prominent venous collaterals. In some patients, deoxygenated hemoglobin in stagnant
veins imparts a cyanotic hue to the limb, a condition called
phlegmasia cerulea dolens
In markedly edematous legs, the interstitial tissue pressure may exceed the capillary
perfusion pressure, causing pallor, a condition designated
phlegmasia alba dolens
The diagnosis ofDVT
of the calf is often difficult to make at the bedside. This is so
because only one of multiple veins may be involved, allowing adequate venous return
through the remaining patent vessels. The most common complaint is calf pain.
Examination may reveal posterior calf tenderness, warmth, increased tissue turgor or
modest swelling, and, rarely, a cord. Increased resistance or pain during dorsiflexion of
the foot (Homans' sign) is an unreliable diagnostic sign.
occurs less frequently in the upper extremity than in the lower extremity, but the
incidence is increasing because of greater utilization of indwelling central venous
catheters. The clinical features and complications are similar to those described for the
D-Dimer, a degradation product of cross-linked fibrin, is often elevated inpatients with venous thrombosis. It is a sensitive, but not specific, test for venous
thrombosis. The noninvasive test used most often to diagnoseDVT
is duplex venous
ultrasonography (B-mode, i.e., two-dimensional, imaging, and pulse-wave Doppler
interrogation). By imaging the deep veins, thrombus can be detected either by direct
visualization or by inference when the vein does not collapse on compressive
maneuvers. The Doppler ultrasound measures the velocity of blood flow in veins. This
velocity is normally affected by respiration and by manual compression of the foot or
calf. Flow abnormalities occur when deep venous obstruction is present. The sensitivity
of duplex venous ultrasonography approaches 95% for proximal DVT and 75% for
symptomatic calf vein thrombosis.
Magnetic resonance imaging (MRI) is another noninvasive means to detectDVT
diagnostic accuracy for assessing proximal DVT is similar to that of duplex
ultrasonography. It is useful in patients with suspected thrombosis of the superior and
inferior venae cavae or pelvic veins.
can also be diagnosed by venography. Contrast medium is injected into a
superficial vein of the foot and directed to the deep system by the application of
tourniquets. The presence of a filling defect or absence of filling of the deep veins is
required to make the diagnosis.
must be differentiated from a variety of disorders that cause unilateral leg pain or
swelling, including muscle rupture, trauma, or hemorrhage; a ruptured popliteal cyst;
and lymphedema. It may be difficult to distinguish swelling caused by the postphlebitic
syndrome from that due to acute recurrent DVT. Leg pain may also result from nerve
compression, arthritis, tendinitis, fractures, and arterial occlusive disorders. A careful
history and physical examination can usually determine the cause of these symptoms.