WFUMB Course Book
DEEP VEIN THROMBOSIS
29. Deep Vein Thrombosis
Leandro Fernandez, Michael Kawooya
Keywords: Deep vein thrombosis, venous thromboembolic disease, Doppler
ultrasound, POCUS, DVT ultrasound technique.
29.1. Introduction
Deep Venous Thrombosis (DVT) is an important disease that occurs worldwide
and should be evaluated thoroughly because of its direct relationship with another
potentially fatal disease - Pulmonary Thromboembolism (PE). Both are jointly
referred to as Venous Thromboembolic Disease (VTE). VTE is the third leading cause
of cardiovascular disease morbidity and mortality after ischemic heart disease and
cerebrovascular disease. We do not have exact data regarding the incidence and
prevalence of this disease worldwide; however, it seems that its global incidence
is 100-200/100,000 per year, but this figure may vary by country. There are data
supporting the fact that the number is lower in young population with values below
5/100,000 in children under 15 years of age, whereas in the population over 80
years of age, it reaches 500 cases per 100,000 inhabitants. It has been estimated
that 300,000 to 600,000 cases may occur in the U.S. each year; this is a wide range
due to under-diagnosis and the resulting under-reporting. It has been reported that
about 460,000 cases occur annually in the European Union. Latin America shows
a similar pattern. A significant number of untreated patients die from PE within the
first month of diagnosis, and in patients who receive treatment, mortality can be
as high as 10%, which is still a remarkable figure. The risk factors for VTE are well
known: age >60 years, cancer, liver or cardiovascular disease, smoking, use of oral
contraceptives or hormone replacement therapy, trauma, prolonged immobilization,
and recent surgery within 12 weeks - especially orthopedic, gynecological and
abdominal. There are also less frequent causes, called intrinsic or of genetic origin,
which lead to a state of hypercoagulability commonly referred to as thrombophilia,
including antiphospholipid syndrome, deficiency of specific factors, etc. High levels
of prevalence of DVT in hospitalized patients have been identified during the 2020
COVID-19 pandemic, with values reaching almost 50% of cases. The evolution
of these patients has been torpid, presenting greater complications compared to
those patients who did not have DVT.
Patients who have suffered a DVT may develop a condition called Post Thrombotic
Syndrome (PTS) which is typically accompanied by persistent edema of the affected
limb that sometimes shows greater involvement alternating with some improvement,
inflammation, changes in skin color and scaling, as well as persistent pain.
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29.
The occurrence of the PTS varies according to the published series, from 8% to 50%.
29.2. Anatomy of the venous system
As with any ultrasound (US) study, the examiner must have adequate knowledge of
the anatomy of the organ or region to be evaluated. This principle is also true for the
evaluation of DVT. It therefore is necessary to have a good knowledge of the vascular
routes, the anatomical nomenclature of the veins and then write the report according to
the clinical concerns of the referring physician. A close link between these professionals
and the examiner or vascular laboratory is recommended. We can divide the veins of
the lower extremities into 3 systems: superficial, deep and perforating.
29.2.1. The superficial venous system
It has multiple veins but the main components are the great or magna saphenous
vein (GSV) and the small or parva saphenous vein (SSV), which carry the blood from
the superficial levels of the skin and subcutaneous tissue to the veins of the deep
system. They are located in the so-called epifascial space, external to the muscular
aponeurosis. The GSV originates anterior to the medial the malleolus and ascends
along the leg lateral to the medial edge of the tibia. It passes posterior to the medial
epicondyle of the femur and continues along the anteromedial aspect of the thigh
until it reaches the groin where, after perforating the aponeurosis, it drains into the
common femoral vein about 4 cm inferior to the inguinal ligament. The SSV originates
posterior the lateral malleolus and courses along the posterior aspect of the calf until
it becomes subaponeurotic in the upper third of the leg and converges in the popliteal
vein. Both in the leg and in the thigh, there are communicating veins that connect both
saphenous veins.
29.2.2. The deep venous system
This is the main focus of this chapter. Deep veins are usually even vascular structures
that accompany the arteries within the intermuscular fascia of the lower limb. They are
located in the subfascial space, that is, below the fascia and the aponeurosis, within the
muscle mass and accompanying the corresponding arteries in a parallel arrangement.
Deep veins are the anterior and posterior tibial, peroneal, gastrocnemius, soleus,
popliteal, femoral, deep femoral, common femoral and iliac veins. The posterior tibial
veins originate in the internal retromalleolar canal and ascend in the medial aspect
of the leg within the calf muscles. The anterior tibial veins are a continuation of the
dorsalis pedis veins and ascend within the anterior compartment of the leg, very close
to or in contact with the interosseous membrane.
WFUMB Course Book
The soleus and gastrocnemius veins are in the posterior leg muscle mass in the
soleus and gastrocnemius muscles and are collecting venous lakes that drain into
the popliteal vein. The peroneal veins have their origin in the plantar surface of the
foot and malleolar region, to end up joining the posterior tibial veins and forming
the tibioperoneal trunk in the upper third of the leg that will later give rise to the
popliteal vein. The popliteal vein is usually a single vein, although it can often be
duplicated. It becomes the femoral vein after passing through the adductor canal
ring and changing its position from the posterior aspect to the medial aspect of
the limb. The femoral vein ascends and then crosses the Scarpa’s triangle and
receives the deep femoral vein to then form the common femoral vein which, after
the confluence with great saphenous vein, passes under the crural arch to become
the external iliac vein (Fig 29.1).
View enlarged image
Fig 29.1
Schematic image of lower
extremity deep veins
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29. DEEP VEIN THROMBOSIS
Deep venous system
• tibial anterior and posterior tibial
• peroneal
• gastrocnemius
• soleus
• poplitea
• femoral, deep femoral, common femoral
• iliac veins
29.2.3. The perforating system
This is very important for draining blood from the superficial to the deep system and
owes its name to the fact that the vessels that compose it cross the aponeurotic
fascia. The vascular elements that form part of this system are numerous and are
located in various points of the thigh and leg.
29.2.4. The communicating system
These veins communicate with veins of the same system without crossing the
aponeurosis.
29.3. Sensitivity and specificity of ultrasound in the US
room/vascular laboratory and POCUS. Indications.
Duplex Ultrasonography (DUS) is currently the first line method for the diagnosis of
DVT in patients with suspected disease. Today it is a routine and inexpensive study
that offers anatomical and hemodynamic evaluation, is non-invasive, produces no
ionizing radiation, and can be performed with more robust cart-based y equipment or
very compact handheld equipment, which makes it practical and portable. Although
it is a test not without limitations, many authors consider it the gold standard for the
diagnosis of DVT of proximal and distal location in the lower limb. The sensitivity of
the DUS is 96-98% with a specificity of 98-100% but these values will depend on
the technique and transducers used. These values of high sensitivity and specificity
are observed in multiple and diverse series where a comparison is made between
the studies carried out by technical personnel in the ultrasound rooms or by the
medical specialists or residents in the emergency areas.
WFUMB Course Book 29. DEEP VEIN THROMBOSIS

