Venous Duplex Research Articles

Ventilation-Perfusion Scintigraphy Is Comparable to CT Pulmonary Angiography for the Diagnosis of Pulmonary Embolism in Sickle Cell Disease: A 16-Year Experience

Sickle cell disease (SCD) has been associated with an increased incidence of pulmonary embolism (PE) but not an increased incidence of deep vein thrombosis (DVT). Because of this and other chest complications associated with SCD, these individuals undergo frequent imaging. Computerized tomographic pulmonary angiography (CTPA) is the most common diagnostic imaging test for PE but repeated CTPAs in a chronically ill, younger population with potential renal dysfunction may not be optimal. Ventilation perfusion (VQ) scintigraphy is an alternate imaging modality for PE with a generally lower radiation exposure. However, the diagnostic utility of VQ in SCD is uncertain as ventilation/perfusion mismatches from other diseases, such as acute chest syndrome, may be misdiagnosed as PE. With this in mind, we investigated the performance of CTPA and VQ for the diagnosis of PE in patients with SCD.Material and Methods: We performed a retrospective cohort study of all adults with SCD imaged for PE with either CTPA or VQ scan at our institution, for the years 2000-2016. Our imaging algorithms recommend VQ scans for patients with normal chest radiographs (CXR) and when CTPA is contraindicated. Demographics, age at imaging and CXR results prior to PE imaging were collected. Results of index PE imaging with VQ or CTPA were reviewed and concordance with follow-up imaging within 90 days was noted. When available, venous duplex results for positive and indeterminate imaging were analyzed. Repeated imaging over the 16-year period was documented. Summary statistics, t-tests, Chi Square and Fisher exact tests were used as appropriate with significance at p<0.05.Results: The cohort comprised 245 individual patients with SCD, 58% (141) men, mean age 33 ± 10.5 years. Index imaging was VQ in 63% (154) and CTPA in 37% (91). CXRs were performed in 96% (236/245) and were normal in 60.6% (143/236). Of those who had a CXR, Index VQ or CTPA was negative in 87.8% (207), positive in 4.2% (10) and indeterminate/chronic in 8.9% (19/2). There was no difference by imaging technique in the %positive PE diagnosed (VQ vs CTPA: 3.4% vs 5.7%, p=0.39)or in the number of indeterminate/chronic PE scans (VQ vs CTPA: 9.5% vs 8.0%, p=0.69). Of the ten positive PEs, half had duplexes; of these, 3/5 had lower extremity thrombosis; 2/10 patients had vascular access devices as a potential source. Of the 19 indeterminate exams, 2 of the 9 duplexes performed were positive.Repeat imaging studies. 9.4% (23/245) of the study population had repeat imaging within 90 days of index exam, concordant in 54.2% (13/24). 36.7% (90/245) had at least one additional imaging study for PE after more than 90 days, during a different clinical presentation. Patients with index VQ has more second imaging exams than those with index CTPA, 52.6% vs. 36.2% (p=0.01). None of the 5 CTPA positive patients were repeated within 1-3 days but 3/5 positive VQs were repeated within 1-2 days of diagnosis. Of these, 1 was negative by CTPA. Of the 7.8% (19/245) patients with indeterminate results, 47% (9/19) underwent reimaging within 90 days. Seven indeterminate VQ scans were reimaged within 3 days by CTPA; 6 were negative and one was diagnosed as chronic PE. One CTPA was reimaged by VQ on Day 7 and was considered positive. Although additional imaging was more likely when the index examination was positive or indeterminate for both CTPA and VQ scan (p<0.01, both), 4.6% (10/216) with negative index imaging also had repeat imaging within 90 days. These results were again negative for PE in 90% (9/10) while 1 demonstrated new findings at Day 57 that did not change management.Prevalence of PE: Over the 16-year study period 11% (27/245) of patients were diagnosed with PE at least once. Multiple exams were frequent: 47% (114/245) had at least 2, 15% at least 3 (36/245), and 7% (17/245) had 4 or more studies for PE. One patient underwent 21 scans (18 VQ, 3 CTPA).Conclusion : In sickle cell disease, the greater index of suspicion for PE may result in a lower rate of %positive PE imaging than is generally acknowledged, for a given presentation. However, over an extended time period (16 years), 11% of patients had evidence of PE. In SCD patients with suspected PE, VQ scan and CTPA perform comparably when imaging recommendations are guided by CXR results. [Display omitted] DisclosuresBillett:Janssen Pharmaceutical: Research Funding.

Thrombophilia and Preoperative Deep Venous Thrombosis and Their Effect on Free Flap Survival: A Scoping Review.

