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Deep Venous Thrombosis: Recent Advances and Optimal Investigation with US¹

¹ From the Departments of Radiology (J.D.F.) and Medicine (D.R.A.), Queen Elizabeth II Health Sciences Centre, 1278 Tower Rd, Halifax, Nova Scotia, Canada B3H 2Y9. Received February 12, 1998; revision requested March 18; final revision received September 9; accepted October 19. D.R.A. is a Research Scholar of the Canadian Heart and Stroke Foundation. Address reprint requests to J.D.F.

View larger version (182K): [in a new window]   Figure 1a. (a) Transverse US image of the left common femoral vein (arrowhead) and smaller adjacent artery (arrow). (b) With compression, in the absence of thrombosis, the walls of the vein are completely apposed while the artery (arrow) remains patent.

View larger version (170K): [in a new window]   Figure 1b. (a) Transverse US image of the left common femoral vein (arrowhead) and smaller adjacent artery (arrow). (b) With compression, in the absence of thrombosis, the walls of the vein are completely apposed while the artery (arrow) remains patent.

View larger version (74K): [in a new window]   Figure 2a. Location of the calf veins. (a) Location of the paired calf veins just above the ankle. ATV = anterior tibial veins, F = fibula, PTV = posterior tibial veins, PV = peroneal veins, T = tibia, TN = tibial nerve. (b) Transverse US image just above ankle demonstrates the paired posterior tibial veins (V) and posterior tibial artery (A) imaged from a posteromedial approach. Note there is inadequate venous flow velocity to visualize with color Doppler without flow augmentation. (c) Longitudinal image with Doppler interrogation of one of the posterior tibial veins during flow augmentation. This can be used to help confirm the location of the vein and suggests patency. (d) Color Doppler US demonstration of the paired peroneal veins (V) and artery (A) just above the ankle during augmentation via a posterolateral approach. (e) Paired anterior tibial veins (V) and artery (A) during flow augmentation via an anterior approach. (f) Location of the paired calf veins at the midcalf level. ATV = anterior tibial veins, F = fibula, IM = interosseous membrane, PTV = posterior tibial veins, PV = peroneal veins, T = tibia, TN = tibial nerve. (g) Transverse color Doppler image of the paired larger posterior tibial veins (arrows) and smaller peroneal veins (arrowheads) at the level of the midcalf during flow augmentation imaged from a posterior medial approach. (h) Transverse US image of the paired anterior tibial veins (arrowheads) during augmentation imaged via an anterior approach. The vessels are often difficult to visualize at or proximal to this level because of their deep location just anterior to the interosseous membrane between the tibia and fibula.

View larger version (173K): [in a new window]   Figure 2b. Location of the calf veins. (a) Location of the paired calf veins just above the ankle. ATV = anterior tibial veins, F = fibula, PTV = posterior tibial veins, PV = peroneal veins, T = tibia, TN = tibial nerve. (b) Transverse US image just above ankle demonstrates the paired posterior tibial veins (V) and posterior tibial artery (A) imaged from a posteromedial approach. Note there is inadequate venous flow velocity to visualize with color Doppler without flow augmentation. (c) Longitudinal image with Doppler interrogation of one of the posterior tibial veins during flow augmentation. This can be used to help confirm the location of the vein and suggests patency. (d) Color Doppler US demonstration of the paired peroneal veins (V) and artery (A) just above the ankle during augmentation via a posterolateral approach. (e) Paired anterior tibial veins (V) and artery (A) during flow augmentation via an anterior approach. (f) Location of the paired calf veins at the midcalf level. ATV = anterior tibial veins, F = fibula, IM = interosseous membrane, PTV = posterior tibial veins, PV = peroneal veins, T = tibia, TN = tibial nerve. (g) Transverse color Doppler image of the paired larger posterior tibial veins (arrows) and smaller peroneal veins (arrowheads) at the level of the midcalf during flow augmentation imaged from a posterior medial approach. (h) Transverse US image of the paired anterior tibial veins (arrowheads) during augmentation imaged via an anterior approach. The vessels are often difficult to visualize at or proximal to this level because of their deep location just anterior to the interosseous membrane between the tibia and fibula.

