Bilateral Lower Extremity Venous Duplex Research Articles

Abstract 18212: The Fat Embolism Enigma: Unveiling the Intricate Complications of Breast Reconstructive Surgery

Background: Fat embolism can occur after plastic surgery, especially when injecting fat into subcutaneous tissue. It can be asymptomatic or can have hypoxia, mental status changes, and petechiae rash. Diagnosis is challenging but the workup includes imaging to exclude other differentials including pulmonary thromboembolism. Echocardiography assists in identifying fat emboli. Case Presentation: A middle-aged female with no prior cardiac history was undergoing right-sided breast reconstructive surgery with liposuction from the abdomen and fat grafting. Intraoperatively, the patient became hypoxic and hypotensive. The patient was started on vasopressors. A CT-Angiogram Chest revealed multiple bilateral pulmonary emboli, with some emboli having negative Hounsfield units (HU). Anticoagulation was started. Fat emboli could not be excluded. The patient was ultimately transitioned to venoarterial extracorporeal membrane oxygenation. Transthoracic echocardiogram showed right ventricular (RV) hypokinesis with preserved apical function and multiple, mobile, irregular masses in the RV. Figure 1 With the patient’s history, this was concerning for fat emboli. A transesophageal echocardiogram (TEE) showed multiple (4 visualized) masses seen in the RV, caught into the subvalvular tricuspid apparatus on the chordae and the RV trabeculation. (Largest mass: 1 cm in diameter). Figure 2 A bilateral lower extremity venous duplex was negative. The patient was diagnosed with obstructive shock secondary to fat embolism. She was eventually weaned off of mechanical support and discharged in stable condition. Discussion: Autologous fat grafting (AFG) has gained popularity in reconstructive and aesthetic surgery. It is important to remain vigilant about fat embolism as a complication that presents as sudden hypoxia and obstructive shock in the appropriate setting. DVT should be ruled out. Echocardiography can assist in diagnosis. Treatment is supportive.

LEFT ATRIAL SEPTAL POUCH IN A PATIENT WITH RECURRENT STROKE

LEFT ATRIAL SEPTAL POUCH IN A PATIENT WITH RECURRENT STROKE

PHLEGMASIA CERULEA DOLENS ASSOCIATED WITH OBSTRUCTIVE SHOCK

TOPIC: Critical Care TYPE: Fellow Case Reports INTRODUCTION: Phlegmasia cerulea dolens (PCD) is a rare, fulminant condition caused by massive venous thrombosis associated with a high morbidity (amputation rates 20-50%) and mortality (25-40%)1. PCD often presents as a triad of limb swelling, acute ischemic pain, and reddish purple to blue skin discoloration1. This case presents a patient who developed PCD involving complete obstruction of the inferior vena cava (IVC) leading to obstructive shock. CASE PRESENTATION: Shortly after admission a 67 year old female with a relevant past medical history of metastatic tonsillar cancer on chemotherapy, Sjogren's disease, and previous venous thromboembolism (no longer on anticoagulation) developed acute onset of abdominal pain and hypotension associated with significant mottling and edema in her bilateral lower extremities. Six months prior to presentation she had an IVC filter placed. She developed worsening shock, acute kidney injury, and metabolic academia. A CT abdomen/pelvis revealed an extensive clot burden distal to the IVC filter with extension down through the bilateral iliac veins (img 1). Bilateral lower extremity venous duplex ultrasound scans showed extensive bilateral acute deep vein thromboses (img 2). Vascular surgery took the patient to the operating room for mechanical thrombectomy of the IVC and left iliac vein (img 3) and right above-the-knee amputation due to the severity of injury to right lower extremity. After returning from the operating room she developed worsening shock despite continued resuscitative measures, and after discussion with the patient's family her goals of care were transitioned to comfort-focused. DISCUSSION: Similar to DVT risk, factors associated with the development of PCD include congestive heart failure, immobility post-operatively, and malignancy1,2. Chemotherapy may increase the risk by up to six to seven times3. Initial management of PCD includes elevation of affected limbs, judicious fluid resuscitation, and anticoagulation1. Definitive therapeutic interventions include catheter-directed thrombolysis and surgical thrombectomy1. IVC filter presence is also a rare but important risk factor for the development of PCD associated with up to 3.2% of cases in one review1. The presence of an IVC filter may lead to the development of inferior vena cava syndrome which is often mistaken for other conditions. Complications associated with IVC filter presence also highlights the value of bedside ultrasound which could help to identify non-collapsible femoral veins. CONCLUSIONS: The clinical triad of PCD includes limb swelling, acute ischemic pain, and reddish purple to blue skin discoloration. Early recognition and treatment is critical to improved outcomes.Risk factors for the development of PCD are the same as those associated with DVT or PE IVC filter presence can be a nidus for thrombus development which can progress to the point of filter occlusion REFERENCE #1: Chinsakchai K, Ten Duis K, Moll FL, de Borst GJ. Trends in management of phlegmasia cerulea dolens. Vasc Endovascular Surg. 2011;45(1):5-14. doi:10.1177/1538574410388309 REFERENCE #2: Mohammed, M., Elhamdani, S., Abusnina, W., Majdi, A., & Yousef, S. (2018). Inferior Vena Cava Obstruction and Shock. Journal of emergencies, trauma, and shock, 11(2), 146–148. https://doi.org/10.4103/JETS.JETS_22_17 REFERENCE #3: Söderman, M., & Grimm, P. (2020). Phlegmasia cerulea dolens in a patient treated with carboplatin. BMJ case reports, 13(4), e233760. https://doi.org/10.1136/bcr-2019-233760 DISCLOSURES: No relevant relationships by Avraham Cooper, source=Web Response No relevant relationships by Sarah MacDowell, source=Web Response

