Patrick Vogel, MD Faye

#{149} C. Laing, MD R.
#{149} Brooke Jeffrey, Jr., MD Vivian
#{149} W. Wing, MD

Deep Venous Thrombosis of the

Lower Extremity: US Evaluation’

The sensitivity of duplex ultraso- D EEP venous thrombosis of the suggested that abnormal compress-
nography (US) for detecting deep lower extremity is a common ibility of the deep veins in the upper
venous thrombosis of the lower ex- disease that can result in significant leg was 100% sensitive and specific
tremity was compared with that of morbidity and even mortality. Be- for detecting deep venous thnombo-
venography in a prospective study cause the clinical diagnosis of lower sis (19).
of 54 patients. Doppler analysis of extremity venous thrombosis is often The present prospective blind
the common femoral vein and US inaccurate (1) and because complica- study addresses a larger patient pop-
imaging of the deep venous system tions associated with anticoagulation ulation and attempts to assess the
from the common femoral vein to are significant, contrast material- sensitivity of US for detecting lower
the popliteal vein was performed. enhanced venography remains the extremity deep venous thrombosis
Common femoral vein response to standard for diagnosing deep venous and to analyze the various sono-
the Valsalva maneuver was record- thrombosis. Although venography is graphic criteria for establishing the
ed. Sonographically visible thrombi the accepted standard, there is limit- diagnosis.
and abnormal vein compressibility ed information to support this con-
were 91% sensitive for the common tention. A postmortem study report- MATERIALS AND METHODS
femoral vein, and 94% sensitive for ed in 1969 that compared venog-
the superficial femoral or popliteal raphy and anatomic venous dissec- Fifty-four patients with clinically sus-
veins, with no false-positive exami- pected deep venous thrombosis were
tion had a sensitivity of 89% and a
evaluated in this study. The patients in-
nations. Abnormal Doppler flow specificity of 97% (2). Concern over
cluded 34 men and 20 women, aged 23-85
and abnormal response of the com- potential complications of contrast
years (average, 51 years). Contrast venog-
mon femoral vein to the Valsalva venography (3-5) has led to the de- maphy was performed within 24 hours of
maneuver enabled thrombi to be de- ve!opment of several noninvasive the US examination in each case.
tected only in the common femoral techniques with which to diagnose US was performed with either a 7.5- or
and iliac veins Combined data a!- venous thrombosis, including Dopp- 10-MHz imaging duplex transducer (with
lowed accurate diagnoses in all pa- len ultrasonography (US), phlebor- a 3.0- or 4.5-MHz Doppler transducer
tients with deep venous thrombosis heography, impedance plethysmog- [Diasonics, Milpitas, Calif.]) for examin-
proximal to the deep calf veins. US raphy, and iodine-125 fibrinogen ing the common femoral vein. Doppler
flow within the common femoral vein
should be the screening examina- scanning (6-13). The most widely
was considered normal when it was de-
tion of choice for evaluating pa- used noninvasive examination is im-
tectable and showed an increase during
tients with suspected lower extrem- pedance plethysmography, which expiration and a decrease during inspira-
ity deep venous thrombosis. has a reported sensitivity as high as tion (Fig. 1). Augmentation of flow dur-
95% for detecting proximal lower ex- ing compression of the lower extremity
tremity venous thrombosis (13-15). was not evaluated. Variations within the
Other reports, however, have sug- common femoral vein during the Valsal-
Index terms: Extremities, thrombosis, 44.8 Ex-
#{149}
va maneuver were measured as a percent-
gested a lower sensitivity (in the
tremities, US studies, 44.1298 Thrombosis,
#{149} ye- age change in the anterior-posterior lumi-
nous, 93.751 Thrombosis,
#{149} US studies,
range of 63%) for detecting deep ye-
nal diameter of the vessel. In question-
93.1298 Veins,
#{149} extremities Veins,
#{149} grafts and nous thrombosis proximal to the calf
able cases findings in the symptomatic
prostheses veins (16).
leg were compared with those in the con-
The development of high-resolu-
tralateral leg. In addition, an electronical-
tion US has led to its use to study ye- ly focused 5-MHz linear array transducer
Radiology 1987; 163:747-751 nous thrombosis of the lower extrem- (Acuson, Mountain View, Calif.) was used
ity. The common femonal vein and its to image the deep veins of the symptom-
response to changes in venous pres- atic leg in both longitudinal and trans-
sure have been described in the nor- verse planes. The common femoral and
I From the Department of Radiology, San ma! state and in patients with venous superficial femoral veins were examined
Francisco General Hospital, 1001 Potrero Ave., with the patient supine, while the popli-
San Francisco, CA 94110. From the 1986 RSNA
thrombosis (17). In addition, the son-
teal vein was examined with the patient
annual meeting. Received November 11, 1986; ographic appearance of thrombus
prone or in the lateral decubitus position.
accepted and revision requested December 18; within the deep veins of the leg has
The lumen of each vein was carefully in-
revision received January 27, 1987. Address re- been correlated with venographic
print requests to F.C.L. spected for the presence or absence of vis-
findings in six patients (18). Recent- ible thrombus. To minimize artifactual
© RSNA, 1987
See also the article by Appelman et al. (pp. !y, a sonognaphic study of 20 patients echoes, we adjusted the time gain com-
743-746) in this issue. who had also undergone venography pensation curve such that the accompany-