View larger version (126K): [in a new window]   Figure 2c. Location of the calf veins. (a) Location of the paired calf veins just above the ankle. ATV = anterior tibial veins, F = fibula, PTV = posterior tibial veins, PV = peroneal veins, T = tibia, TN = tibial nerve. (b) Transverse US image just above ankle demonstrates the paired posterior tibial veins (V) and posterior tibial artery (A) imaged from a posteromedial approach. Note there is inadequate venous flow velocity to visualize with color Doppler without flow augmentation. (c) Longitudinal image with Doppler interrogation of one of the posterior tibial veins during flow augmentation. This can be used to help confirm the location of the vein and suggests patency. (d) Color Doppler US demonstration of the paired peroneal veins (V) and artery (A) just above the ankle during augmentation via a posterolateral approach. (e) Paired anterior tibial veins (V) and artery (A) during flow augmentation via an anterior approach. (f) Location of the paired calf veins at the midcalf level. ATV = anterior tibial veins, F = fibula, IM = interosseous membrane, PTV = posterior tibial veins, PV = peroneal veins, T = tibia, TN = tibial nerve. (g) Transverse color Doppler image of the paired larger posterior tibial veins (arrows) and smaller peroneal veins (arrowheads) at the level of the midcalf during flow augmentation imaged from a posterior medial approach. (h) Transverse US image of the paired anterior tibial veins (arrowheads) during augmentation imaged via an anterior approach. The vessels are often difficult to visualize at or proximal to this level because of their deep location just anterior to the interosseous membrane between the tibia and fibula.

View larger version (125K): [in a new window]   Figure 2d. Location of the calf veins. (a) Location of the paired calf veins just above the ankle. ATV = anterior tibial veins, F = fibula, PTV = posterior tibial veins, PV = peroneal veins, T = tibia, TN = tibial nerve. (b) Transverse US image just above ankle demonstrates the paired posterior tibial veins (V) and posterior tibial artery (A) imaged from a posteromedial approach. Note there is inadequate venous flow velocity to visualize with color Doppler without flow augmentation. (c) Longitudinal image with Doppler interrogation of one of the posterior tibial veins during flow augmentation. This can be used to help confirm the location of the vein and suggests patency. (d) Color Doppler US demonstration of the paired peroneal veins (V) and artery (A) just above the ankle during augmentation via a posterolateral approach. (e) Paired anterior tibial veins (V) and artery (A) during flow augmentation via an anterior approach. (f) Location of the paired calf veins at the midcalf level. ATV = anterior tibial veins, F = fibula, IM = interosseous membrane, PTV = posterior tibial veins, PV = peroneal veins, T = tibia, TN = tibial nerve. (g) Transverse color Doppler image of the paired larger posterior tibial veins (arrows) and smaller peroneal veins (arrowheads) at the level of the midcalf during flow augmentation imaged from a posterior medial approach. (h) Transverse US image of the paired anterior tibial veins (arrowheads) during augmentation imaged via an anterior approach. The vessels are often difficult to visualize at or proximal to this level because of their deep location just anterior to the interosseous membrane between the tibia and fibula.

View larger version (147K): [in a new window]   Figure 2e. Location of the calf veins. (a) Location of the paired calf veins just above the ankle. ATV = anterior tibial veins, F = fibula, PTV = posterior tibial veins, PV = peroneal veins, T = tibia, TN = tibial nerve. (b) Transverse US image just above ankle demonstrates the paired posterior tibial veins (V) and posterior tibial artery (A) imaged from a posteromedial approach. Note there is inadequate venous flow velocity to visualize with color Doppler without flow augmentation. (c) Longitudinal image with Doppler interrogation of one of the posterior tibial veins during flow augmentation. This can be used to help confirm the location of the vein and suggests patency. (d) Color Doppler US demonstration of the paired peroneal veins (V) and artery (A) just above the ankle during augmentation via a posterolateral approach. (e) Paired anterior tibial veins (V) and artery (A) during flow augmentation via an anterior approach. (f) Location of the paired calf veins at the midcalf level. ATV = anterior tibial veins, F = fibula, IM = interosseous membrane, PTV = posterior tibial veins, PV = peroneal veins, T = tibia, TN = tibial nerve. (g) Transverse color Doppler image of the paired larger posterior tibial veins (arrows) and smaller peroneal veins (arrowheads) at the level of the midcalf during flow augmentation imaged from a posterior medial approach. (h) Transverse US image of the paired anterior tibial veins (arrowheads) during augmentation imaged via an anterior approach. The vessels are often difficult to visualize at or proximal to this level because of their deep location just anterior to the interosseous membrane between the tibia and fibula.