Background: A proper preoperative planning is essential to prevent flap failure. However, venous workup for flaps has not been commonly performed or utilized as a preoperative screening tool. A scoping review was conducted to explore preoperative venous system screening, including deep vein thrombosis diagnosis, and its effect on flap survival rate. This review identified existing gaps of knowledge and emphasized potential research areas for future studies. Methods: Two independent reviewers searched 3 electronic databases from inception to September 2020. Retrieved appropriate articles were selected systematically by title, abstract, and full review of the article. Studies were included if they enrolled patients who had thrombophilia or deep venous thrombosis (DVT) preoperatively and had undergone a free flap reconstruction. For eligible studies, the following information was extracted: basic demographics (sex, age, comorbidities), preoperative scans type, free flap type, clotting mode (causes), wound type, and flap survival. Results: Seventeen articles were found eligible for this review. Traumatic aetiology was found in 63 (33.6%) patients, while 124 (66.3%) patients had a non-traumatic aetiology. Preoperative screening for patients with non-traumatic aetiology was reported in 119 patients. In these patients, the flap survived in 107 (89.91%) patients. Four studies investigating patients with traumatic DVT aetiology, 60 patients (out of 63) had a preoperative computed tomography angiography or duplex. Those patients had 100% flap survival rates. Conclusion: Further investigations are required to identify venous thrombosis incidence in patients with non-traumatic thrombosis aetiology as this cohort of patients is at high risk of flap failure. Finally, the prognostic validity of available preoperative screening tools to identify high-risk patients should be assessed, such as imaging techniques, which would include venous duplex scanning, may prevent failure in free flap surgery.

High incidence of patients lost to follow-up after venous thromboembolism diagnosis - Identifying an unmet need for targeted transition of care.

Venous thromboembolism, including deep venous thrombosis and pulmonary embolism, is a major source of morbidity, mortality, and healthcare utilization. Given the prevalence of venous thromboembolism and its associated mortality, our study sought to identify factors associated with loss to follow-up in venous thromboembolism patients. This is a single-center retrospective study of all consecutive admitted (inpatient) and emergency department patients diagnosed with acute venous thromboembolism via venous duplex examination and/or chest computed tomography from January 2018 to March 2019. Patients with chronic deep venous thrombosis and those diagnosed in the outpatient setting were excluded. Lost to venous thromboembolism-specific follow-up (LTFU) was defined as patients who did not follow up with vascular, cardiology, hematology, oncology, pulmonology, or primary care clinic for venous thromboembolism management at our institution within three months of initial discharge. Patients discharged to hospice or dead within 30 days of initial discharge were excluded from LTFU analysis. Statistical analysis was performed using STATA 16 (College Station, TX: StataCorp LLC) with a p-value of <0.05 set for significance. During the study period, 291 isolated deep venous thrombosis, 25 isolated pulmonary embolism, and 54 pulmonary embolism with associated deep venous thrombosis were identified in 370 patients. Of these patients, 129 (35%) were diagnosed in the emergency department and 241 (65%) in the inpatient setting. At discharge, 289 (78%) were on anticoagulation, 66 (18%) were not, and 15 (4%) were deceased. At the conclusion of the study, 120 patients (38%) had been LTFU, 85% of whom were discharged on anticoagulation. There was no statistically significant difference between those LTFU and those with follow-up with respect to age, gender, diagnosis time of day, venous thromboembolism anatomic location, discharge unit location, or anticoagulation choice at discharge. There was a non-significant trend toward longer inpatient length of stay among patients LTFU (16.2 days vs. 12.3 days, p = 0.07), and a significant increase in the proportion of LTFU patients discharged to a facility rather than home (p = 0.02). On multivariate analysis, we found a 95% increase in the odds of being lost to venous thromboembolism-specific follow-up if discharged to a facility (OR 1.95, CI 1.1-3.6, p = 0.03) as opposed to home. Our study demonstrates that over one-third of patients diagnosed with venous thromboembolism at our institution are lost to venous thromboembolism-specific follow-up, particularly those discharged to a facility. Our work suggests that significant improvement could be achieved by establishing a pathway for the targeted transition of care to a venous thromboembolism-specific follow-up clinic.

