reflux. J Vasc Surg 1993; 18:742-748.[Medline]
  18. Koopman MMW, Prandoni P, Piovella F, et al. Treatment of venous thrombosis with intravenous unfractionated heparin administration in the hospital as compared with subcutaneous low-molecular-weight heparin administered at home. N Engl J Med 1996; 334:682-687.[Abstract/Free Full Text]
  19. Stulberg BN, Insall JN, Williams GW, Ghelman B. Deep-vein thrombosis following total knee replacement: an analysis of six hundred and thirty-eight arthroplasties. J Bone Joint Surg Am 1984; 66:194-201.[Abstract/Free Full Text]
  20. Planes A, Vochelle N, Fagola M. Total hip replacement and deep vein thrombosis: a venographic and necropsy study. J Bone Joint Surg Br 1990; 72:9-13.
  21. Ascani A, Radicchia S, Parise P, Nenci GG, Agnelli G. Distribution and occlusiveness of thrombi in patients with surveillance detected deep vein thrombosis after hip surgery. Thromb Haemost 1996; 75:239-241.[Medline]
  22. Mantoni M, Strandberg C, Neergaard K, et al. Triplex US in the diagnosis of asymptomatic deep venous thrombosis. Acta Radiol 1997; 38:327-331.[Medline]
  23. Elliott CG, Suchyta M, Rose SC, et al. Duplex ultrasonography for the detection of deep vein thrombi after total hip or knee arthroplasty. Angiology 1993; 44:26-33.
  24. Robinson KS, Anderson DR, Gross M, et al. Ultrasonographic screening before hospital discharge for deep venous thrombosis after arthroplasty: the post-arthroplasty screening study. Ann Intern Med 1997; 127:439-445.[Abstract/Free Full Text]
  25. Caprini JA, Arcelus JI, Motykie G, et al. The influence of oral anticoagulation therapy on deep vein thrombosis rates four weeks after total hip replacement. J Vasc Surg 1999; 30:813-820.[Medline]
  26. Blanchard J, Meuwly JY, Leyvraz PF, et al. Prevention of deep-vein thrombosis after total knee replacement: randomized comparison between a low-molecular-weight heparin (nadroparin) and mechanical prophylaxis with a foot-pump system. J Bone Joint Surg Br 1999; 81:654-659.
  27. Moser KM, LeMoine JR. Is embolic risk conditioned by location of deep venous thrombosis?. Ann Intern Med 1981; 94:439-444.
  28. Philbrick JT, Becker DM. Calf vein thrombosis: a wolf in sheep's clothing?. Arch Intern Med 1988; 148:2131-2138.[Abstract/Free Full Text]



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