The location of the thrombus contributes greatly to good sensitivity and specificity In these cases, the possibility of having the emergency specialist staff or resident
of diagnostic ultrasound (DUS). The thrombus located in the iliac veins account doctors from other specialties to perform the ultrasound study is of great benefit since,
for only 1-2% of cases and for this this region, DUS is limited whereas the thrombi in this way, a quick, reliable and accurate diagnosis can be obtained. Depending
located in the femoral-popliteal region femoral-popliteal regions contribute to 80- on the technique used, as well as the degree of training and experience of the
90% of the thrombi and here DUS is more useful.The indication for suspected DVT examiner, the study can take about 30-40 minutes with a complete and detailed
can be guided by the use of the Wells’ scale (table 29.1). protocol performed in the ultrasound room, down to a very short time of 3-4 minutes,
when the study is performed in the emergency area by the specialist or resident medical
Table 29.1 Wells Scale staff. The various techniques are implemented according to the specific needs of the
hospital, based on the availability of the above-mentioned resources.
Clinical Background Scores
Active cancer 1
Immobility >3 days or major surgery ≤ 4 weeks 1 29.4.1. Point-of-care ultrasound, (POCUS)
This is a study performed at the patient’s location, either with a portable ultrasound
Swelling of the whole leg 1
machine or a handheld device. This is a targeted, limited, guided and time-sensitive
Swelling of the calf 1 study. There are several ways to perform this study, the first one by using the 2-point
Non-varicose superficial collateral veins 1 compressive ultrasound (CUS) technique which is carried out only by compressing
the common femoral vein and the popliteal vein. To address the limitations of this
Sensitivity located along the path of the deep system 1
simple method, many authors recommend CUS in two areas; first in the femoral
Edema with major pitting in the symptomatic leg 1 region which allows observation of the saphenofemoral junction, the common
Paresis, paralysis or recent cast immobilization 1 femoral vein and the more proximal segments of the femoral and deep femoral
veins and secondly, in the popliteal region where the objective is to document
Previous confirmed DVT 1 the popliteal vein and the confluence of the calf veins. Both areas are usually
Alternative diagnosis with higher probability -2 3-4 cm long. The 2-region POCUS technique has been widely accepted. Another
evaluation method is to perform extended compressive ultrasound (ECUS) on the
Interpretation: -2- 0 Low risk 1-2 Moderate risk >3 High risk entire limb to visualize all of the vessels in the deep vein system, which improves
the chances of detecting DVT. This latter technique is our preferred technique
when opting for POCUS.
Remember
• US is currently the method of choice for venous study of the lower limbs
29.4.2. DUS (Doppler US) complete study
The recommendation for a complete study of the entire limb from the groin
to the ankle has been adopted by many centers worldwide, including ours.
29.4. Technique, transducers and settings The examination includes initial visualization in B-mode, performing venous
compression on all deep vessels, use of Color Doppler (CD) and subsequent
Several techniques have been described for performing DUS in DVT diagnosis. documentation of the spectrum with Pulsed Doppler (PW). Another topic for discussion
Choosing the method to be used will depend on the availability of equipment and in various countries is whether to examine only the symptomatic limb or both. The
qualified personnel. Not all health care facilities offer 24/7 imaging services and answer to this question will depend on the recommendations issued by the local
vascular technicians. In some cases, these imaging services or vascular labs are health authorities, the guidelines of the health system, whether public or private, as
located far from the emergency area where the patient is being seen. well as the medical societies linked to the diagnosis and treatment of DVT.