Prevalence and clinical outcomes of hospitalized patients with upper extremity deep vein thrombosis

ObjectiveUpper extremity (UE) deep vein thrombosis (DVT) is a common and increasing complication in hospitalized patients. The objective of the present study was to determine the prevalence, treatment strategies, complications, and outcomes of UE-DVT. MethodsWe performed a retrospective single-institution study of patients with a diagnosis of UE-DVT from January 2016 through February 2018 (26 months). Patients aged ≥18 years who had been admitted to the hospital and who had had positive UE duplex ultrasound findings for acute UE-DVT were included in the present study. The outcomes were in-hospital mortality, major bleeding, pulmonary embolism (PE), and recurrent UE-DVT. ResultsAmong 63,045 patients admitted to the hospital, 1000 (1.6%) had been diagnosed with UE-DVT. Of 3695 UE venous duplex ultrasound examinations performed during the study period, almost one third (27.0%) were positive for acute UE-DVT. The mean age was 55.0 ± 17.2 years, and most patients were men (58.3%), white (49.2%), and overweight (mean body mass index, 29.4 ± 10.3 kg/m2). The most affected vein was the right internal jugular vein (54.8%). Most of the patients (96.9%) has been receiving venous thromboembolism prophylaxis or anticoagulation therapy at the diagnosis. Most patients (77.8%) had had an intravenous device (IVD) in place at the diagnosis. Most of the patients (84.4%) were treated with anticoagulation therapy in the hospital but only one half (54.5%) were discharged with anticoagulation therapy. In-hospital mortality was 12.1% unrelated to UE-DVT, major bleeding occurred in 47.6% of the patients during hospitalization (fatal bleeding, 1%), PE was diagnosed in 4.8% of the patients, and 0.7% were fatal. Recurrent UE-DVT occurred in 6.1% of the patients. On multivariable analysis, the risk of death was increased by older age, cancer, intensive care unit admission, concomitant lower extremity DVT, and bleeding before the UE-DVT diagnosis. The presence of an IVD increased the risk of PE and the risk of recurrent UE-DVT. The risk of major bleeding was increased by the presence of an IVD, female sex, and concomitant lower extremity DVT. ConclusionsUE-DVT is a common complication in hospitalized patients (1.6%). Consequent acute PE and recurrent DVT remain important complications, as does bleeding. It is unclear whether standard thromboprophylaxis effectively protects against UE-DVT. More studies dedicated to UE-DVT are required to provide appropriate guidance on prophylaxis and treatment.

Predictable Risk Factors of Upper-Extremity Deep Venous Thrombosis in a Level I Trauma Center.

BackgroundVenous thromboembolism is a common cause of morbidity and mortality in hospital patients, especially that of the lower extremities. Risk factors and diagnostic elements of upper-extremity deep-vein thrombosis (UEDVT) are poorly understood compared to those of the lower extremities. The primary objectives of this study were to identify predictive risk factors of secondary UEDVT.MethodsThis retrospective study included all nonpregnant patients aged >18 years who had undergone upper-extremity duplex scans to check for the presence of secondary UEDVT at Richmond University Medical Center from January 2014 to March 2020. Patients were stratified by presence or absence of UEDVT. Collected data points included patient demographics, comorbidities, central-line use, platelet count at time of scan, length of stay, and overall mortality. IBM 27.0 was used for all statistical analysis, with p<0.05 considered significant.ResultsA total of 1,009 upper extremity venous duplex studies were included. There were no significant differences in age, sex, race, or mean platelet levels between patients diagnosed with DVT and those without (p<0.05). After multinomial regression analysis, central venous catheter (CVC; 26.8% versus 78.5%, aOR 1.770, 95% CI 1.150–2.725; p<0.002), peripherally inserted central catheter (PICC) line (17.5% versus 82.5%, aOR3.254, 95% CI 1.997–5.304; p<0.001), hypertension (67.8% versus 28.8%, aOR 1.641, 95% CI 1.136–2.369; p<0.001), chronic kidney disease (CKD; 34.5% versus 65.5%, aOR 1.743, 95% CI 1.201–2.531; p<0.001), and malignancy (27.1% versus 74.6%, aOR 1.475, 95% CI 0.994–2.190; p<0.053) were found to be independent predictors of UEDVT.ConclusionUse of CVC or PICC line, preexisting diagnosis of hypertension, malignancy, and CKD were independent risk factors of UEDVT, while there was no significant correlation between increased platelet levels and UEDVT.

Treatment of Nonthrombotic Iliac Vein Lesions.

Nonthrombotic iliac vein lesions (NIVLs) most frequently result from extrinsic compression of various segments of the common or external iliac vein. Patients develop symptoms associated with chronic venous insufficiency (CVI); female patients may develop symptoms of pelvic venous disease. Given that iliac vein compression can be clinically silent, a thorough history and physical examination is mandatory to exclude other causes of a patient's symptoms. Venous duplex ultrasound, insufficiency examinations, and axial imaging are most commonly used to assess for the presence of a NIVL. Catheter venography and intravascular ultrasound (IVUS) are the mainstay for invasive assessment of NIVLs and planning prior to stent placement. IVUS in particular has become the primary modality by which NIVLs are evaluated; recent evidence has clarified the lesion threshold for stent placement, which is indicated in patients with moderate to severe symptoms. In appropriately selected patients, stent placement results in improved pain, swelling, quality of life, and, when present, healing of venous stasis ulcers. Stent patency is well preserved in the majority of cases, with a low incidence of clinically driven need for reintervention. In this article, we will discuss the clinical features, workup, endovascular management, and treatment outcomes of NIVL.

