Clinical Vascular Laboratory Diagnosis of Deep Venous Thrombosis GARY G. NICHOLAS, M.D., F.A.C.S., FRANKLIN J. MILLER, JR., M.D.,* WILLIAM E. DEMUTH, JR., M.D., F.A.C.S., JOHN A. WALDHAUSEN, M.D., F.A.C.S.
The accuracy of our clinical vascular laboratory was evaluated. Sixty-nine limbs (55 patients) were examined clinically for thrombophlebitis. All of these patients were then evaluated using segmental plethysmography and Doppler ultrasound techniques. Each limb was then studied with venography. In 57 of the 69 (82.6%) limbs evaluated, measurement of the maximum venous outflow accurately reflected the venographic findings. Doppler augmented venous sounds were correct when compared to venography in 77.6% of limbs. In the 59 limbs that exhibited clinical signs of deep venous thrombosis, only 35.6% had venographic confirmation of the diagnosis. The clinical vascular laboratory provides an accuracy of diagnosis of deep venous thrombosis not achieved by clinical examination. If both segmental plethysmography and Doppler ultrasound were negative, it was very unlikely that deep venous thrombosis had occurred.
mHE FREQUENCY WITH WHICH thrombophlebitis and pulmonary emboli are noted at autopsy makes the early and accurate diagnosis ofdeep venous thrombosis essential.5 The inaccuracy of clinical examination in detecting deep venous thrombosis is clearly established.3'4 Although venography remains the standard for the diagnosis, reports from numerous authors using noninvasive techniques show significantly improved accuracy over clinical examination alone.1'3'4'12 The data presented in this manuscript support the value of noninvasive testing in the clinical vascular laboratory when deep venous thrombosis is suspected. Method
There were 55 patients evaluated for this study. These were patients referred to our clinical vascular laboratory for the diagnosis of possible thrombophlebitis. Each patient was evaluated by physical * Present address: Department of Radiology, University of Utah Medical Center, Salt Lake City, Utah. Submitted for publication: December 13, 1976. Reprint requests: Gary G. Nicholas, M.D., Department of Surgery, The Milton S. Hershey Medical Center, Hershey, Pennsylvania 17033.
From the Departments of Surgery and Radiology, The Milton S. Hershey Medical Center, The Pennsylvania State University, Hershey, Pennsylvania
examination, Doppler ultrasound, segmental plethysmography, and venography. Physical examination of the extremity included the determination of the presence of localized tenderness, swelling, or a positive Homans' sign. If any of these findings were present, the patient was considered to have clinical evidence of deep venous thrombosis. Doppler ultrasound determination of the presence of augmented venous sounds over the femoral vein was performed according to the method described by Sigel.10 Augmented venous sounds in response to thigh, popliteal, and calf compression were either present, absent, or less than usual. If augmented venous sounds were diminished or absent, ultrasound evidence of deep venous thrombosis was considered present. Segmental plethysmography was utilized to determine maximum venous outflow. The technique utilized by Johnston and Kakkar was employed.8 Using an airfilled cuff, volume change in the portion of limb beneath the cuff was measured in response to release of a proximal venous tourniquet. Instrumentation employed was the pulse volume recorder® (Life Sciences, Inc., Greenwich, Conn.). In a series of patients without venographic evidence of deep venous thrombosis, it was found that greater than 50% of the blood entrapped by the venous tourniquet leaves the leg in the first two seconds after the tourniquet is released (Fig. 1). Any patient found to have a maximum venous outflow of less than 50%o in two seconds was considered to have segmental plethysmographic evidence of deep venous thrombosis. Venography was performed in all patients in both the anterior-posterior and the lateral projection with the knee slightly flexed using 70-100 ml of contrast per extremity. The deep venous system was visualized from the arch of the foot to the pelvis.
213
Ann. Surg. * August 1977
NICHOLAS AND OTHERS
214
thrombosis in 23. Plethysmography was correct as determined by contrast venography in 57 limbs for an overall accuracy of 82.6%. It should be noted that there were only two limbs in which a false negative result was encountered (Table 2).
0
0 -i L..