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WFUMB Course Book 29. DEEP VEIN THROMBOSIS

Therefore, we see that some authors recommend studying only the symptomatic View enlarged image
leg, while others recommend evaluating both legs. Those who support evaluating
only the symptomatic leg rely on statistical studies suggesting that the probability of
finding a thrombus in the asymptomatic leg varies from 0-1%, and hence the cost
and time required for the evaluation of the second limb would not be warranted. At
the WFUMB Education Center in Venezuela we evaluate both extremities and not
rarely we have found old thrombi in the asymptomatic leg of oncological patients
being treated with chemotherapy.

29.4.3. Patient’s position

With any of the above techniques, the patient is placed in a supine position, the
Fig 29.2
limb to be examined is rotated externally and gently so as not to hurt the hip joint,
High frequency linear
especially in the elderly, and then the knee is flexed to present the popliteal region.
transducer

29.4.4. Ultrasound equipment Ultrasound protocols

The transducer to be used must be high frequency linear with a 10-5 MHz or more, • POCUS compressive 2-regions: GOOD
connected to analog or digital equipment (Fig 29.2). Most manufacturers offer • POCUS extended compressive ultrasound ECUS: BETTER
default settings that we will use by choosing the vein-specific program. Depending • Complete Doppler Ultrasound DUS entire limb: BEST
on the manufacturer, these settings usually have a B mode gain of 45-55%, color
PRF at 1800-2200 Hz with color gain at 65%. All the settings can be modified by the
operators in order to obtain the image that will enable them to make their diagnosis.
The proximal vessels require higher PRF and the distal vessels are evaluated with View enlarged image

lower PRF, due to the difference in flow velocity between them, with higher flow
velocity in the proximal region and slower velocity in the distal region (Fig 29.3).