Usefulness of triggered non-contrast-enhanced magnetic resonance angiography in assessing lower extremity venous disease.

Although venous duplex ultrasonography (USG) is reliable for diagnosing lower extremity venous disease (LEVD), cross-sectional imaging studies were usually required before intervention or surgery. Patients of LEVD with renal insufficiency usually restrict the use of contrast-enhanced imaging modalities. In seeking an alternative imaging solution for these patients, we explore the clinical utility of triggered angiography non-contrast-enhanced magnetic resonance imaging (TRANCE-MRI) in the assessment of LEVD.We collected data from patients presenting to a tertiary wound-care center with symptoms of LEVD from April 2017–November 2019. Each participant underwent baseline USG followed by TRANCE-MRI on a 1.5T MR scanner (Philips Ingenia, Philips Healthcare, Best, The Netherlands). Inter-rater reliability was measured using Cohen's kappa (κ).All 80 participants (mean age, 61.9 ± 14.8 years; 35 males, 45 females) were assessed and were classified into one of five disease groups, deep vein thrombosis (n = 38), venous static ulcer (n = 16), symptomatic varicose veins (n = 18), recurrent varicose veins (n = 3), and lymphoedema (n = 5). The inter-rater reliability between TRANCE-MRI and doppler USG showed substantial agreement (κ, 0.73). The sensitivity, specificity, and accuracy of TRANCE-MRI were 90.5%, 88.1%, and 88.8%, respectively. In 59 (73.8%) USG-negative patients, we were able to diagnose positive findings (deep venous thrombosis, n = 7; varicose veins, n = 15; lymphedema, n = 10; iliac vein compression with thrombosis, n = 6; external venous compression, n = 5; vena cava anomaly, n = 2; occult peripheral artery disease, n = 5; ccluded bypass graft, n = 1) by using TRANCE-MRI. Of these, 9 (15.3%) patients underwent additional vascular surgery based on positive TRANCE-MRI findings.TRANCE technique provides the limb's entire venous drainage in clear images without background contamination by associated arterial imaging. Additionally, simultaneous evaluation of bilateral lower extremities can help determine the lesion's exact site. Although TRANCE-MRI can provide MR arteriography and MR venography, we recommend performing only MR venography in symptomatic LEVD patients because the incidence of occult arterial disease is low.

The pattern of cardiovascular manifestations in Egyptian Beh\xe7et\u2019s patients and its relation to disease activity

BackgroundBehçet’s disease (BD) is also referred to as vascular BD when it frequently involves the heart and vessels. This study aimed to describe the cardiovascular manifestations in patients with BD and its correlation to disease activity. We conducted a cross-sectional study on 40 patients diagnosed with BD according to the International Criteria for Behçet’s Disease 2014. All the patients were subjected to detailed history taking, full clinical examination, lab investigations, resting electrocardiogram, trans-thoracic echocardiography, and carotid artery duplex for measuring intimal thickness, peripheral arterial and venous duplex, computed tomography pulmonary angiography, and full ophthalmological examination. Regarding the activity of the disease, it was assessed according to the score of Behçet’s Disease Current Activity Form (BDCAF).ResultsThe most common cardiac manifestation was valvular lesion (67.5%) where the most frequently affected valve was the tricuspid valve (27.5%). Although 25% of patients had left ventricular diastolic dysfunction, only 5% had intracardiac masses. Approximately 52.5% of patients had vascular lesion (deep venous thrombosis 45%, arterial involvement 7.5% [as pulmonary artery thrombosis 5% and aneurysm 2.5%]). Increase in intima media thickness (IMT) was observed in 7.5% of patients, while 60% had abnormal lipid profiles. Hypercholesterolemia was the most common lipid abnormality (50%). BDCAF score range was 4–12, which was significantly correlated to multiple cardiovascular parameters as a mitral, tricuspid valve, and vascular venous involvement (p < 0.05), while not significantly correlated to lipid profile (p > 0.05).ConclusionCardiovascular complications are frequent among patients with BD, even those who are asymptomatic; therefore, these complications must be screened for early detection and proper management.