Discussion
0
There were 55 patients (69 limbs) examined clinically for the presence of localized pain, tenderness on palpation, swelling, or a positive Homans' sign. In all of these patients the diagnosis of deep venous thrombosis was being considered. One or more of the above findings was present in 59 of the limbs examined. Only 21 (35.6%) of these 59 limbs had venographic evidence of deep venous thrombosis. Doppler ultrasound evaluation for augmented venous sounds was performed in 49 limbs (Table 1). All ofthese limbs subsequently underwent venographic evaluation, and 19 were found to have deep venous thrombosis. The evaluation of augmented venous sounds correctly diagnosed the presence or absence of deep venous thrombosis found on venography in 38 of these limbs (77.6%). In only two limbs did Doppler ultrasound examination yield a false negative result when compared to the venogram. In the 69 limbs evaluated using the segmental plethysmograph, venography revealed deep venous
Clinical signs of deep venous thrombosis were present in 59 of the limbs examined, yet only 21 (35.6%) had venographic evidence of thrombosis. The results of others confirm the inaccuracy of clinical examination in this disease process. Cranley found clinical signs of deep venous thrombosis to be present with an equal frequency in two groups, one with and one without venographic evidence of deep venous thrombosis.4 Barnes noted objective confirmation of the clinical diagnosis of acute venous thrombosis in only 37% of 527 patients.3 Haeger found venographic confirmation of the clinical diagnosis of acute venous thrombosis in less than half of the 72 patients in the series he reported.6 It is data such as these that lead one to suggest the need for objective confirmation of venous thrombosis. Doppler ultrasound analysis and segmental plethysmography are used by many clinical vascular laboratories to more clearly define abnormal venous hemodynamics. Sigel outlined an extensive technique for evaluating venous hemodynamics with doppler ultrasound.10 The presence of augmented Doppler sounds in response to limb compression allows one to define patency as well as value function in the segment being tested. Yao et al. examined 162 patients and found the Doppler ultrasound technique to be 82.9%o accurate.12 Alexander et al. noted a 93% accuracy of this technique in the 166 patients they evaluated.1 The Doppler ultrasound technique has several limitations. 10 Examination of a leg that has been drained of blood either by recent elevation or external compression may yield erroneous results. Errors related to the disease process are also possible. In the presence of only tributary or calf clots and in the presence of extensive collateralization, ultrasound results may be misleading. Indeed, Sigel reported 39Wo false negative results with
TABLE 1. Doppler Ultrasound Accuracy in Detecting Deep Venous Thrombosis as Determined by Venography
TABLE 2. Segmental Plethysmographic Accuracy in Detecting Deep Venous Thrombosis as Determined by Venography
50
z
LUJ
C-)
LUJ ci
l
_
1001 0
1
2
3
4
5
TIME (sec.)
FIG. 1. Normal maximum venous outflow. Proximal venous occlusion cuff deflated at time 0. Normal venous outflow is greater than 50o decrease in segmental volume in two seconds.
Results
Result
No.
Percent
Result
No.