747
ing artery was free of luminal echoes. To by thrombus. Of the ten patients ed by applying gentle pressure with
optimize evaluating vein compressibility, with thrombosis and with abnormal the linear array transducer (Fig. 2).
we applied gentle transducer pressure Doppler flow in the common femoral In 24 of 25 patients with veno-
over each of the deep veins while scan-
vein, nine (90%) had thrombus with- graphic evidence of venous thrombo-
ning in a transverse plane. The veins
in the common femoral vein and one sis, the common femoral, superficial
were considered normal when very little
had thrombus involving the iliac femoral, and popliteal veins were ad-
pressure was required to completely
obliterate their lumens. No attempt was vein alone. Doppler examination equately seen on sonograms. In a sin-
made to evaluate the deep veins of the could not be performed in the me- gle patient with complete thrombosis
calf. A complete examination required ap- maining two patients because of the seen on venograms, the deep venous
proximately 20 minutes. At our institu- depth of the vein. system could not be identified on
tion the costs of US and contrast venogra- sonograms. This patient, however,
phy are comparable, with US costing $25 had significant abnormality of the
more than venography. Common Femoral Vein
deep venous system because not only
Lower extremity venography was per- Response to Valsalva Maneuver
was there nonvisualization of the
formed with the patient in the 45#{176}
up-
Of the 29 patients with normal deep veins, but also extensive collat-
right position; 150 ml of Conray-43 (ioth-
venognams, 12 demonstrated a great- eral vessels could be seen on sono-
alamate meglumine; Mallinckrodt, St.
Louis) was injected into a dorsal foot en than 50% increase in the AP diam- grams (Fig. 3).
vein. At least two radiographs of the calf eten of the common femoral vein US-demonstrated thrombus and
and a single anteroposterior (AP) projec- during the Valsalva maneuver, and abnormal vein compressibility were
tion over the knee, thigh, and pelvis were 15 demonstrated a 10%-50% increase. evident in ten of 1 1 involved com-
obtained. In two patients, the Valsalva maneu- mon femora! veins (91%.), in 17 of 18
In each case the US examination was yen could not be performed because involved superficial femoral veins
interpreted by an attending radiologist of lack of patient cooperation. (94c7), and in 17 of 18 involved pop-
(F.C.L., R.B.J., V.W.W.) without knowl- Of the 25 patients with proved liteal veins (94%) (Fig. 4). Two pa-
edge of the venographic results. The son-
thrombosis, three demonstrated a tients with isolated iliac vein throm-
ographic interpretation was subsequently
greater than 50% increase in the AP bosis had no sonographically visible
correlated with the venographic findings
as well as clinical information obtained diameter of the common femomal thrombus and had normal compress-
from the patient’s chart. vein during the Valsalva maneuver,
and six had a 10%-50% increase. Only
one of 25 patients had thrombus in-
RESULTS volving the common femonal vein.
Of the eight patients who had less
Contrast Venography than 10% increase during the Valsal-
Twenty-five of 54 (46%) lower ex- va maneuver, all but one (88%) had
tremity venograms demonstrated thrombus involving the common
deep venous thrombosis, while the femonal vein or iliac vein confirmed
remaining 29 examinations (54%) did with venography . Valsalva maneuver
not. Seventeen of the 25 patients was omitted as part of the examina-
with thrombus (68%) had multiple tion in eight patients with visible
sites of involvement: the common thrombi.
femoral vein contained thrombus in
1 1 patients, the superficial femoral US Visualization of Thrombus
vein in 18, and the popliteal vein in and Abnormal Compression of
18. Four patients (16%) had isolated the Deep Venous System
calf vein thrombosis, and two pa-
tients had isolated iliac vein throm- In the 29 patients for whom venog-
raphy revealed no thrombus, the US
bosis. Figure 1. Doppler study of a common fem-
results were also normal. Further-
oral vein shows increased flow during expi-
more, in each of these patients the lu- ration and decreased flow during inspira-
Duplex Doppler Examination of men of the vein was easily obliterat- tion.
the Common Femoral Vein