View larger version (108K): [in a new window]   Figure 2f. Location of the calf veins. (a) Location of the paired calf veins just above the ankle. ATV = anterior tibial veins, F = fibula, PTV = posterior tibial veins, PV = peroneal veins, T = tibia, TN = tibial nerve. (b) Transverse US image just above ankle demonstrates the paired posterior tibial veins (V) and posterior tibial artery (A) imaged from a posteromedial approach. Note there is inadequate venous flow velocity to visualize with color Doppler without flow augmentation. (c) Longitudinal image with Doppler interrogation of one of the posterior tibial veins during flow augmentation. This can be used to help confirm the location of the vein and suggests patency. (d) Color Doppler US demonstration of the paired peroneal veins (V) and artery (A) just above the ankle during augmentation via a posterolateral approach. (e) Paired anterior tibial veins (V) and artery (A) during flow augmentation via an anterior approach. (f) Location of the paired calf veins at the midcalf level. ATV = anterior tibial veins, F = fibula, IM = interosseous membrane, PTV = posterior tibial veins, PV = peroneal veins, T = tibia, TN = tibial nerve. (g) Transverse color Doppler image of the paired larger posterior tibial veins (arrows) and smaller peroneal veins (arrowheads) at the level of the midcalf during flow augmentation imaged from a posterior medial approach. (h) Transverse US image of the paired anterior tibial veins (arrowheads) during augmentation imaged via an anterior approach. The vessels are often difficult to visualize at or proximal to this level because of their deep location just anterior to the interosseous membrane between the tibia and fibula.

View larger version (169K): [in a new window]   Figure 2g. Location of the calf veins. (a) Location of the paired calf veins just above the ankle. ATV = anterior tibial veins, F = fibula, PTV = posterior tibial veins, PV = peroneal veins, T = tibia, TN = tibial nerve. (b) Transverse US image just above ankle demonstrates the paired posterior tibial veins (V) and posterior tibial artery (A) imaged from a posteromedial approach. Note there is inadequate venous flow velocity to visualize with color Doppler without flow augmentation. (c) Longitudinal image with Doppler interrogation of one of the posterior tibial veins during flow augmentation. This can be used to help confirm the location of the vein and suggests patency. (d) Color Doppler US demonstration of the paired peroneal veins (V) and artery (A) just above the ankle during augmentation via a posterolateral approach. (e) Paired anterior tibial veins (V) and artery (A) during flow augmentation via an anterior approach. (f) Location of the paired calf veins at the midcalf level. ATV = anterior tibial veins, F = fibula, IM = interosseous membrane, PTV = posterior tibial veins, PV = peroneal veins, T = tibia, TN = tibial nerve. (g) Transverse color Doppler image of the paired larger posterior tibial veins (arrows) and smaller peroneal veins (arrowheads) at the level of the midcalf during flow augmentation imaged from a posterior medial approach. (h) Transverse US image of the paired anterior tibial veins (arrowheads) during augmentation imaged via an anterior approach. The vessels are often difficult to visualize at or proximal to this level because of their deep location just anterior to the interosseous membrane between the tibia and fibula.

View larger version (173K): [in a new window]   Figure 2h. Location of the calf veins. (a) Location of the paired calf veins just above the ankle. ATV = anterior tibial veins, F = fibula, PTV = posterior tibial veins, PV = peroneal veins, T = tibia, TN = tibial nerve. (b) Transverse US image just above ankle demonstrates the paired posterior tibial veins (V) and posterior tibial artery (A) imaged from a posteromedial approach. Note there is inadequate venous flow velocity to visualize with color Doppler without flow augmentation. (c) Longitudinal image with Doppler interrogation of one of the posterior tibial veins during flow augmentation. This can be used to help confirm the location of the vein and suggests patency. (d) Color Doppler US demonstration of the paired peroneal veins (V) and artery (A) just above the ankle during augmentation via a posterolateral approach. (e) Paired anterior tibial veins (V) and artery (A) during flow augmentation via an anterior approach. (f) Location of the paired calf veins at the midcalf level. ATV = anterior tibial veins, F = fibula, IM = interosseous membrane, PTV = posterior tibial veins, PV = peroneal veins, T = tibia, TN = tibial nerve. (g) Transverse color Doppler image of the paired larger posterior tibial veins (arrows) and smaller peroneal veins (arrowheads) at the level of the midcalf during flow augmentation imaged from a posterior medial approach. (h) Transverse US image of the paired anterior tibial veins (arrowheads) during augmentation imaged via an anterior approach. The vessels are often difficult to visualize at or proximal to this level because of their deep location just anterior to the interosseous membrane between the tibia and fibula.