Percent
Correct Incorrect false positive false negative Total
38
77.6
57
11 9 2
22.4 18.4 4.0 100
Correct Incorrect false positive false negative Total
82.6 17.4 14.5 2.9 100
49
12 10 2 69
Vol. 186 . No. 2
215
THROMBOSIS DIAGNOSIS
Doppler ultrasound if only leg vein thrombosis was seen on venography.10 Even with these limitations, Barnes was able to accurately diagnose calf deep venous thrombosis in 84% of 55 limbs they studied.2 In the 49 patients examined by Doppler ultrasound, the diagnosis was correct in 38 at 77.6%. Although 11 were incorrectly diagnosed, it is important that in only two (4%) was the test a false negative. Thus, the presence of a normal Doppler ultrasound examination is excellent evidence that deep venous thrombosis is not present. Segmental plethysmography is also useful in evaluating limb hemodynamics. Alterations in limb volume are reflected in changes in limb impedance or pressure changes in an air-filled cuff placed on the limb. A variety of respiratory maneuvers as well as proximal venous compression are used to produce fluctuations in limb volume. The use of respiratory mechanics to alter limb volume as originally outlined by Mullick et al.9 has been found by others to be an insensitive indicator of venous thrombosis.7'8 Improved accuracy can be achieved if one uses proximal venous occlusion with quantitation of subsequent venous outflow from the extremity being examined.8 Johnston found the maximum rate of venous emptying to be the most sensitive index of deep venous thrombosis. This technique also overcomes many of the shortcomings encountered when one depends upon respiratory maneuvers requiring patient cooperation. The accuracy of maximum venous outflow determination is limited by the inability to detect tributary and calf thrombi that are so clearly demonstrated with 1125 fibrinogen techniques. Extensive venous collateralization in limbs with chronic venous occlusive disease will also cause errors in diagnosis. In the 69 limbs we examined, the correct diagnosis was made in 57 (82.6%) when compared to venography. Segmental plethysmographic results were incorrect in 12 limbs, but in only two (2.9Wo) was a false negative result obtained. Thus, an examination finding normal results for maximum venous outflow is strong evidence for the absence of deep venous thrombosis. Only in those patients with classic phlegmasia can one feel assured as to the correctness of the clinical
diagnosis without obtaining more objective data. At the present time, Doppler ultrasound and segmental plethysmography are recommended for all patients with clinical signs of deep venous thrombosis. Altough noninvasive clinical vascular laboratory testing has not been able to achieve the accuracy obtained with venography in the detection of deep venous thrombosis, it is clear that results obtained surpass those achieved on the basis of clinical examination alone. If one is going to institute anticoagulation with its attendant risks, inconvenience, and expense, objective data obtained in the clinical vascular laboratory is useful to confirm the clinical impression. References 1. Alexander, R. H., Folse, R., Pizzorne, J., and Conn, R.: Thrombophlebitis and Thromboembolism. Ann. Surg., 180: 883, 1974. 2. Barnes, R. W., Russell, H. E., Wu, K. K., and Hoak, J. C.: Accuracy of Doppler Ultrasound in Clinically Suspected Venous Thrombosis of the Calf. Surg. Gynecol. Obstet., 143: 425, 1976. 3. Barnes, R. W., Wu, K. K., and Hoak, J. C.: Fallibility of the Clinical Diagnosis of Venous Thrombosis. JAMA, 234:605, 1975. 4. Cranley, J. L., Canos, A. J., and Sull, W. J.: Phleborheographic Technique for Diagnosing Deep Venous Thrombosis of the Lower Extremities. Surg. Gynecol. Obstet., 141:331, 1975. 5. Freiman, D., Suyemoto, J., and Wissler, S.: Frequency of Pulmonary Thromboembolism in Man. N. Engl. J. Med., 272: 1278, 1965. 6. Haeger, K.: Problems of Acute Deep Venous Thrombosis I: The Interpretation of Signs and Symptoms. Angiology, 20:219, 1969. 7. Harris, W. H., Sara, S. M., Salzman, E. W., et al.: Impedance Phlebography: A Correlation with Lower Limb Venography in the Diagnosis of Deep Vein Thrombosis. Surgery, 74:385, 1973. 8. Johnston, K. W. and Kakkar, V. V.: Plethysmographic Diagnosis of Deep Vein Thrombosis. Surg. Gynecol. Obstet., 139: 41, 1974. 9. Mullick, S. C., Wheeler, H., and Sheperd, M. H.: Diagnosis of Deep Venous Thrombosis by Measurement of Electrical Impedance. Am. J. Surg., 119:417, 1970. 10. Sigel, B., Felix, W. R., Popky, G. L., and Ipsen, J.: Diagnosis of Lower Limb Venous Thrombosis by Doppler Ultrasound Technique. Arch. Surg., 104:174, 1972. 11. Steer, M. L., Spotnitz, A. J., Cohen, S. I., et al.: Limitation of Impedance Phlebography for Diagnosis of Venous Thrombosis. Arch. Surg., 106:44, 1973. 12. Yao, J. S., Henkin, R. E., and Bergan, J. L.: Venous Thromboembolic Disease: Evaluation of New Methodology in Treatment. Arch. Surg., 109:664, 1974.