Twenty-six of the 29 patients with-

out deep venous thrombosis had nor-
ma! flow in the common femomal
vein demonstrated with duplex
Doppler US. A single patient without
thrombosis but with extrinsic corn-
pression of the iliac vein had abnon-
ma! flow, and in the remaining two
patients Doppler examination could
not be performed with our equip-
ment because of an unusually deep-
seated common femoma! vein.
Thirteen of the 25 patients with
proved venous thrombosis had nor- a. b.
mal flow in the common femora! Figure 2. Transverse US scan of a normal right common femoral vein (V) and artery (A) ob-
vein. In each of these cases, the corn- tamed without (a) and with (b) compression. Note that the lumen of the vein is essentially
mon femoral vein was not involved obliterated by transducer pressure.

748 #{149} Radiology June 1987

ibility within the common femoral, not made from sonographic findings. investigation, our laboratory was not
superficial femora!, and popliteal In the two patients with isolated iliac equipped with a deep pulsed Dopp-
veins. The deep veins of the calf vein thrombosis, duplex Doppler US len system. In addition, the sensitiv-
were not assessed with US. of the common femoral vein demon- ity of our Doppler system was such
strated abnormality in one, and in that inconclusive responses were ob-
Ancillary Findings both these patients there was no sig- tamed when attempts were made to
Three patients without venous nificant response of the common measure Doppler flow in the poplite-
thrombosis had other abnormalities femoral vein during the Valsalva ma- a! vein. In all probability, Doppler
that were detected with US. Two pa- neuvem. In each of the four patients examination of the superficial femo-
tients had Baker cysts, while the with isolated calf thrombosis, the ral and popliteal veins (with aug-
third had a complex groin mass that sonographic and Doppler examina- mentation maneuvers) will also
proved to be a sterile hematoma. tions were entirely normal. prove to be sensitive for detecting
The combined findings from abnormal flow when these veins are
Doppler examinations and US imag- involved with thmombus.
DISCUSSION
ing studies enabled deep venous Although the literature suggests
thrombosis in the common femoral, The results of this prospective, that measuring the response of the
superficial femoral, or popliteal veins comparative study suggest that US common femoral vein to the Valsalva
to be diagnosed specifically in all but can be used to screen patients with maneuver can be used to evaluate for
one patient. The single exception was suspected deep venous thrombosis of the presence of deep venous throm-
the patient in whom the deep venous the lower extremity. Although van- bosis, the results of our study raise
system could not be seen because of ous sonographic criteria have been some questions about the usefulness
complete thrombosis. In this patient, proposed for establishing the diagno- of this technique.
an abnormality was clearly recog- sis of lower extremity deep venous Compared with the work of Ef-
nized on sonograms, but the specific thrombosis, it appears that some cni- feney et al. (17), our results demon-
diagnosis of venous thrombosis was tenia are more sensitive than others. strate a less dramatic and more van-
Doppler flow analysis of the com- able response of the common femoral
mon femora! vein alone has signifi- vein to the Va!sa!va maneuver. In
cant limitations. Our results suggest their study of 23 patients, an increase
that when the common femora! vein of less than 10% in the AP diameter
is itself involved with thrombus, during Valsalva maneuver was 83%
Doppler flow analysis will be abnor- sensitive for detecting deep venous
ma!. Doppler study was 100% sensi- thrombosis. In our study, only eight
tive for detecting thrombus involv- of 17 patients with venous thrombo-
ing the common femoral vein and sis (47%) who were tested for me-
also revealed abnormality in one pa- sponse to Valsalva maneuvers dem-
tient with isolated iliac vein throm- onstrated less than a 10% increase.
bus. If thrombus is below the level of Five of these patients had thrombus
the common femoral vein, Doppler involving the common femoral vein,
evaluation at the level of the com- while two had thrombus involving
mon femomal vein (without augmen- the iliac vein. Although one can only
tation maneuvers) will probably be speculate as to the reasons for these
normal. The literature suggests that discrepant sensitivities, they may me-
the use of augmentation maneuvers flect differing numbers of patients
can increase the sensitivity for de- with proximal iliofemora! thrombus
Figure 3. Collateral veins (*) were readily
visible in a patient with a completely throm- tecting deep venous thrombosis to as (the actual site of thrombus was not
bosed deep venous system. high as 93% (7). At the time of this specified in the group of patients me-