View larger version (169K): [in a new window]   Figure 3a. Case of a 34-year-old woman who presented early in the postpartum period with buttock, groin, and upper thigh pain. (a) Transverse US image of the common femoral vein (arrow) shows a noncompressible segment with distention of the vein from acute thrombus. This also involved the proximal superficial femoral vein. Distance between cursors (1, dotted line) is 1.07 cm. (b, c) US images demonstrate normal compressibility of popliteal segment. (b) Transverse image of the popliteal artery (red) and vein (blue) shows spontaneous venous flow. (c) With compression, there is complete apposition of the vein walls, while the artery (arrowhead) is patent; this excludes popliteal vein thrombosis. (d) Longitudinal color Doppler image along the left iliac artery (yellow and blue) and thrombosed left iliac vein (arrowheads). Note that a lower frequency transducer was required to visualize the vessels due to their deeper location in the pelvis. (e) Longitudinal color Doppler image demonstrates the patent inferior vena cava (orange) in this patient.

View larger version (97K): [in a new window]   Figure 3b. Case of a 34-year-old woman who presented early in the postpartum period with buttock, groin, and upper thigh pain. (a) Transverse US image of the common femoral vein (arrow) shows a noncompressible segment with distention of the vein from acute thrombus. This also involved the proximal superficial femoral vein. Distance between cursors (1, dotted line) is 1.07 cm. (b, c) US images demonstrate normal compressibility of popliteal segment. (b) Transverse image of the popliteal artery (red) and vein (blue) shows spontaneous venous flow. (c) With compression, there is complete apposition of the vein walls, while the artery (arrowhead) is patent; this excludes popliteal vein thrombosis. (d) Longitudinal color Doppler image along the left iliac artery (yellow and blue) and thrombosed left iliac vein (arrowheads). Note that a lower frequency transducer was required to visualize the vessels due to their deeper location in the pelvis. (e) Longitudinal color Doppler image demonstrates the patent inferior vena cava (orange) in this patient.

View larger version (96K): [in a new window]   Figure 3c. Case of a 34-year-old woman who presented early in the postpartum period with buttock, groin, and upper thigh pain. (a) Transverse US image of the common femoral vein (arrow) shows a noncompressible segment with distention of the vein from acute thrombus. This also involved the proximal superficial femoral vein. Distance between cursors (1, dotted line) is 1.07 cm. (b, c) US images demonstrate normal compressibility of popliteal segment. (b) Transverse image of the popliteal artery (red) and vein (blue) shows spontaneous venous flow. (c) With compression, there is complete apposition of the vein walls, while the artery (arrowhead) is patent; this excludes popliteal vein thrombosis. (d) Longitudinal color Doppler image along the left iliac artery (yellow and blue) and thrombosed left iliac vein (arrowheads). Note that a lower frequency transducer was required to visualize the vessels due to their deeper location in the pelvis. (e) Longitudinal color Doppler image demonstrates the patent inferior vena cava (orange) in this patient.

View larger version (192K): [in a new window]   Figure 3d. Case of a 34-year-old woman who presented early in the postpartum period with buttock, groin, and upper thigh pain. (a) Transverse US image of the common femoral vein (arrow) shows a noncompressible segment with distention of the vein from acute thrombus. This also involved the proximal superficial femoral vein. Distance between cursors (1, dotted line) is 1.07 cm. (b, c) US images demonstrate normal compressibility of popliteal segment. (b) Transverse image of the popliteal artery (red) and vein (blue) shows spontaneous venous flow. (c) With compression, there is complete apposition of the vein walls, while the artery (arrowhead) is patent; this excludes popliteal vein thrombosis. (d) Longitudinal color Doppler image along the left iliac artery (yellow and blue) and thrombosed left iliac vein (arrowheads). Note that a lower frequency transducer was required to visualize the vessels due to their deeper location in the pelvis. (e) Longitudinal color Doppler image demonstrates the patent inferior vena cava (orange) in this patient.