COMPLEX VENOUS THROMBOEMBOLISM DECISION-MAKING IN POSTPARTUM PATIENT

Background May-Thurner syndrome and pregnancy are independent risk factors for the development of deep vein thrombosis (DVT). Emerging data suggests an association for venous thromboembolism (VTE) development in COVID-19 patients. Treatments for DVT vary and include thrombolysis, mechanical thrombectomy and long-term anticoagulation. We describe a unique case of this in a postpartum female. Case A 31 year old female G3P0121 and recent cesarean section 1 month ago presented with left lower extremity swelling, severely limited ambulation and 3+ edema of the left leg extending to the hip without any right leg edema. She was COVID-19 antibody positive. Occlusive DVTs were confirmed via venous duplex ultrasound and computed tomographic venography of the abdomen and pelvis, extending from distal inferior vena cava to the left popliteal vein. Decision-making Invasive venography confirmed the non-invasive imaging findings. After administering 12-14 mg of tissue plasminogen activator (tPA), multiple aspirations were performed using a rheolytic thrombectomy catheter. However persistent dense thrombus in the iliac and femoral veins remained, thus subsequent balloon angioplasty was performed but unsuccessful. Intravascular ultrasound confirmed the presence of May-Thurner syndrome at the junction of the left common iliac vein and the inferior vena cava. Finally an infusion catheter was placed for tPA. Within 48 hours, patient developed oliguric renal failure likely due to a combination of contrast-induced and pigment nephropathy requiring intermittent hemodialysis. Repeat ultrasound showed resolution of DVT along with improving edema and renal function. Warfarin was chosen for long-term anticoagulation due to renal failure and breast-feeding. Conclusion Pregnancy is a pro thrombotic state that may lead to VTE even in the postpartum period. Decision-making and treatment in these patients may be complex and require a multidisciplinary approach.

Abstract No. 118 A multicenter observational study to determine the incidence of catheter-related venous thrombosis using a novel antimicrobial and anti-thrombogenic peripherally inserted central catheter

This study evaluated the impact of a novel antimicrobial and antithrombogenic peripherally inserted central catheter (PICC) and its impact on associated complications within inpatient and outpatient populations. Various strategies are used in an attempt to decrease the incidence of catheter-related complications. This IRB-approved, multicenter, prospective observational study was performed at 3 large US academic hospitals. Adults who required PICC ≥14 days were considered. Patients were monitored throughout entire catheter dwell, to a maximum of 90 days. Data was collected from hospital, outpatient and patient PICC records. Duplex venous ultrasounds were performed for thrombosis before insertion, dwell day 10-14 and upon removal. 103 patients were enrolled through interventional radiology teams; 56% were male, mean BMI was 29 ± 8.8. Majority (79%) were high-risk groups—cancer, infectious diseases, transplant, and trauma. Primary indications were antibiotics (66.99%) and chemotherapy (25.24%). Double lumen PICCs (59%) and basilic vein (71.84%) were highest selected. Fourteen (13.5%) remained inpatients, (46.6%) were discharged to home health, (20.38%) to outpatient therapy, and (19.4%) into family care. Seven (6.8%) were lost to follow-up. Mean catheter dwell was 38.74 ± 25.81 days (n = 96); Eight (7.7%) PICCs remained indwelling and functional at day 90. Three (2.9%) CRBSIs were reported at days 14, 27, and 60 and were all dual-lumen catheters (59.2%). Seven (6.8%) reported symptomatic catheter-related thromboses (CRT) and 2 (28.5%) used a standardized catheter-vessel ratio vein measurement. Several patients with asymptomatic CRT at the initial screening had complete thrombosis resolution on follow-up scanning at removal. The incidence of CRBSI was 0.81/1000 days, compared to currently reported rates of 1.8–7.7/1000 days . The overall symptomatic CRT rate was 1.87/1000 days. Evans et al (2013) reported symptomatic CRT rates of 2.7–4.3/1000 days. The focus on patient harm and safety have contributed to the implementation of infection prevention and thrombosis-reduction strategies. Antimicrobial PICCs should be considered for use in high-risk populations.

Sonographic Evaluation of a Perpetual Penetrating Retained Wood Splinter, Ulnar Artery Occlusion, and Soft Tissue Swelling in the Left Arm

Penetrating foreign bodies are frequently encountered, most commonly wood, glass, or metal slivers. Retained foreign bodies are often overlooked on initial examination and only 15% of wooden foreign bodies are detected by radiographic visualization such as radiography (X-ray), computerized tomography (CT), and magnetic resonance imaging (MRI). Soft tissue infection is the most common complication of a penetrating foreign body. This case report describes a 63-year-old man who was caught under a falling tree limb. His left forearm was speared by a large branch causing an open wound. Ten years later, the patient presented to the emergency department with pain, edema, and erythema. A left arm venous duplex was performed using dynamic B-mode imaging with pulsed Doppler to evaluate the venous system for thrombosis and a palpable mass. Sonography revealed a “perpetual” retained linear foreign body encased in a fluid collection and a distal ulnar artery occlusion with reconstitution of flow at the level of the wrist. Surgical correlation confirmed the presence, size, and location of the foreign body and associated fluid and debris. The foreign body, a wood splinter, was surgically removed without complications.