b. c.
Figure 4. Sonographic demonstration of echogenic clot. Each vein was essentially noncompressible. (a) Thrombosed right common femoral
vein (arrow) positioned medial to the artery (A). (b) Thrombosed superficial femoral vein in midthigh (arrow) positioned deep to the artery
(A). (c) Thrombosed popliteal vein (arrow) positioned superficial to the artery (A).

Volume 163 Number 3 Radiology 749

#{149}
ported by Effeney et al). thrombosis of the deep venous sys- veins of the calf. The inability to vi-
One-half of our patients without tern. In this patient, US demonstrated sualize the iliac vein may be compen-
venous thrombosis demonstrated a extensive collateral circulation; these sated for by detecting abnormal
10%-50% increase in the diameter of findings were suggestive of an ab- Doppler flow in the common femoral
the common femoral vein during normality of the deep venous system, vein and by noting a less than 10%
Valsalva maneuver, a response that which was confirmed venognaphi- change in the common femoral vein
was interpreted as dampened in the cally. during the Valsalva maneuver. In
study by Effeney et a!. and that was Unlike other examinations used to rare cases, US may be limited by its
associated with venous thrombosis in detect deep venous thrombosis, US inability to show a completely
five of eight patients. These differ- can image other structural abnormal- thnombosed venous system.
ences most likely reflect variability ities that can clinically cause diagnos- Because of the anatomic constraints
in patient ability to perform Valsalva tic confusion. In our study, US me- of trying to visualize all of the deep
maneuver. vealed two Baker cysts and a groin veins of the calf and because physi-
Although it was not a sensitive in- hematorna that were believed to be cians at our institution do not give
dicator of lower extremity deep ye- responsible for symptoms that clini- anticoagu!ants to patients with isolat-
nous thrombosis, a common femoral cally mimicked deep venous throm- ed calf vein thrombosis, our examina-
vein response of less than 10% dur- bosis. tion was limited to the more proxi-
ing a Valsalva maneuver proved to Anatomic limitations of US include ma! deep venous system. Although
be a specific indicator of venous an inability to visualize the iliac vein large numbers of patients with exten-
thrombosis at or above the level of and the superficial femoral vein sive follow-up have not been stud-
the common femoral vein. In two of within the adductor canal and to ied, the literature suggests that in
our patients, this finding alone sug- demonstrate completely the deep most cases isolated calf vein throm-
gested iliac vein obstruction when
the remainder of the US examination
was normal. Because of significant
overlap of responses between pa-
tients with and without thrombosis
below the common femoral vein, we
believe that one should not use the
results of the Valsalva maneuver per-
formed at the level of the common
femoral vein to indicate distal ye-
nous thrombosis.
Of the criteria evaluated with son-
ography in this study, visible throrn-
bi in association with abnormal vein
compressibility was the most sensi-
tive for detecting deep venous
thrombosis. The results revealed a
91% sensitivity within the common
femoral vein and 94% sensitivity
within the superficial and pop!iteal
veins. A single false-negative diagno-
sis was in a patient in whom the deep a. b.
veins of the lower extremity could Figure 5. (a) Precompression sonogram of popliteal vein (arrow) without apparent throm-
not be identified because of complete bus. (b) On the compression scan, echogenic thrombus becomes visible (arrow).

a. b. c.
Figure 6. (a) Transverse scan shows echoes within left common femoral vein caused by slow blood flow. Although from this image the vein
could be misdiagnosed as thrombosed, the Doppler study (b) demonstrated flow. (c) Normal vein compression was also present.