29.4.5. Technique
The transducer is placed in a transverse position with the orientation mark to the
right of the patient and using the B mode, then venous compression is performed
on all deep vessels, at a distance of about 2 cm between each compression. The
transducer is then oriented longitudinally with the mark towards the patient’s head, Fig 29.3
in order to document the spontaneous CD signal or with a distal compression Distal leg. Low velocity flow
maneuver and thus be able to see the filling of the vessel in which the PW-generated in posterior tibial veins well
spectral analysis will later be recorded. depicted adjusting PRF to
low settings

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WFUMB Course Book 29. DEEP VEIN THROMBOSIS

29.5. Ultrasound findings. Acute vs. chronic thrombus View enlarged image

The venous walls are fine and smooth, with no irregularities and only the anechoic
image of the blood circulating through them can be appreciated. Under normal
conditions, by using the transducer, which should always be placed in a transverse
position, a slight pressure can be exerted on the soft tissues in the study region,
thus compressing the vessel and showing that its anterior and posterior walls
are in contact, thereby obstructing the vein during the maneuver. At the end of Fig 29.4
compression, the vein reopens and flow is reestablished. When there is a Transversal plane in crural
thrombosis, the clot is observed as an image formed by low to medium amplitude region: a: common femoral
echoes that partially or totally occludes the lumen and that will change based on vein; b - great saphenous
evolution time. When the compression maneuver is performed, the thrombus inside mouth with thrombus; c -
superficial femoral artery; d
the vein prevents the vascular walls from becoming attached. This is called a
- deep femoral artery; Arrow
positive compression maneuver that will confirm the presence of DVT (Fig 29.4-5).
- thrombus
Evaluation of the normal vein by the Color/Power Doppler signal shows a complete
filling of the vessel which is more evident in the thigh veins due to their higher
flow rate (Fig 29.6). If the filling is not sufficient after increasing the color gain and
decreasing PRF in our equipment, a manual compression is performed distally to
the transducer and this will allow obtaining the image of the full filling process. In the
presence of a thrombus, the Color/Power Doppler signal will show irregularities in
the flow path or no flow at all and the filling will not be revealed when performing the
distal compression maneuver either (Fig 29.7-8). Normal spectral analysis shows
phasic and oscillating flow associated with respiratory movements (Fig 29.9-10). In
the case of thrombosis, the flow distal to the thrombus will be continuous with loss
of its oscillating pattern (Fig 29.11) and there will be no flow at the thrombus site if View enlarged image

the obstruction is complete or it may be equally continuous but accelerated in the

residual lumen (Fig 29.12).

Ultrasound findings in DVT

• Echogenic image within the vessel
• Positive compression maneuver
• No color Doppler signal
• No color Doppler flow with distal compression maneuver
• Continuous and non-oscillating distal flow pattern with PW Fig 29.5a
Transversal plane in crural
region, no compression