A CASE OF PULMONARY VEIN THROMBOSIS WITH EXTENSION INTO THE LEFT ATRIUM

SESSION TITLE: Medical Student/Resident Signs and Symptoms of Chest Disease Posters SESSION TYPE: Med Student/Res Case Rep Postr PRESENTED ON: October 18-21, 2020 INTRODUCTION: Pulmonary vein thrombosis (PVT) is a rare and often misdiagnosed condition due to nonspecific symptoms at presentation. PVT is most commonly associated with lung malignancy, recent major pulmonary surgery, or atrial fibrillation. Symptoms generally include cough, dyspnea, nonspecific chest pain, and hemoptysis, similar to pulmonary embolism. Delay in diagnosis can be lethal. CASE PRESENTATION: A 76-year-old female with hyperthyroidism, history of DVT in 2018 previously on rivaroxaban, venous insufficiency and hypertension presented with cough, congestion, and progressive fatigue for 3 days. She was increasingly dyspneic at rest and with activity the day prior to admission. She required supplemental oxygenation with 2 L/minute via nasal cannula on evaluation at our emergency center. She additionally tested positive for influenza A and B. She denied chest pain, palpitations, or orthopnea, but did have associated worsening right lower extremity edema. Bilateral lower extremity venous duplex showed evidence of an acute thrombus in the right common femoral, superficial femoral, deep femoral, and popliteal veins; the left leg had no thromboses. Given evidence of acute DVT and acute hypoxemic respiratory failure on presentation, a CT PE protocol was done, noting a thrombus in the left lower pulmonary vein that extended into the left atrium (figures 1-3), with chronic occlusion of the left lower lobe pulmonary arteries as well as enlarged pulmonary arteries. She was initially treated with a heparin drip from 1/23/2020 to 1/27/2020, then she was transitioned to oral anticoagulation with rivaroxaban 20 mg PO daily. She maintained resting oxygen saturations on room air for three days prior to discharge on 1/28/2020 and her respiratory symptoms improved significantly. She had no evidence of underlying malignancy at the time. She has followed up twice with her primary care physician, remains on oral anticoagulation, and has had no respiratory complaints since discharge. Pending outpatient hypercoagulable workup and repeat chest imaging, which was recommended in 6 months. DISCUSSION: PVT is a rare yet life threatening condition if undiagnosed. It can lead to pulmonary hypertension, cor pulmonale, TIA or stroke, and even pulmonary infarction or gangrene. Though there is no present gold standard for diagnosis of PVT, CT pulmonary angiography led to the diagnosis in this case. CONCLUSIONS: Chronic anticoagulation is the mainstay of therapy for PVT. Though some cases may be idiopathic, it is prudent to investigate further for hypercoagulable states, including malignancy. Reference #1: Chaaya, G., & Vishnubhotla, P. (2017). Pulmonary Vein Thrombosis: A Recent Systematic Review. Cureus, 9(1), e993. https://doi.org/10.7759/cureus.993 Reference #2: Rana, M. A., Tilbury, N., & Kumar, Y. (2016). Idiopathic pulmonary vein thrombus extending into left atrium: a case report and review of the literature. Hindawi Publishing Corporation: Case Reports in Medicine, 2016, (article ID 3528393), 1-3. https://www.hindawi.com/journals/crim/2016/3528393/ Reference #3: Sahay, S., & Lodato, R. (2013). Pulmonary vein thrombosis: a rare entity. CHEST Journal, 144 (4_MeetingAbstracts). https://journal.chestnet.org/article/S0012-3692(16)42762-5/fulltext DISCLOSURES: No relevant relationships by Kendall Creed, source=Web Response No relevant relationships by Peter Khalil, source=Web Response No relevant relationships by Victor Test, source=Web Response No relevant relationships by Alexandra Wichmann, source=Web Response