750 Radiology
#{149} June 1987
bosis is self-limited, without signifi- femoral vein to Valsa!va maneuver is 7. Sumner DS, Lambeth A. Reliability of
cant embo!ic risks or postph!ebitic se- useful for suggesting the presence of Doppler ultrasound in the diagnosis of
acute venous thrombosis both above and
que!ae (20, 21). Because calf thrombi thrombus within the common femo-
below the knee. Am J Surg 1979; 138:205-
may occasionally propagate into the ral or iliac veins, a dampened re- 210.
popliteal vein, it seems reasonable to sponse (10%-50% increase) lacks sen- 8. Howe HR. Hansen KJ, Plonk GW. Ex-
perform a limited follow-up evalua- sitivity and specificity. In our study, panded criteria for the diagnosis of deep
venous thrombosis. Arch Surg 1984; 119:
tion of the poplitea! vein to detect the combined results of Doppler and
1167-1170.
such propagation. Alternatively, as real-time US examinations were 100% 9. Cranley JJ, Canos AJ, Sull WJ, Grass AM.
indicated in a recent report (22), me- sensitive for detecting venous throm- Phleborheographic technique for diag-
ticulous US scanning of the calf can bosis above the level of the calf. nosing deep venous thrombosis of the
Because our results show that US is lower extremities. Surg Gynecol Obstet
be undertaken in an effort to detect
1975; 141:331-339.
calf vein thrombosis. highly sensitive, we believe that this
10. Moser KM. Brach BB, Dolan GF. Clinical-
There are also several technical relatively simple, noninvasive mo- ly suspected deep venous thrombosis of
limitations of US that must be ad- da!ity should be used as the screen- the lower extremities: a comparison of ye-
dressed. If veins are examined only ing examination of choice in patients nography, impedance plethysomography,
and radiolabeled fibrinogen. JAMA 1977;
along their longitudinal axes, it is suspected of having lower extremity
237:2195-2198.
possible to misinterpret thrombosed deep venous thrombosis. A complete- 11. Prescott SM, Tikoff G, Coleman RE, et al.
veins as compressible because the !y normal US study from the level of ‘311-labeled fibrinogen in the diagnosis of
transducer laterally displaces them the common femoral to the popliteal deep vein thrombosis of the lower ex-
tremities. AJR 1 978; 131:451-453.
out of the field of view. For similar vein would exclude the diagnosis of
12. Holden RW, Klatte EC, Park HM, et al.
reasons, erroneous measurements venous thrombus from the level of Efficacy of noninvasive modalities for di-
can be obtained during the Valsa!va the iliac to the popliteal vein. If the agnosis of thrombophlebitis. Radiology
maneuver if the vein is imaged along clinical setting requires exclusion of 1981; 141 :63-66.
13. Hull R, Hirsh J, Sackett DL, et al. Corn-
its long axis. Because of these prob- isolated calf vein thrombosis, an I-
bined use of leg scanning and impedance
lems, our laboratory depends pnimar- 125 fibninogen scan should be con- plethysrnography in suspected venous
ily on cross-sectional, as opposed to sidered or venography should be thrombosis: an alternative to venography.
sagitta!, images. performed. If the US examination re- N Engl J Med 1977; 296:1497-1500.
Another technical problem can oc- veals an isolated Doppler flow abnor- 14. Hull R, Hirsh J, Sackett DL, Stoddart G.
Cost effectiveness of clinical diagnosis.
cur in the presence of a relatively hy- mality within the common femora! venography, and noninvasive testing in
poechoic thmombus. Raghavendna et vein or an isolated lack of response to patients with symptomatic deep-vein
a!. (19) noted that in three of 14 pa- the Valsa!va maneuver within the thrombosis. N Engl J Med 1981; 304:1561-
tients, thrombus was not seen, a!- common femoral vein, the diagnosis 1567.
15. Hull R, Hirsh J, Sackett DL. Replacement
though its presence was suggested of an iliac vein obstruction should be