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WFUMB Course Book
View enlarged image
Fig 29.5b
Transversal plane in crural
region. Right positive
compression maneuver
in great saphenous with
thrombus. Common femoral
with normal wall contact
View enlarged image
Fig 29.6
Power Doppler longitudinal
image of femoral v. and
deep femoral v. confluence
to common femoral vein.
Because non-directional
Power Doppler was used,
the superficial femoral artery
on top is coded with the
same color
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29. DEEP VEIN THROMBOSIS
View enlarged image
Fig 29.7
Longitudinal plane of
posterior tibial veins. Color
Doppler shows 2 veins
coded in blue and a tiny
communicant vein coded in
red, bringing flow from lower
to upper vessel
View enlarged image
Fig 29.8
Posterior tibial v. thrombosis
(arrows) Low amplitude
echoes (hypoechoic) within
both vessels. No color signal
with the lowest PRF of
the system. Aliasing in the
posterior tibial artery due
the adjusted low PRF (pulse
repetition frequency)
WFUMB Course Book
View enlarged image
Fig 29.9
Normal longitudinal CD
image of femoral v. and
deep femoral v. confluence
to common femoral vein
View enlarged image
Fig 29.10
Normal spectral analysis
shows phasic and oscillating
flow associated with
respiratory movements
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29. DEEP VEIN THROMBOSIS
View enlarged image
Fig 29.11
In the case of proximal
thrombosis of measurement
site, the flow distal to the
thrombus will be continuous
with loss of its oscillating
pattern
View enlarged image
Fig 29.12
In the case of partial
thrombosis, the flow of the
residual lumen is continuous
and accelerated
WFUMB Course Book 29. DEEP VEIN THROMBOSIS

29.5.1. Acute vs. chronic thrombosis View enlarged image

The DUS makes it possible to differentiate between acute and chronic thrombosis.
The ultrasound characteristics allow us to make the diagnosis of DVT and its
evolution over time. This information is necessary to make therapeutic decisions
such as anticoagulation. The more recent the clot is, the more hypoechoic it is,
so much so that sometimes it is not visible and only the compression maneuver
can make it apparent. As the days pass, the clot increases in echogenicity and
becomes more heterogeneous and firmer. In the acute phase the vein is dilated
and the compression is painful (Fig 29.13-14).
Fig 29.14
As progress continues, the vein decreases in size and the pain at compression Longitudinal B mode image
with popliteal incipient
decreases or disappears. After the fourth week it can be considered a chronic
thrombosis affecting the
event and with time, a hyperechoic line can be observed inside the vessel, called
valve. The vein is dilated.
the intraluminal membrane or scar. In chronic cases there is often evidence of Painful compression
valvular insufficiency due to lesions of the valves caused by the thrombus.

The extension of the clot should be reported detailing the location and length of the
clot, the vessels involved, whether it is in an acute or chronic phase, whether the
occlusion is partial or total, and whether there is recanalization or disappearance of
the thrombus due to the effect of the anticoagulant treatment (Fig 29.15-16).
View enlarged image
The term chronic post-thrombotic changes is recommended to describe persistent
residual material after an episode of acute DVT in order to avoid unnecessary
anticoagulation treatment (Fig 29.17-20) (table 29.2). The DUS is an operator-
dependent method that shows decreased sensitivity and specificity in the presence
of severe edema, lipodermatosclerosis, obesity and immobilization by casts, splints
or osteosynthesis material. It has significant advantages such as availability, it is
painless, accessible, risk-free and has no side effects, and it is the method of first
choice for the evaluation of patients with DVT.

Table 29.2 Acute vs. chronic thrombosis - characteristics

Acute Thrombus Chronic Thrombus
Anecoic or Hypoechoic Hyperechoic
Homogeneous Heterogeneous
Not much adherence Adhered
Fig 29.13
Floating Firm
Normal longitudinal CD of
popliteal vein. Total filling Spongy and deformable Rigid and non-deformable
with no echoic images within
Dilated and painful vein Contracted, non-painful vein
the vessel