Pelvic Congestion Syndrome: Surgical Treatment

Aims: To evaluate the mid and long term efficacy of surgical interruption of the refluxing ovarian veins as a treatment modality for pelvic congestion syndrome. Study Design: A prospective non comparative interventional study. Place and Duration of Study: This study was conducted between February 2015 and October 2019 in Alexandria Medical Centre and Tanta Main University Hospital. Methodology: The study included a 27 patient’s undergone surgical interruption of refluxing ovarian veins with or without sclerotherapy of vulval, perineal or thigh varices, and data were collected prospectively. Detailed history was taken and clinical examination was done for every patient along with routine laboratory investigations and radiological work up was transvaginal and abdominal venous duplex. Follow up was done considering the change in pelvic venous images and pelvic pain scores in comparison to the pre-operative state. Results: Twenty seven female patients were treated for pelvic congestion syndrome using single session surgical intervention with or without sclerotherapy to pudendal varices. The patients age ranged from 21 to 43 (mean 33.1). All patients presented with chronic continuous pelvic pain. Other associated symptoms as dyspareunia, dysmenorrhea and pudendal varices were found in some cases. Surgical ligation of the ovarian veins were done to all cases, sclerotherapy/ligation of internal iliac varices was done for 6 cases and scerotherapy or surgical interruption of pudendal or thigh varicose veins was done in 21 cases. Technical success was achieved in all patients. Mean pelvic pain score was improved from 7.33 preoperatively to 1.33 and 0.89 in 6 and 12 months of the post-operative recordings. On sonographic basis pelvic reflux disappeared in 26 patients by the end of the follow up. Out of 27 patients treated there were 24 patients satisfied of the procedures at the end of the follow up. Conclusion: Surgical treatment for pelvic congestion syndrome combined with sclerotherapy to the associated varices was found to be effective, safe and affordable modality of treatment.

Improving follow-up of incomplete lower extremity venous duplex ultrasound examinations performed for deep and superficial vein thromboses

ObjectiveA lower extremity venous duplex ultrasound (LEVDUS) examination is the standard diagnostic test to evaluate patients for lower extremity deep vein thrombosis (DVT). However, some studies will be incomplete for a variety of reasons, including patient-related factors such as pain, edema, a large leg circumference, or the presence of overlying bandages or orthopedic devices. We previously reported that the frequency of obtaining a follow-up examination after an incomplete and negative (I/N) LEVDUS examination was low but that the rates of DVT found on the follow-up studies of initially I/N LEVDUS studies were similar to the rates of DVT found with initially complete LEVDUS examinations. Therefore, we recommended process improvements to increase follow-up LEVDUS studies after an I/N LEVDUS examination. In the present study, we have described the results of appending a recommendation to obtain a follow-up LEVDUS study to preliminary and final reports of I/N LEVDUS. MethodsStarting in January 2019 through December 2019, a recommendation to obtain a repeat LEVDUS examination after an I/N study was appended to the preliminary and final reports of all I/N LEVDUS examination of patients who did not, otherwise, have an indication for anticoagulation (group 2). The patients were identified on an ongoing basis through the study period and entered into an Excel database (Microsoft Corp, Redmond, Wash). Group 2 was compared with a previously reported historic control cohort of patients identified from January 2017 to December 2017 (group 1). We compared groups 1 and 2 with respect to the frequency of the repeat studies performed within 4 weeks after an I/N LEVDUS examination and the DVT rates found from the follow-up LEVDUS examinations after an I/N LEVDUS study. ResultsOf the patients in groups 1 and 2, 187 and 229 had had I/N LEVDUS examinations, with 28% and 40.2% of group 1 and 2 studies having follow-up LEVDUS examinations (P < .01). Previously unidentified lower extremity thrombi were discovered in 21% of the group 2 follow-up examinations. Also, the rate of new thrombi detected was not different between groups 2 and 1 (historic controls; DVT, 14.3% vs 18.5% [P = .25]; SVT, 6.3% vs 3.3% [P = .15]). A definitive finding of either positive or negative for DVT and SVT with a complete examination in 50% of the group 2 patients with follow-up examinations. ConclusionsA recommendation to obtain a follow-up examination appended to the preliminary and final I/N LEVDUS reports was associated with an increased rate of follow-up examinations, which revealed many previously undetected DVTs and SVTs or had allowed for definitive exclusion of DVT.

