DVT Ultrasound Lecture

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December Case #1 Discussion

This patient has a normal ultrasound of the deep veins of the lower extremity- common femoral vein, junction point at the saphenous vein (superficial circulation), profunda femoris and superficial femoral vein. However, the area to which he was most tender was along his medial thigh. At the point of the images and video, he had a small palpable knot. The resultant images indicate superficial thrombophlebitis.

Deep Venous Thrombosis

When evaluating a patient for DVT, we usually look only at the deep circulation of the leg. The picture below illustrates the veins of the leg. Notice that the superficial circulation (dark blue) joins with the deep veins (light blue) to become the common femoral vein (CFV).

Traditional ultrasound protocols scan through the CFV, the junction point with the saphenous vein, the profunda femoris and the superifical femoral vein (SFV), then look at the popliteal above the trifurcation in the calf, illustrating compressibility as they go. However, in this month's edition of the Annals of Emergency Medicine, Crisp et al, illustrate that compression ultrasound performed at 2 points only, CFV and popliteal, had a 100% sensitivity for DVT (link to article at bottom of page). Since previous studies have illustrated that DVTs never occur solely in the SFV, it is important to know that the CFV, and not the SFV, is visualized on the screen. Therefore, I advocate that you still scan caudal to cranial in the inguinal canal to locate the CFV. Scanning through the profunda and the junction point ensures that the CFV will not be mistaken for the SFV. Once the CFV is visualized, then video clips or split screen still images should be taken to illustrate compressibility.

Superficial Thrombophlebitis

On the other hand, superficial thrombophlebitis is characterized by a clot within the lumen of a superficial vein, which leads to inflammation of the walls of the vessels, as well as, the surrounding tissue. It is most commonly found in varicose veins of the lower extremity but can proliferate up the venous circulation. If it extends through the greater saphenous vein into the common femoral vein, then it may become a deep venous thrombosis (rare).

On Ultrasound the thrombosed vein wall appears thickened, lacks compressibility and may have a hyperechoic center, indicating clot. Due to the inflammation and edema, the surrounding tissue may show evidence of this as a cobblestone appearance on ultrasound.

In the original case, a superficial branch of the great saphenous vein is identified with visible clot and non-compressibility, about 1cm below the skin's surface.

To further illustrate superfical thrombophlebitis, here are images from another case, clearly demostrating a hyperechoic clot in the lumen with surrounding tissue edema and a lack of compresibility.

December Case #1

50 y/o WM presents to the ED with complaints of R leg pain for 3 days. He denies trauma or physical exertion. He admits to edema localized to the thigh, but denies calf swelling. Denies redness, warmth or pointing of the skin.
PMHx: HTN
PSHx: none
Social: denies ETOH, tobacco or drug use
Meds: HCTZ
Allergies: NKDA

PE: VS WNL
GEN: WNWD, WM, NAD
CHEST: CTA B
CV: RRR, no M/R/G
ABD: soft, NTND, +BS
EXT: no C/C, edema to R mid thigh with tenderness to palpation that extends to R calf, distal pulses 2+ bilaterally. No palpable cords noted

Bedside ultrasound is performed to rule out deep venous thrombosis:


What is your interpretation of this DVT study?

While scanning for DVT the patient states, "the pain is actually here" and points to the medial thigh. The area is then scanned and the following are noted:




What is the diagnosis?