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WFUMB Course Book
DVT differential diagnosis
• Baker’s cyst
• cellulitis
• lymphedema
• chronic venous insufficiency
• superficial thrombophlebitis
• popliteal venous or arterial aneurysm
• enlarged lymph nodes compressing the veins
• foreign body substances: biopolymers
• muscle tears
View enlarged image
Fig 29.15
Longitudinal image
of common femoral
vein thrombosis. After
unsuccessful thrombolytic
treatment the vessel is
dilated, has echogenic
material within the vein and
the Color box (ROI, region
of interest) shows no flow
signal
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29. DEEP VEIN THROMBOSIS
View enlarged image
Fig 29.16
Incipient gastrocnemius
veins thrombosis. The
site, extension and
characteristics of thrombosis
must be reported
View enlarged image
Fig 29.17
Common femoral v. chronic
thrombosis. Hypoechoic
B mode image with
scattered hyperechoic
dots. Vessel diameter is
normal. Insignificant pass
of flow coded in blue and
retrograde flow in red due
the obstruction caused by
the thrombus
WFUMB Course Book 29. DEEP VEIN THROMBOSIS

View enlarged image View enlarged image

Fig 29.18
Common femoral vein with
chronic post-thrombotic
changes. Partial obstruction Fig 29.20
of the vessel and clot Common femoral vein with
remnants with well-defined chronic post-thrombotic
edges changes. “Thrombotic scar”

View enlarged image

Fig 29.19
Common femoral vein
with chronic post-
thrombotic changes. Partial
recanalization is seen
with CD that shows flow
circulating between the clot
remnants adhered to the
vein walls

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WFUMB Course Book 29. DEEP VEIN THROMBOSIS

Recommended reading

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of the veins of the lower limb: Extensions, refinements and clinical application.
J Vasc Surg 2005; 416:719-24.
• Cohen A, Agnelli G, Anderson F, Arcelus J, Bergqvist D, Brecht J, et al. Venous
thromboembolism (VTE) in Europe. The number of VTE events and associated
morbidity and mortality. Thrombosis and haemostasis. 2007;987:56-64.
• Data and Statistics on Venous Thromboembolism. Centers for Disease Control
and Prevention, CDC. [cited Feb 7, 2020]. URL: https://www.cdc.gov/ncbddd/
dvt/data.html
• Galanaud JP, Monreal M, Kahn S. Epidemiology of the post-thrombotic
syndrome. Thrombosis Research. 2018;(164):100-109.
• Gianesini S, Obi A, Onida S , Baccellieri D, Bissacco D, Borsuk D et al. Global
guidelines trends and controversies in lower limb venous and lymphatic
disease: Narrative literature revision and experts’ opinions following the
vWINter international meeting in Phlebology, Lymphology & Aesthetics, 23-25
January 2019. Phlebology. 2019 Sep;34(1 Suppl):4-66. Available from: https://
pubmed.ncbi.nlm.nih.gov/31495256/
• Grimm L, Taylor C. Bedside Ultrasonography in Deep Vein Thrombosis
[Updated: Nov 08, 2017]. Available from: https://emedicine.medscape.com/
article/1362989-overview
• Lee DK, Ahn KS, Kang C, and Cho S. Ultrasonography of the lower extremity
veins: anatomy and basic approach. Ultrasonography. 2017 Apr;36(2):120–
130.
• Luo Z, Chen W, Li Y, Wang X, Zhang W, Zhu Y et al. Preoperative incidence
and locations of deep venous thrombosis (DVT) of lower extremity following
ankle fractures. Sci Rep. 2020;10:10266.
• Needleman L, Cronan J, Lilly M, Merli G, Adhikari S, Hertzberg B, et al.
Ultrasound for Lower Extremity Deep Venous Thrombosis Multidisciplinary
Recommendations From the Society of Radiologists in Ultrasound Consensus
Conference. Circulation. 2018;137:1505–1515
• Ren B, Yan F, Deng Z, Zhang S, Xiao L, Wu M, Cai L. Extremely high incidence
of lower extremity deep venous thrombosis in 48 patients with severe COVID-19
in Wuhan. Circulation. 2020;142:181–183
• Schick M, Pacifico L. Deep Venous Thrombosis (DVT) Of the Lower Extremity.
[updated Aug 10, 2020]. Available from: https://www.ncbi.nlm.nih.gov/books/
NBK470381/

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