Short Term Evaluation of Warfarin Versus Rivaroxaban Regimens in the Treatment of Deep Venous Thrombosis

The Low molecular weight heparin (LMWH) and vitamin K antagonists (VKAs) were considered as the first line management option for the prevention and treatment of deep venous thromboembolism for several decades as warfarin was the only oral anticoagulation option; but new oral anticoagulants have the potential to change the management of coagulation disorders. As they differ from VKAs in their anticoagulation mechanism because of direct inhibition of proteins of the coagulation cascade. They have more predictable pharmacokinetics that leads to a fixed and convenient dosing regimens with no need for routine monitoring, as well as in a rapid onset of action, and high efficacy and low risk of bleeding. Their limitations are their higher cost, limited monitoring (if needed, as only qualitative measures available) and the lack of a specific antidote. This study aims to studythe short term outcome of two regimens Rivaroxaban versus warfarin in acute deep venous thrombosis treatment regarding their rate of recanalization using venous duplex. This work was done over 100 patients, divided into 2 equal groups: Group received Rivaroxaban for 1 month, and group 2 received warfarin. The following was done for all patients: creatinine venous duplex at time of diagnosis and another follow up after one month and rate of recanalization was assessed. Rivaroxaban (group 1) included 25 males and 25 females with a mean age of 54.14 (29-81), and a mean BMI of 24.64 ± 3.73. Warfarin (group 2) included 24 males and 26 females with a mean age of 52.04 (28- 80), and a mean BMI of 23.64 ± 3.57. There were 22% in the Rivaroxaban group had no or minimal recanalization versus 70% in the warfarin group. While 78% had partial to complete recanalization in the Rivaroxaban group versus 30% in the warfarin group with a statistical significant differences between the 2 arms of the study. Rivaroxaban showed a better rate of recanalization compared to warfarin in short term follow up of patients with acute DVT.

Utility of unilateral versus bilateral venous reflux studies for venous insufficiency

Duplex ultrasonography is the reference standard for diagnosing chronic venous insufficiency. Bilateral venous reflux ultrasound studies are among the most time-consuming and physically demanding tests for vascular ultrasound technologists to perform. Furthermore, if a venous procedure is required, many insurance policies require that a diagnostic venous ultrasound scan for reflux must be performed within 1year of the procedure. If the intervention is scheduled for >1year after the ultrasound scan, the insurance company might require a repeat venous ultrasound scan before granting insurance authorization. Hence, ordering bilateral venous duplex ultrasound scans to evaluate for reflux when an intervention might only be performed on one limb within the year could be a waste of time and resources. The aim of the present study was to determine the utility of ordering bilateral vs unilateral studies to evaluate for reflux in patients with suspected chronic venous insufficiency and to determine whether a resource-saving potential exists for vascular laboratories through optimization of the process of ordering venous duplex ultrasound studies. A retrospective review of all patients who had undergone bilateral lower extremity ultrasound scanning to evaluate for reflux from January 1, 2016 to December 31, 2016 at the Massachusetts General Hospital vascular laboratory was performed. The demographics, indications for ultrasound scanning, comorbidities, time required to perform the ultrasound study, and interval to intervention were documented. The data were analyzed using SPSS statistical software (IBM Corp, Armonk, NY). During the study period, 13,854 ultrasound studies had been performed in our vascular laboratory, of which 606 (4.4%) had been bilateral ultrasound scans for venous insufficiency. The time allotted for a bilateral study was 2hours. Of the 606 studies evaluated, 152 (25.1%) showed no evidence of reflux, 284 (46.9%) showed bilateral lower extremity reflux, and 170 (28.1%) showed only venous insufficiency in one leg. Venous ablation, phlebectomy, and/or sclerotherapy were performed for 28.7% of the patients. However only 6.2% of patients had undergone venous procedures on both legs within 1year after the ultrasound studies. Ablation was the most common procedure performed (54.6%), followed by phlebectomy (27.%) and sclerotherapy (17.9%). Overall, 94.7% of patients had not undergone a venous procedure on both legs within 1year after the ultrasound studies and, hence, would have required a repeat duplex ultrasound scan to ensure insurance coverage for future procedures. Most bilateral ultrasound scans for venous insufficiency will not result in an intervention. Thus, most patients (95%) could have undergone a unilateral scan before the initial intervention instead of bilateral duplex ultrasound scanning.

Arterial and venous thromboembolic complications of COVID-19 detected by CT angiogram and venous duplex ultrasound.