Biases of Villalta scale in classifying post-thrombotic syndrome in patients with pre-existing chronic venous disease

ObjectiveThe Villalta scale (VS) is a recommended and widely used clinical severity score for diagnosis and grading of post-thrombotic syndrome (PTS). However, patients with primary chronic venous disease (CVD) who have a history of deep venous thrombosis (DVT) may be classified as having PTS even though post-thrombotic disease is not actually present. The purpose of this study was to investigate the biases of the VS with use in patients with pre-existing CVD. MethodsThis single-center, prospective, observational study included patients who were diagnosed with CVD during a 12-month period from 2016 to 2017. The VS and the Venous Clinical Severity Score (VCSS) were completed, and bilateral lower extremity venous duplex ultrasound studies were performed. The correlation of the VS with the VCSS was analyzed. Sensitivity, specificity, positive bias, and negative bias of the VS combined with a history of DVT were calculated. For patients in whom DVT developed during the study, the VS score was taken 12 months after the onset of DVT and compared with the score before DVT. ResultsA total of 288 patients were included. The VS score correlated well with the VCSS, with a correlation coefficient of 0.86 (P < .001). The two scores changed similarly over time. The accuracy of the VS combined with a history of DVT was 94.1%, with a sensitivity of 71.4% and a specificity of 95.9%. The positive bias was as high as 42.3%, although the negative bias was 2.3%. The VS score decreased to a normal level during follow-up in 41.7% of the CVD patients in whom a new DVT developed (n = 12). ConclusionsThe use of the VS for defining PTS appeared to misclassify those with primary CVD and a history of DVT as having PTS by 42.3%. Using the VS at follow-up in patients with PTS and pre-existing CVD may be misleading. Re-evaluation of the results of previous studies that used the VS may be needed.

IPC01. The Utilization of Bilateral Lower Extremity Venous Duplex in Patients With Bilateral Lower Extremity Swelling in an Acute Setting: Emergency Department

IPC01. The Utilization of Bilateral Lower Extremity Venous Duplex in Patients With Bilateral Lower Extremity Swelling in an Acute Setting: Emergency Department

Pulmonary tumor embolism secondary to soft tissue and bone sarcomas: a case report and literature review

