ultrasound venography - prof neil pugh
TRANSCRIPT
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ULTRASOUND VENOGRAPHY
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SCAN PROTOCOL
• Linear array transducer
for thigh and calf veins
• 5MHz-9MHz
• Curvilinear transducer for
pelvic and abdominal
veins
• 2MHz-6MHz
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SCAN PROTOCOLILIO-FEMORAL SEGMENT
• Patient supine - trunk slightly elevated
• Common femoral vein - Valsalva response
• abnormal : scan iliac veins
• normal : proceed distally
• Femoral veins
• scan both in longitudinal and transverse planes
• look for complete colour “fill-in” of the vessels
• compression (look out for incompressible segments!)
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SCAN PROTOCOLPOPLITEAL SEGMENT
• Lateral decubitus with slight
knee bend
• scan both in longitudinal and
transverse planes
• look for complete colour “fill-in”
• compression
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SCAN PROTOCOLTHE CALF VEINS
• Most easily visualised with leg
dependant
• Scan in sitting position
• Starting in mid calf scan proximally
and distally
• Scan predominantly in longitudinal
plane but transverse can also be
useful
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THE CALF VEINS
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SCANNING TIPS• Positive anatomical identification
• Deep veins
• lie deep to the facia between the muscle fascia
• accompanied by an artery and are paired distal to the knee
• Muscular veins
• lie within the muscle and do not run in the facial planes
• accompanied by a small artery and are paired
• Superficial veins
• usually lie between the deep and superficial fascia
• not accompanied by an artery
• Perforating veins
• connect deep to superficial system
• do not run in the fascial planes
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NORMAL VEINSB-MODE APPEARANCE
• Vein lumen is echo free
• Interior surface of the vein wall is smooth
• The wall itself should be thin with no structure
• Valves when seen should be free to move
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NORMAL VEINSCOMPRESSIBILITY
• Uniform compressibility
• Complete apposition of anterior & posterior wall
• Minimal probe pressure
• Note - Incompressible segments
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NORMAL VEINSRESPIRITORY CHANGES
• Diameter of large veins increase with deep inspiration
or valsalva
• Venous system proximal to point of examination is
patent
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NORMAL VEINSFLOW PARAMETERS
• Spontaneous flow with respiration
• Phasic flow with respiration
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NORMAL VEINSAUGMENTATION
• Manual compression of the extremity distal to site of
examination should increase venous flow
• Confirms patency between examination and compression site
• Absent or delayed & weak response suggest a substantial
obstruction distal to examination site
• Partial obstruction or minor clot may not alter the
augmentation response
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NORMAL VEINSVALSALVA MANOEUVRE
• Valsalva should result in abrupt cessation in flow
• Demonstrates the patency of the venous system from the
point of examination to the thorax
• Useful in documenting the patency of the iliac veins
• Abnormal response to valsalva occurs only in MAJOR
obstructions
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RECENT (ACUTE) THROMBUS
• Low echogenicity intraluminal material producing flow
and colour void
• very recent clot may be almost completely anechoic
• Venous distention
• most important criterion of acute clot
• Loss of compressibility
• not so important with CDI
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ACUTE DVT
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ACUTE DVT
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ACUTE DVT
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ACUTE DVT
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ACUTE DVT
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ACUTE DVT
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PROBLEMATIC AREAS
• Isolated iliac DVT
• Isolated calf vein DVT
• Duplication of femoral & popliteal veins
• Partially occlusive clot
• Chronic vs. acute DVT
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ISOLATED ILIAC DVT
• Isolated iliac DVT occurs
in <1% of general DVT
population
• High risk groups
• pregnancy
• malignancy
• pelvic surgery
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ISOLATED ILIAC DVT
• Indirect assessment
• flow pattern (phasicity)
• response to Valsalva
• Direct imaging
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HOW SHOULD WE DIAGNOSE ISOLATED ILIAC DVT?
• Look for phasicity of femoral waveform
• Perform a Valsalva manoeuvre if unsure
• Remember
• indirect assessment suggestive but not definitive
• spontaneous flow pattern may still persist in the presence of clot -
particularly partially occlusive clot
• can still maintain normal response to valsalva in the presence of clot -
again particularly partially occlusive clot
• Iliac veins should be scanned, especially in high risk patients
• Scanning of iliac veins should be possible in majority of cases
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ISOLATED CALF VEIN DVT
• Isolated calf vein DVT only
occurs in 15% of positive
DVT studies
• Calf vein DVT important
because
• potential to propagate
(~20% of cases within 72hr)
• potential to embolise and
cause PE (low risk)
• post thrombotic syndrome
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ISOLATED CALF VEIN DVT
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ISOLATED CALF VEIN DVT
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DUPLICATIONS
• Duplication of the femoral vein occurs in ~20% of the
population
• Duplication of the popliteal vein higher
• DVT can occur in one or both branches of the vein
• Duplication best seen in transverse plane
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DUPLICATIONS
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PARTIALLY OCCLUSIVE CLOT
• Isolated partially occlusive DVT is a rare occurrence (high risk cases)
• Problematic because it does not necessarily change the flow pattern
• Best seen in transverse plane and on colour flow
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PARTIALLY OCCLUSIVE CLOT• Adhere to the wall or appear as free floating
• Best demonstrated on colour image
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ACUTE VS CHRONIC DVT
• Acute DVT
• venous distension (probably the most important diagnostic
criterion for acute DVT)
• low echogenicity intraluminal material producing flow and
colour void (very recent clot may be completely anechoic)
• compressibility - non discriminatory
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ACUTE VS CHRONIC DVT
• Chronic DVT
• eccentric linear recanalisation
of vessel
• collateralisation
• venous reflux
• “tatty” vessels (vein wall
thickening)
• no venous distention (for
occlusive clot)
• compressibility - non
discriminatory
• more echoic clot (non-specific)
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ACUTE VS CHRONIC(SUMMARY)
• Acute
• venous distention
• Chronic
• venous reflux
• eccentric linear recanalisation
• collateralisation
• Non-specific
• echogenicity
• completely echolucent - acute
• vein wall thickening
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MUSCULAR VEIN THROMBOSIS
• Thrombosis of in muscular veins not uncommon
• Gastrocnemius most common
• Soleal also possible
• Paired with a small artery
• confused for paired deep veins
• can propagate into deep system
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SUPERFICIAL THROMBO-PHLEBITIS
• Superficial thrombo-phlebitis common
• cause of pain and swelling
• raises D-dimer value
• can propagate into deep system
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SUPERFICIAL THROMBO-PHLEBITIS
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OTHER PATHOLOGIES
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CHALLENGES OF COLOUR DOPPLER VENOGRAPHY
Practical
• Oedema
• Obesity
• Pain
• Wounds/dressings
• Immobility
• Scanner setting
• Chronic venous disease
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COMPLICATIONS – A WORD OF CAUTION
• Venous duplex ultrasonography causing acute pulmonary
embolism: a brief report
• Schroder et al; J. Vasc. Surg. 15; 1082; 1992
• I prefer using CDI
• less likely to break of clot
• better diagnostic accuracy
• see partial filling
• don’t have to worry about incompressible segments
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THANK YOU FOR YOUR ATTENTION