Deep vein thrombosis (DVT) most commonly occurs in the lower limbs, however, are not uncommon in the upper limb and neck veins. Other types of venous thrombosis, such as intra-abdominal and intracranial, are discussed in separate articles.
The term indeterminate (equivocal) DVT is preferred over subacute DVT when the ultrasound features are of neither acute DVT nor chronic post-thrombotic change (although subacute DVT can be used in the follow-up of a known acute DVT). The term chronic post-thrombotic change is preferred over chronic or residual DVT to prevent overtreatment with anticoagulation 7,8.
- 1.6 new cases per 1000 per year
- 2.5-5% of the population is affected
- >50% have long terms symptoms of post-thrombotic syndrome
- 6% of DVT patients report eventual venous ulcers (0.1% general population)
- age (relative risk increase ~2 per 10-year increase)
- surgery (orthopedic patients at highest risk: hip 48%, knee 61%)
- history of venous thromboembolism (2-9% increase)
- primary hypercoagulable states
- estrogen replacement (2-4 x increased risk)
- immobilization (2 x increased risk)
- pregnancy (0.075% of pregnancies)
- greatest risk is in the postpartum period, risk returns to baseline 6 weeks after delivery 9
- malignancy (4-6 x increased risk)
- in-dwelling vascular device (e.g. PICC line and upper limb DVT) 6
In the lower limbs, patients often present with unilateral leg pain, swelling, and erythema. On physical examination, the affected leg is often tender and warm, and there may be dilation of superficial veins. Additionally, some patients may have a positive Homan sign on physical examination, whereby there is pain on forceful dorsiflexion while the knee is extended.
The majority of DVTs occur in the lower extremities and begin in the soleal veins of the calf.
In patients deemed to "unlikely" have a DVT via the Wells score, a negative d-dimer can safely exclude acute DVT 8.
Complete duplex ultrasound is the imaging modality of choice 8.
- non-compressible venous segment
- loss of phasic flow on Valsalva maneuver
- absent color flow if completely occlusive
- lack of flow augmentation with calf squeeze
- increased flow in superficial veins
- increased venous diameter
- soft/deformable intraluminal material
- smooth surface
- free-floating edge (uncommon)
chronic post-thrombotic change
- normal or decreased venous diameter
- rigid intraluminal material
- irregular surface
- synechiae or bands
- calcifications (rare)
- +/- acute thrombus
Vascular structures should always be interrogated during routine assessment of the peripheries and pelvis. Incidental DVT has a prevalence of around 0.3% on routine outpatient knee MRI 4:
- luminal abnormalities (abnormal flow voids or filling defects)
- vein wall thickening
- perivascular edema
- perifascial edema
- local intramuscular T2/PD hyperintensity
- subcutaneous edema
- dermal thickening (related to venous obstruction)
Treatment and prognosis
Treatment is with anticoagulation, often for at least 3 months in duration 5.
- "above knee DVT", or proximal DVT, is a lower limb DVT involving the popliteal vein or more proximal vessels 5
- 1. Atri M, Herba MJ, Reinhold C et-al. Accuracy of sonography in the evaluation of calf deep vein thrombosis in both postoperative surveillance and symptomatic patients. AJR Am J Roentgenol. 1996;166 (6): 1361-7. AJR Am J Roentgenol (abstract) - Pubmed citation
- 2. Watson L, Broderick C, Armon MP. Thrombolysis for acute deep vein thrombosis. Cochrane Database of Systematic Reviews 2016, Issue 11
- 3. Meissner MH et al. Acute venous disease: Venous thrombosis and venous trauma Journal of Vascular Surgery, 2007-12-01, Volume 46, Issue 6, Pages S25-S53
- 4. Shulman RM, Buchan C, Bleakney RR, White LM. Low prevalence of unexpected popliteal DVT detected on routine MRI assessment of the knee. Clin Imaging. 2016; 40(1):79-85.
- 5. Venous thromboembolic diseases: diagnosis, management and thrombophilia testing (NICE guideline). (n.d.). Retrieved March 01, 2018, from https://www.nice.org.uk/guidance/cg144/chapter/recommendations
- 6. Peter J. Carr, James C. R. Rippey. Upper extremity deep vein thrombosis: a complication of an indwelling peripherally inserted central venous catheter. (2015) Clinical Case Reports. 3 (3): 170. doi:10.1002/ccr3.187 - Pubmed
- 7 Gianesi et al. Global guidelines trends and controversies in lower limb venous and lymphatic disease: Narrative literature revision and experts’ opinions following the vWINter international meeting in Phlebology, Lymphology & Aesthetics, 23–25 January 2019. (2019) Phlebology. 34 (1_suppl): 4-66. doi:10.1177/0268355519870690 - Pubmed
- 8. Laurence Needleman, John J. Cronan, Michael P. Lilly, Geno J. Merli, Srikar Adhikari, Barbara S. Hertzberg, M. Robert DeJong, Michael B. Streiff, Mark H. Meissner. Ultrasound for Lower Extremity Deep Venous Thrombosis. (2018) Circulation. 137 (14): 1505-1515. doi:10.1161/CIRCULATIONAHA.117.030687 - Pubmed
- 9. Gonzalo-Carballes M, Ríos-Vives MÁ, Fierro EC, Azogue XG, Herrero SG, Rodríguez AE, Rus MN, Planes-Conangla M, Escudero-Fernandez JM, Coscojuela P. A Pictorial Review of Postpartum Complications. (2020) Radiographics : a review publication of the Radiological Society of North America, Inc. 40 (7): 2117-2141. doi:10.1148/rg.2020200031 - Pubmed