BackgroundTumor embolisms (TE) are an underappreciated source of pulmonary embolisms in sarcoma. Most evidence in the literature is limited to case reports and none have described the presence of TE secondary to myxofibrosarcoma. We report the first case of myxofibrosarcoma TE and perform a review of the literature for TE secondary to bone and soft tissue sarcomas (STS).Case presentationA 36-year-old female presented with debilitating pain of the right upper extremity secondary to a recurrent soft tissue sarcoma. She had distant metastasis to the lung. An MRI revealed a 25-cm shoulder mass involving the proximal arm muscles with encasement of the axillary artery, vein, and brachial plexus. A palliative forequarter amputation was performed and tumor thrombus was evident within the axillary artery and vein. Postoperatively, she developed an acute onset of dyspnea and hypoxia. A computed tomography scan revealed a pulmonary saddle embolism. A bilateral lower extremity venous duplex was negative. She became hemodynamically unstable despite resuscitation and was placed on vasopressor support. A transthoracic echocardiogram revealed elevated pulmonary artery pressure, tricuspid regurgitation, right heart dilation, and reduced right heart systolic function consistent with acute cor pulmonale. The patient did not want to pursue a median sternotomy with pulmonary artery embolectomy and expired from cardiopulmonary arrest within 24 h of the operation. The final pathology revealed a 25 × 16 × 13 cm high-grade myxofibrosarcoma with invasion into the bone, skin, and neurovascular bundle as well as evidence of tumor thrombus.ConclusionTE is a rare but deadly cause of pulmonary embolism in sarcoma. A high index of suspicion is necessary in individuals who present with respiratory-related symptoms, especially dyspnea. Diagnostic confirmation with a computed tomography scan of the chest and echocardiogram should be rapid. Unlike venous thromboembolism, pulmonary embolectomy remains the preferred therapeutic approach.

DVT surveillance program in the ICU: analysis of cost-effectiveness.

BackgroundVenous Thrombo-embolism (VTE – Deep venous thrombosis (DVT) and/or pulmonary embolism (PE) – in traumatized patients causes significant morbidity and mortality. The current study evaluates the effectiveness of DVT surveillance in reducing PE, and performs a cost-effectiveness analysis.MethodsAll traumatized patients admitted to the adult ICU underwent twice weekly DVT surveillance by bilateral lower extremity venous Duplex examination (48-month surveillance period – SP). The rates of DVT and PE were recorded and compared to the rates observed in the 36-month pre-surveillance period (PSP). All patients in both periods received mechanical and pharmacologic prophylaxis unless contraindicated. Total costs – diagnostic, therapeutic and surveillance – for both periods were recorded and the incremental cost for each Quality Adjusted Life Year (QALY) gained was calculated.Results4234 patients were eligible (PSP – 1422 and SP – 2812). Rate of DVT in SP (2.8%) was significantly higher than in PSP (1.3%) – p<0.05, and rate of PE in SP (0.7%) was significantly lower than that in PSP (1.5%) – p<0.05. Logistic regression demonstrated that surveillance was an independent predictor of increased DVT detection (OR: 2.53 – CI: 1.462–4.378) and decreased PE incidence (OR: 0.487 – CI: 0.262–0.904). The incremental cost was $509,091/life saved in the base case, translating to $29,102/QALY gained. A sensitivity analysis over four of the parameters used in the model indicated that the incremental cost ranged from $18,661 to $48,821/QALY gained.ConclusionsSurveillance of traumatized ICU patients increases DVT detection and reduces PE incidence. Costs in terms of QALY gained compares favorably with other interventions accepted by society.

Isolated calf muscular vein thrombosis is associated with pulmonary embolism and a high incidence of additional ipsilateral and contralateral deep venous thrombosis.

Little is known about the natural history of isolated gastrocnemial and soleal vein thrombosis (IGSVT), and recommendations for treatment and follow-up are therefore anecdotal. This study sought to determine the rates of venous thromboembolism (VTE) progression and resolution and theeffect of antithrombotic therapy in patients with IGSVT. A vascular laboratory database was queried from January 2002 to December 2006 to identify patients with duplex-diagnosed IGSVT and follow-up duplex scan studies. Duplex scan examinations were reviewed to determine rates ofresolution and development of new ipsilateral and contralateral VTE. Records were reviewed for comorbid conditions, VTE risk factors, anticoagulation therapy, the effect of anticoagulation on resolution of IGSVT, and diagnosis of pulmonary embolism (PE) confirmed by computed tomographic angiography. Patients with at least one follow-up duplex scan studywere included in our analysis. Sixty-five limbs with isolated IGSVT were identified in 57 patients with follow-up duplex scans (mean, 2.75 studies per patient; mean follow-up, 113days). Twenty patients (35%) received therapeutic anticoagulation after the IGSVT diagnosis. There were sevenPEs, two on the same day as initial IGSVT diagnosis, and two within 1 week of diagnosis. IGSVT resolution rates by Kaplan-Meier analysis at 1 and 3 months were 20% and 41%, respectively. Eleven patients (19%) developed additional ipsilateral deep venous thrombosis (DVT; three axial calf vein thromboses and five proximal DVT) or contralateral DVT (oneaxialcalf vein thrombosis [CVT], one IGSVT, and one proximal DVT) during follow-up. Of the eight patients who developed additional ipsilateral DVT, five also developed concurrent contralateral DVT. Overall, 14% of patients developed contralateral DVT. Median time to development of additional DVT was 10 days. Therapeutic anticoagulation was associated with DVT resolution. However, VTE recurrence was not significantly affected by age, gender, anticoagulation, oral contraceptives, known hypercoagulable states, or comorbidities (smoking, cancer, trauma, postsurgical status, renal failure, hyperlipidemia, diabetes, or cardiopulmonary abnormalities; P> .05). Isolated calf muscular vein thrombosis is associated with PE and a significant incidence of VTE progression. Therapeutic anticoagulation is associated with DVT resolution, but its effect on VTE recurrence was not demonstrated. Untreated patients with IGSVT should receive follow-up bilateral lower extremity venous duplex scans within 10 days of diagnosis.