of venography in suspected venous
because of abnormal vein compres- considered and contrast venography thrombosis by impedance plethysmogra-
sion. In our study, there was only should be performed. phy and ‘25I-fibrinogen leg scanning: a
one patient in whom thrombus was Although our results are extremely less invasive approach. Ann Intern Med
1981; 94:12-15.
not visible until venous compression favorable insofar as the sensitivity of
16. Ramchandani P, Soulen R, Fedullo L,
was applied (Fig. 5). Perhaps the US in the diagnosis of lower extrem- Gaines V. Deep vein thrombosis: signifi-
variable frequency of this finding re- ity deep venous thrombosis, because cant limitations of noninyasiye tests. Ra-
lates to different transducer sensitiv- these techniques are operator depen- diology 1985; 156:47-49.
17. Effeney DJ, Friedman MD, Gooding GAW.
ities for detecting very low level ech- dent, we suggest that each center de-
Iliofernoral venous thrombosis: real-time
oes. A final technical problem termine its own accuracy by initially ultrasound diagnosis, normal criteria, and
encountered on noncompression performing the US studies with yen- clinical applications. Radiology 1984;
views was the potential for misdiag- ographic confirmation. U 150:787-792.
nosis of visibly flowing blood (due to 18. Raghavendra BN, Rosen RJ, Lam 5, Riles
T, Horii SC. Deep venous thrombosis:
slow flow associated with Rou!eaux References detection by high resolution real-time
formation) (23) as thrombus (Fig. 6). 1. Hull R, Hirsh J, Sackett DL, Stoddart G. sonography. Radiology 1984; 152:789-793.
The results of our study suggest Cost effectiveness of clinical diagnosis, 19. Raghavendra BN, Horii SC, Hilton 5, Su-
that abnormal vein compression in venography, and noninvasive testing in bramanyam BR, Rosen RJ, Lam S. Deep
patients with symptomatic deep-vein venous thrombosis: detection by probe
association with visible intraluminal
thrombosis. N EngI J Med 1981; 304:1561- compression of veins. J Ultrasound Med
thrombi is the most sensitive US 1567. 1986; 5:89-95.
finding for diagnosing lower extrem- 2. Lund F, Diener L, Ericsson J. Postmortem 20. Moser KM. LeMoine JR. Is embolic risk
ity deep venous thrombosis. Abnor- intraosseous phlebography as an aid in conditioned by location of deep venous
studies of venous thromboembolism. An- thrombosis? Ann Intern Med 1981; 94:
ma! Doppler flow within the corn-
giology 1969; 20:155-176. 439-444.
mon femoral vein suggests thrombus 3. Albrechtsson U, Olsson C-G. Thrombotic 21. Kakkar V. Howe C, Flank C, Clarke M.
within the common femoral vein, side-effects of lower-limb phlebography. Natural history of postoperative deep
and, in all likelihood, as deep Dopp- Lancet 1976; 1:723-724. vein thrombosis. Lancet 1967; 2:230-232.
4. Bettman MA, Paulin S. Leg phlebogra- 22. Dauzat MM, Laroache J-P, Charras C, et al.
ler analysis becomes more available,
phy: the incidence, nature, and modifica- Real-time B-mode ultrasonography for
this technique will also be useful for tion of undesirable side effects. Radiology better specificity in the noninvasive diag-
examining the distal portions of the 1977; 122:101-104. nosis of deep vein thrombosis. J Ultra-
deep venous system. Although a 5. Bettmann MA, Salzman EW, Rosenthal D, sound Med 1986; 5:625-631.
et al. Reduction of venous thrombosis 23. Machi J, Sigel B, Beitler JC, Coelho JC, Jus-
markedly diminished (less than 10%
complicating phlebography. AJR 1980; tin JR. Relation of in vivo blood flow to
increase) response of the common 134:1169-1172. ultrasound echogenicity. JCU 1983; 11:3-
6. Barnes RW. Ultrasound techniques for 10.
evaluation of lower extremity venous dis-
ease. In: Zwibel WJ, ed. Introduction to
vascular ultrasonography. New York:
Grune & Stratton, 1982; 273.

Volume 163 Number 3 Radiology 751

#{149}