May 2024

70 Year-old Female with Unilateral Lower Extremity Swelling

Author:  Ben Caviston, MD PGY-2

Peer Reviewers: Lee LaRavia, DO; Dan Kaminstein, MD

Learning Objectives:

• Discuss the differential of unilateral lower extremity edema
• Discuss use of POCUS in the workup 
• Discuss the US characteristics/findings associated with DVT
• Review of literature related to POCUS for diagnosis of DVT

Case Presentation: H&P and Differential

• 70F hx of Endometrial Carcinoma presenting with Right lower extremity swelling for one week now today with additional malaise, nausea and vomiting, No SOB or CP
• T: 37.1 °C (Oral) HR: 111(Peripheral) RR: 20 BP: 110/57 SpO2: 96%
• Exam: Ill Appearing, Tachycardic, Lungs Clear, Abdomen soft, RLE 2+ Pitting edema
• DDx: : DVT/PE, Cellulitis, Myositis, Abscess, Lymphangitis, Thrombophlebitis, CHF, Lymphedema, Necrotizing Fasciitis, Fracture, Baker’s Cyst, Septic Joint

POCUS Images

 

 

DVT POCUS Technique

• DVT most likely to form at branch points
• Identified by non-compressible vein
• Visualizing echogenic clot is a late finding
• Zone-1 Proximal Thigh: Frog Leg Position
• Begin scanning just below inguinal ligament in transverse axis, slide inferiorly

  1.Identify the Femoral-Saphenous Junction

  2.Identify the Femoral-Deep Femoral Junction

 

DVT POCUS Technique

• Zone-2 Popliteal Fossa
• Knee partially flexed

  1. Identify the Popliteal Vein

  2. 1.Identify the Popliteal Trifurcation

     • Splits into:

       • Peroneal Vein
       • Anterior Tibial Vein
       • Posterior Tibial Vein

Diagnosis and Case Disposition

• CTA showed Occlusive PE of the Right Superior Pulmonary Artery
• Heparin drip started at 13:37 after POCUS
• Radiology read of CTA 14:46
• Recognizing DVT on POCUS allowed heparin to be initiated >1hr sooner

Literature Review

• Bernardi et al 2008; 2465 patients randomized to either 2-Point Ultrasonography Plus D-Dimer (Repeat US in 1wk if positive) vs Whole-Leg Doppler Ultrasonography

  • 2 Point: Common femoral + Popliteal
  • Both strategies equivalent in DVT detection

  Crisp et al 2015; ED POCUS 2 Point Compression vs Radiology Venous Duplex

  • ED physicians received 10min of training and used Portable Vascular Access Ultrasound
  • 199 Patients and 45 w/DVTs all were identified by ED POCUS ( Sensitivity 100% )

  Adhikari et al 2014; 6.3% of ED patients with suspected deep venous thrombosis had isolated thrombi in proximal veins other than Common Femoral and Popliteal

  Highlights importance of visualizing Femoral+Deep Femoral in addition to Common Femoral

Take Away Points

• POCUS is highly sensitive and specific for DVT
• Literature suggests similar Sensitivity as Radiology Whole Leg Venous Duplex
• DVT most likely to form at branch points
• Recommend Use of 2-Zone as opposed to 2-Point Compression
• Ensuring visualization of the Deep Femoral Vein improves sensitivity
• Consider routine use of POCUS in patients with signs of DVT or suspected PE

References

• Adhikari S, Zeger W, Thom C, Fields JM. Isolated Deep Venous Thrombosis: Implications for 2-Point Compression Ultrasonography of the Lower Extremity. Ann Emerg Med. 2015 Sep;66(3):262-6. doi: 10.1016/j.annemergmed.2014.10.032. Epub 2014 Nov 20. PMID: 25465473.
• Bernardi E, et al; Erasmus Study Group. Serial 2-point ultrasonography plus D-dimer vs whole-leg color-coded Doppler ultrasonography for diagnosing suspected symptomatic deep vein thrombosis: a randomized controlled trial. JAMA. 2008 Oct 8;300(14):1653-9. doi: 10.1001/jama.300.14.1653. PMID: 18840838.
• Crisp JG, Lovato LM, Jang TB. Compression ultrasonography of the lower extremity with portable vascular ultrasonography can accurately detect deep venous thrombosis in the emergency department. Ann Emerg Med. 2010 Dec;56(6):601-10. doi: 10.1016/j.annemergmed.2010.07.010. Epub 2010 Sep 22. PMID: 20864215.