Treatment of Low-risk Pulmonary Embolism Patients in a Chest Pain Unit

Several studies have proposed the Pulmonary Embolism Severity Index (PESI) as a risk stratification tool for discharge of low-risk pulmonary embolism (PE) patients from the emergency department (ED) and treatment as outpatients, but this has not become accepted standard of care in the United States. Chest pain units (CPUs) may serve as ideal locations for the treatment and risk-stratification of low-risk PE patients, thus avoiding lengthy inpatient stays while assuring patients are appropriate for outpatient therapy for PE. We sought to characterize the number of patients at our institution who may be eligible for a short stay in our CPU and then established a protocol for the treatment of low-risk patients in the CPU. We identified all patients admitted to the University of Utah Medical Center from the ED with a diagnosis of PE over the 6-year period between 2002 and 2007. We retrospectively reviewed the electronic medical records to identify clinical variables to calculate a PESI score for each patient. Patients who were considered to be low-risk, on the basis of PESI score (class I and II), were considered eligible for treatment in the CPU, and, on the basis of this, we estimated numbers of patients to be treated in the CPU and patient demographics. We determined results of transthoracic echocardiography (TTE) and bilateral lower extremity (BLE) venous duplex ultrasound for PE patients to estimate potential inpatient admission rates from the CPU. We reviewed the electronic medical records during the 30-day period after hospital admission for patient mortality. We then created a protocol for the treatment of these low-risk patients in the CPU. A total of 545 patients were admitted with PE during the 6-year period. Of these patients, 282 were considered low risk and potentially appropriate for treatment of PE in the CPU. Of those, 43.3% were male, and the average age was 43.9 years (range: 14-92 years). Mortality was 0% for the low-risk group over the 30 days after hospital admission. A total of 108 patients had TTE performed and, of these, 30 had evidence of right heart strain. Ninety patients had BLE venous duplex and, of these, 15 had a deep venous thrombosis proximal to the popliteal veins. On the basis of our findings, we created a protocol for treatment of low-risk PE patients in the CPU. Patients who are low risk according to PESI score are admitted to the CPU with administration of low-molecular-weight heparin in the ED and initiation of oral anticoagulation therapy. Patients are monitored on telemetry for at least 12 hours, with performance of BLE duplex and TTE while in the CPU. Patients are admitted to an inpatient unit from the CPU if during their stay they exhibit unstable vital signs, a new arrhythmia, deep venous thrombosis proximal to the popliteal veins on BLE duplex, or signs of right heart strain on TTE. Patients who do not meet these criteria are considered appropriate for outpatient treatment and discharged with low-molecular-weight heparin and oral anticoagulation with thrombosis clinic follow-up. Given our findings from the retrospective chart review, we estimated that, at our institution, 4 patients per month would be eligible for treatment of PE in the CPU. With the findings on TTE and BLE duplex, we estimated that 25.3% of eligible patients would eventually require inpatient admission from the CPU. We identified a number of low-risk patients who may be eligible for treatment of PE in our CPU. Given the resources of the CPU, this may serve as an ideal location for the treatment of low-risk PE patients and allow further risk stratification and consultation beyond that typically readily available in the ED. We described the creation of a protocol for the treatment of low-risk patients with PE in a CPU.