View larger version (204K): [in a new window]   Figure 3e. Case of a 34-year-old woman who presented early in the postpartum period with buttock, groin, and upper thigh pain. (a) Transverse US image of the common femoral vein (arrow) shows a noncompressible segment with distention of the vein from acute thrombus. This also involved the proximal superficial femoral vein. Distance between cursors (1, dotted line) is 1.07 cm. (b, c) US images demonstrate normal compressibility of popliteal segment. (b) Transverse image of the popliteal artery (red) and vein (blue) shows spontaneous venous flow. (c) With compression, there is complete apposition of the vein walls, while the artery (arrowhead) is patent; this excludes popliteal vein thrombosis. (d) Longitudinal color Doppler image along the left iliac artery (yellow and blue) and thrombosed left iliac vein (arrowheads). Note that a lower frequency transducer was required to visualize the vessels due to their deeper location in the pelvis. (e) Longitudinal color Doppler image demonstrates the patent inferior vena cava (orange) in this patient.

View larger version (195K): [in a new window]   Figure 4a. US images of acute proximal DVT. (a) Transverse image of the superficial femoral artery (A) and vein (V) shows noncompressible vein due to acute thrombus. (b) Longitudinal image at the same level demonstrates lack of spontaneous venous flow. Red represents flow within the adjacent superficial femoral artery. (c) Longitudinal color Doppler image during augmentation demonstrates flow (blue) around the acute thrombus. Red represents arterial flow within the adjacent superficial femoral artery.

View larger version (138K): [in a new window]   Figure 4c. US images of acute proximal DVT. (a) Transverse image of the superficial femoral artery (A) and vein (V) shows noncompressible vein due to acute thrombus. (b) Longitudinal image at the same level demonstrates lack of spontaneous venous flow. Red represents flow within the adjacent superficial femoral artery. (c) Longitudinal color Doppler image during augmentation demonstrates flow (blue) around the acute thrombus. Red represents arterial flow within the adjacent superficial femoral artery.

View larger version (68K): [in a new window]   Figure 4b. US images of acute proximal DVT. (a) Transverse image of the superficial femoral artery (A) and vein (V) shows noncompressible vein due to acute thrombus. (b) Longitudinal image at the same level demonstrates lack of spontaneous venous flow. Red represents flow within the adjacent superficial femoral artery. (c) Longitudinal color Doppler image during augmentation demonstrates flow (blue) around the acute thrombus. Red represents arterial flow within the adjacent superficial femoral artery.

View larger version (178K): [in a new window]   Figure 5a. Appearance of chronic DVT. (a) Transverse US image of the proximal superficial femoral vein just below the bifurcation of the common femoral artery demonstrates echogenic thrombus (arrow) within the vein. (b) Transverse image at the same level during compression shows noncompressible superficial femoral vein (V). Note mild flattening (arrow) of the wall of the femoral artery (A) with compression. (c) Color Doppler image at the same level demonstrates spontaneous venous flow around the thrombus (T) within the partially recanalized superficial femoral vein (V). Arterial flow is seen within the superficial and deep femoral arteries (A). (d) Longitudinal view of the superficial femoral vein with color Doppler flow US demonstrates irregular recanalization of the vein (arrows) with spontaneous flow around the thrombus (T), and arterial flow within the adjacent artery (arrowhead). (e) Longitudinal color Doppler flow image of the superficial femoral vein (V) demonstrates spontaneous phasic flow around the thrombus (T) within the partly recanalized vein (V). Flow is also noted in the adjacent artery (A).