ObjectiveTo investigate the incidence of thromboembolic events, specifically pulmonary embolism (PE), deep vein thrombosis (DVT), and cerebrovascular accidents (CVA), in patients who tested positive for COVID-19 through RT-PCR in a regional healthcare system in Connecticut.Materials and methodsAll CT angiogram (CTA) and venous duplex extremity ultrasound (US) examinations performed on 192 consecutively documented cases of COVID-19 were retrospectively reviewed at a multi-centered healthcare system. Clinical characteristics and patient outcomes were evaluated and compared between two groups based on the presence or absence of acute thromboembolic events.ResultsOf the 16,264 patients tested for COVID-19, 3727 (23%) were positive. Out of those, 192 patients underwent 245 vascular imaging studies including chest CTA (86), venous duplex ultrasound (134), and CTA head and neck (25). Among those who underwent imaging, 49 (26%) demonstrated acute thromboembolic events which included 13/86 (15%) with PE, 34/134 (25%) with DVT, and 6/25 (24%) with CVA. One patient had positive results on all 3 examinations, and 2 patients had positive results on both chest CTA and venous duplex US. Males were more likely to have a thromboembolic event than females (33/103 (34%) vs. 14/89 (16%), p = 0.009). No significant difference was observed with respect to age, cardiopulmonary comorbidities, malignancy history, diabetes, or dialysis.ConclusionApproximately 26% of COVID-19 patients with positive testing who underwent vascular imaging with CTA or venous duplex ultrasound had thromboembolic events including PE, DVT, and CVA. This indicates that COVID-19 patients are at increased risk for thromboembolic complications.

Prevalence of Deep Vein Thrombosis in Patients Supported With Extracorporeal Membrane Oxygenation.

Prevalence of Deep Vein Thrombosis in Patients Supported With Extracorporeal Membrane Oxygenation.

Pain, Swelling and Blue Discoloration of Right Hand in a COVID-19 Patient

A 61-year-old woman with a history of type 2 diabetes mellitus and hypertension presented to the emergency department with sudden onset of right hand pain, swelling, and a dark blue discoloration (Figure 1). She also reported a fever, dyspnea, and dry cough that began 3 days before. Coronavirus disease 2019 infection was confirmed by detection of severe acute respiratory syndrome coronavirus 2 ribonucleic acid from a nasopharyngeal swab. Venous duplex ultrasonography revealed occlusive thrombus in the right brachial vein (Figure 2).

Cerebral vasospasm, intracardiac clot, wellens syndrome, and popliteal vein aneurysm in a hypercoagulable state in lassa fever

Background: Lassa fever could precipitate a condition of hypercoagulable state with multiple organ involvement. We report an unusual presentation of cerebral vasospasm, intracardiac clot, Wellens syndrome, and popliteal vein aneurysm in a case of Lassa fever. We demonstrate the use of noninvasive imaging in the diagnosis and management of hypercoagulable state in a first case presentation in Lassa fever. Methods: We present a 53-year-old Nigerian woman, with a high-grade fever (39°C) that was associated with chills, headaches, insomnia, anxiety, chest pain, diaphoresis, palpitation, general weakness, muscle aches in all extremities, muscle cramps, dizziness spells, hyperacusis, nausea, vomiting, diarrhea, hematochezia, and abdominal pain. She admitted that her home is infested with rodents. Physical examination revealed severe anemia. Laboratory tests including blood sample analysis and biochemistry were conducted. Lassa fever was confirmed using Lassa virus-reverse transcription-polymerase chain reaction tests. Electrocardiography (ECG), two-dimensional echocardiography, venous duplex ultrasound of the leg veins, and transcranial Doppler ultrasound were performed. Results: Blood tests showed electrolyte imbalance and hypertriglyceridemia. Ultrasound tests revealed intracardiac clots with dyskinetic apical septal wall motion abnormality, saccular aneurysm with popliteal venous thrombosis of the right leg popliteal vein, and cerebral vasospasm of the right internal carotid artery due to cardiogenic microemboli. ECG demonstrated Wellens syndrome. The patient was successfully treated with intravenous ribavirin, whole blood transfusion, broad-spectrum antibiotics, isosorbide dinitrate, pentoxifylline, metronidazole, antimalarial, dexamethasone, erythropoietin, anticoagulants (low-molecular-weight heparin and warfarin), and supportive care. Conclusion: Noninvasive ultrasound modalities were useful for early detection and treatment of hypercoagulable state in Lassa fever.

Diagnosis and treatment of iliac vein stenosis

Stenosis of the iliac veins is common in patients with chronic venous insufficiency. The article describes the methods for the diagnosis and treatment of iliac vein stenosis. The causes of iliac vein stenosis include extravasal compression or the consequences of ileofemoral thrombosis. Stenosis of the iliac veins exists in 1/4 of the entire adult population, but clinical manifestations do not occur in all patients. Stenosis of the iliac veins should be considered in case of an unknown edema, more often in the left lower extremity, since venous duplex ultrasound of lower extremities is not sensitive and specific enough when examining the veins above the inguinal ligament. The most accurate diagnostic method is intravascular ultrasound (IVUS) but the appeared computed tomography angiography (CTA) and magnetic resonance angiography (MRA) with high-quality images have become a good replacement for IVUS. The main method of treatment of iliac vein stenosis, besides stenting, isindispensable drug therapy consisting of antithrombotic and phlebotonic drugs.