A Comparative Study of Clinical Outcomes of Vascular Studies Performed Using Protocols from the American College of Radiology and the Intersocietal Commission for the Accreditation of Vascular Laboratories

Introduction Confidence is placed in studies done in any vascular laboratory based on guidelines set forth by the accrediting body governing that service. Within the facilities of a newly formed health network, it was noted that vascular procedures were performed under the guidelines of two separate accrediting bodies. The larger of the two facilities is accredited by the Intersocietal Commission for the Accreditation of Vascular Laboratories (ICAVL) and the satellite facility is accredited by the American College of Radiology (ACR). Methods A comparative review of guidelines was done in an effort to establish “best practice” across the system. Between the two sets of imaging standards, the guidelines for obtaining images vary on lower extremity peripheral venous evaluations. In the exams, calf vein images are not performed under the ACR standards and are obtained under the ICAVL standards. Though not required under the ICAVL standards, it is considered best practice to image these patients during routine unilateral and bilateral exams. Due to the differences in practice between the two facilities, a retrospective chart review was conducted to evaluate clinical outcomes between the two groups of patients. Unilateral and bilateral lower extremity venous duplex examinations had been performed by vascular sonographers on all patients included in the chart review during a period of 12 months. Results Of the 1222 charts reviewed, 63 patients had positive findings of calf vein thrombosis under the ICAVL guidelines and would not have been diagnosed with ultrasound imaging alone under the ACR guidelines. Four patients who had been inpatients at the satellite facility were referred to the larger facility for follow-up care. A second venous duplex exam was performed due to persistence of symptoms. In these four patients that had follow-up exams, a negative interpretation was reported under the ACR guidelines, and a positive report for unilateral deep vein thrombosis in one or more of the calf veins (DVT) was given under the ICAVL guidelines. In another group of nine patients having follow-up procedures under both standards, contralateral comparison of the common femoral vein was not performed under the ACR guidelines. Using ICAVL guidelines, three of these patients were found to have nonphasic flow in the contralateral common femoral vein. Conclusions Such discrepancies have potential for negative clinical outcomes. The findings support the need for standardization of protocols between the two facilities by expansion of the ACR guidelines to include calf veins in the lower extremity venous evaluation. Further revision of the ACR standards is recommended, as well, to include imaging the contralateral common femoral vein in unilateral venous duplex exams in the lower extremity.

Prospective screening for postoperative deep venous thrombosis in patients undergoing infrainguinal revascularization

Purpose: The incidence of deep venous thrombosis (DVT) in patients undergoing infrainguinal bypass graft procedures has not been well documented, and the need for routine prophylaxis remains controversial. The purpose of this study was to prospectively evaluate the risk of postoperative DVT complicating infrainguinal revascularization. Methods: Seventy-four patients undergoing infrainguinal bypass graft procedures during a 12-month period were prospectively screened for DVT. Bilateral lower extremity venous duplex scan imaging was performed preoperatively and within 1 week and 6 weeks, postoperatively. Routine DVT prophylaxis was not used, with anticoagulation reserved for specific indications. Results: Of the 74 patients screened, three patients (4.1%) had DVT identified on preoperative venous duplex scan imaging and were excluded from the study. Of the remaining 71 patients enrolled, only two patients (2.8%) had postoperative DVT. Postoperative DVT was ipsilateral to the bypass graft extremity in both patients, with involvement of the peroneal vein in one patient and the femoral vein in the other. Although routine prophylaxis was not used, 18 of these patients (25%) were anticoagulated for other indications, with DVT occurring in one patient (5.6%). Of the remaining 53 patients who did not receive postoperative anticoagulation, only one patient (1.8%) had DVT. Conclusions: According to this prospective study, the risk of postoperative DVT in patients undergoing infrainguinal revascularization is low. Routine prophylaxis is not recommended, with postoperative anticoagulation reserved for specific indications. (J Vasc Surg 2000;32:669-75.)