View larger version (187K): [in a new window]   Figure 5b. Appearance of chronic DVT. (a) Transverse US image of the proximal superficial femoral vein just below the bifurcation of the common femoral artery demonstrates echogenic thrombus (arrow) within the vein. (b) Transverse image at the same level during compression shows noncompressible superficial femoral vein (V). Note mild flattening (arrow) of the wall of the femoral artery (A) with compression. (c) Color Doppler image at the same level demonstrates spontaneous venous flow around the thrombus (T) within the partially recanalized superficial femoral vein (V). Arterial flow is seen within the superficial and deep femoral arteries (A). (d) Longitudinal view of the superficial femoral vein with color Doppler flow US demonstrates irregular recanalization of the vein (arrows) with spontaneous flow around the thrombus (T), and arterial flow within the adjacent artery (arrowhead). (e) Longitudinal color Doppler flow image of the superficial femoral vein (V) demonstrates spontaneous phasic flow around the thrombus (T) within the partly recanalized vein (V). Flow is also noted in the adjacent artery (A).

View larger version (120K): [in a new window]   Figure 5c. Appearance of chronic DVT. (a) Transverse US image of the proximal superficial femoral vein just below the bifurcation of the common femoral artery demonstrates echogenic thrombus (arrow) within the vein. (b) Transverse image at the same level during compression shows noncompressible superficial femoral vein (V). Note mild flattening (arrow) of the wall of the femoral artery (A) with compression. (c) Color Doppler image at the same level demonstrates spontaneous venous flow around the thrombus (T) within the partially recanalized superficial femoral vein (V). Arterial flow is seen within the superficial and deep femoral arteries (A). (d) Longitudinal view of the superficial femoral vein with color Doppler flow US demonstrates irregular recanalization of the vein (arrows) with spontaneous flow around the thrombus (T), and arterial flow within the adjacent artery (arrowhead). (e) Longitudinal color Doppler flow image of the superficial femoral vein (V) demonstrates spontaneous phasic flow around the thrombus (T) within the partly recanalized vein (V). Flow is also noted in the adjacent artery (A).

View larger version (135K): [in a new window]   Figure 5d. Appearance of chronic DVT. (a) Transverse US image of the proximal superficial femoral vein just below the bifurcation of the common femoral artery demonstrates echogenic thrombus (arrow) within the vein. (b) Transverse image at the same level during compression shows noncompressible superficial femoral vein (V). Note mild flattening (arrow) of the wall of the femoral artery (A) with compression. (c) Color Doppler image at the same level demonstrates spontaneous venous flow around the thrombus (T) within the partially recanalized superficial femoral vein (V). Arterial flow is seen within the superficial and deep femoral arteries (A). (d) Longitudinal view of the superficial femoral vein with color Doppler flow US demonstrates irregular recanalization of the vein (arrows) with spontaneous flow around the thrombus (T), and arterial flow within the adjacent artery (arrowhead). (e) Longitudinal color Doppler flow image of the superficial femoral vein (V) demonstrates spontaneous phasic flow around the thrombus (T) within the partly recanalized vein (V). Flow is also noted in the adjacent artery (A).

View larger version (51K): [in a new window]   Figure 5e. Appearance of chronic DVT. (a) Transverse US image of the proximal superficial femoral vein just below the bifurcation of the common femoral artery demonstrates echogenic thrombus (arrow) within the vein. (b) Transverse image at the same level during compression shows noncompressible superficial femoral vein (V). Note mild flattening (arrow) of the wall of the femoral artery (A) with compression. (c) Color Doppler image at the same level demonstrates spontaneous venous flow around the thrombus (T) within the partially recanalized superficial femoral vein (V). Arterial flow is seen within the superficial and deep femoral arteries (A). (d) Longitudinal view of the superficial femoral vein with color Doppler flow US demonstrates irregular recanalization of the vein (arrows) with spontaneous flow around the thrombus (T), and arterial flow within the adjacent artery (arrowhead). (e) Longitudinal color Doppler flow image of the superficial femoral vein (V) demonstrates spontaneous phasic flow around the thrombus (T) within the partly recanalized vein (V). Flow is also noted in the adjacent artery (A).

View larger version (18K): [in a new window]   Figure 6. A–C, Management algorithms for patients with suspected DVT. A, Serial US; B, US and clinical probability; C, US, clinical probability, D-dimer test. * = alternative is to perform venography in patients with high clinical probability, CUS = compression US.

View larger version (27K): [in a new window]   Figure 7. Management algorithm for patients with suspected pulmonary embolism (PE). * = consider compression US (CUS) and, if negative, pulmonary angiography in patients with low clinical probability, ** = alternative is to perform pulmonary angiography, *** = consider pulmonary angiography in patients with high clinical probability, VQ = ventilation-perfusion lung scan.