Contralateral duplex scanning for deep venous thrombosis is unnecessary in patients with symptoms

Bilateral lower extremity venous duplex scanning for acute deep venous thrombosis (DVT) has been advocated because of the high incidence of occult contralateral leg involvement. We investigated the clinical necessity of such a policy. The results from 2996 venous duplex studies performed during the past 2 years were retrospectively reviewed. A total of 1694 of these scans were performed on patients with symptoms, of whom 248 (15%) were found to have an acute DVT. Symptoms were limited to one side in 198 patients, whereas bilateral complaints were noted in 50 patients. Among the patients with symptoms of acute DVT, 72 (29%) had bilateral involvement. Bilaterality was more likely in patients with bilateral symptoms than in those with only unilateral symptoms (56% vs 22%; p < 0.005). Of the patients with unilateral symptoms and bilateral DVT, all of them had either acute (80%) or acute and chronic (20%) thrombosis in the symptomatic leg. The contralateral asymptomatic limb had fewer acute and more chronic DVT (41% and 55%, respectively). No patient from the entire group admitted with symptoms had an acute DVT in the asymptomatic limb without a concomitant acute DVT in the symptomatic leg. Unilateral scanning would decrease the examination time by 21% and potentially increase total reimbursement for symptomatic venous scans by 9% compared with routine bilateral duplex scanning. Although bilateral involvement is frequent in patients with symptoms of acute DVT, treatment in these patients is not altered by this finding. We conclude that contralateral venous scanning in patients with unilateral symptoms is not clinically indicated and that unilateral scanning would result in improved cost-efficiency for vascular laboratories.

Duplex ultrasonographic findings in patients with suspected DVT

To highlight the usefulness of duplex ultrasonography in assessing patients with clinical features suggestive of DVT in this environment. A total of seventy patients (44 males and 26 females, aged 15-85 years) with a clinical diagnosis of deep venous thrombosis (DVT) were seen between September 2005 and September 2007 in the Radiodiagnosis Department of the Lagos University Teaching Hospital, and a private Multi-specialist hospital both in Lagos, Nigeria. They had bilateral lower extremity venous duplex ultrasonographic examination performed on them. The common femoral vein, superficial femoral vein, proximal deep femoral vein, proximal greater saphenous vein, popliteal vein and posterior tibial veins were evaluated with compression sonography in the transverse plane. Grey scale, colour and pulsed Doppler imaging of the venous segments were observed. The sonographic abnormalities observed included frozen valves, venous reflux, venous dilatation with echogenic thrombus, absence of Doppler signals and narrowed, thick walled veins. It was observed that 30 (42.3%) patients had acute DVT, 11 (15.7%) had chronic venous disease (CVD), while 10 (14.3%) had incompetence of the superficial venous system. Acute DVT was the commonest pathology observed. Duplex ultrasonography should be performed on all patients with a clinical diagnosis of DVT in order to rule out other differential diagnoses.

Heart sounds

The Villalta scale (VS) is a recommended and widely used clinical severity score for diagnosis and grading of post-thrombotic syndrome (PTS). However, patients with primary chronic venous disease (CVD) who have a history of deep venous thrombosis (DVT) may be classified as having PTS even though post-thrombotic disease is not actually present. The purpose of this study was to investigate the biases of the VS with use in patients with pre-existing CVD.This single-center, prospective, observational study included patients who were diagnosed with CVD during a 12-month period from 2016 to 2017. The VS and the Venous Clinical Severity Score (VCSS) were completed, and bilateral lower extremity venous duplex ultrasound studies were performed. The correlation of the VS with the VCSS was analyzed. Sensitivity, specificity, positive bias, and negative bias of the VS combined with a history of DVT were calculated. For patients in whom DVT developed during the study, the VS score was taken 12 months after the onset of DVT and compared with the score before DVT.A total of 288 patients were included. The VS score correlated well with the VCSS, with a correlation coefficient of 0.86 (P < .001). The two scores changed similarly over time. The accuracy of the VS combined with a history of DVT was 94.1%, with a sensitivity of 71.4% and a specificity of 95.9%. The positive bias was as high as 42.3%, although the negative bias was 2.3%. The VS score decreased to a normal level during follow-up in 41.7% of the CVD patients in whom a new DVT developed (n = 12).The use of the VS for defining PTS appeared to misclassify those with primary CVD and a history of DVT as having PTS by 42.3%. Using the VS at follow-up in patients with PTS and pre-existing CVD may be misleading. Re-evaluation of the results of previous studies that used the VS may be needed.