The accuracy of our clinical vascular laboratory was evaluated. Sixty-nine limbs (55 patients) were examined clinically for thrombophlebitis. All of these patients were then evaluated using segmental plethysmography and Doppler ultrasound techniques. Each limb was then studied with venography. In 57 of the 69 (82.6%) limbs evaluated, measurement of the maximum venous outflow accurately reflected the venographic findings. Doppler augmented venous sounds were correct when compared to venography in 77.6% of limbs. In the 59 limbs that exhibited clinical signs of deep venous thrombosis, only 35.6% had venographic confirmation of the diagnosis. The clinical vascular laboratory provides an accuracy of diagnosis of deep venous thrombosis not achieved by clinical examination. If both segmental plethysmography and Doppler ultrasound were negative, it was very unlikely that deep venous thrombosis had occurred.
mHE FREQUENCY WITH WHICH thrombophlebitis and pulmonary emboli are noted at autopsy makes the early and accurate diagnosis ofdeep venous thrombosis essential.5 The inaccuracy of clinical examination in detecting deep venous thrombosis is clearly established.3'4 Although venography remains the standard for the diagnosis, reports from numerous authors using noninvasive techniques show significantly improved accuracy over clinical examination alone.1'3'4'12 The data presented in this manuscript support the value of noninvasive testing in the clinical vascular laboratory when deep venous thrombosis is suspected. Method
There were 55 patients evaluated for this study. These were patients referred to our clinical vascular laboratory for the diagnosis of possible thrombophlebitis. Each patient was evaluated by physical * Present address: Department of Radiology, University of Utah Medical Center, Salt Lake City, Utah. Submitted for publication: December 13, 1976. Reprint requests: Gary G. Nicholas, M.D., Department of Surgery, The Milton S. Hershey Medical Center, Hershey, Pennsylvania 17033.
From the Departments of Surgery and Radiology, The Milton S. Hershey Medical Center, The Pennsylvania State University, Hershey, Pennsylvania
examination, Doppler ultrasound, segmental plethysmography, and venography. Physical examination of the extremity included the determination of the presence of localized tenderness, swelling, or a positive Homans' sign. If any of these findings were present, the patient was considered to have clinical evidence of deep venous thrombosis. Doppler ultrasound determination of the presence of augmented venous sounds over the femoral vein was performed according to the method described by Sigel.10 Augmented venous sounds in response to thigh, popliteal, and calf compression were either present, absent, or less than usual. If augmented venous sounds were diminished or absent, ultrasound evidence of deep venous thrombosis was considered present. Segmental plethysmography was utilized to determine maximum venous outflow. The technique utilized by Johnston and Kakkar was employed.8 Using an airfilled cuff, volume change in the portion of limb beneath the cuff was measured in response to release of a proximal venous tourniquet. Instrumentation employed was the pulse volume recorder® (Life Sciences, Inc., Greenwich, Conn.). In a series of patients without venographic evidence of deep venous thrombosis, it was found that greater than 50% of the blood entrapped by the venous tourniquet leaves the leg in the first two seconds after the tourniquet is released (Fig. 1). Any patient found to have a maximum venous outflow of less than 50%o in two seconds was considered to have segmental plethysmographic evidence of deep venous thrombosis. Venography was performed in all patients in both the anterior-posterior and the lateral projection with the knee slightly flexed using 70-100 ml of contrast per extremity. The deep venous system was visualized from the arch of the foot to the pelvis.
213
Ann. Surg. * August 1977
NICHOLAS AND OTHERS
214
thrombosis in 23. Plethysmography was correct as determined by contrast venography in 57 limbs for an overall accuracy of 82.6%. It should be noted that there were only two limbs in which a false negative result was encountered (Table 2).
0
0 -i L..
Discussion
0
There were 55 patients (69 limbs) examined clinically for the presence of localized pain, tenderness on palpation, swelling, or a positive Homans' sign. In all of these patients the diagnosis of deep venous thrombosis was being considered. One or more of the above findings was present in 59 of the limbs examined. Only 21 (35.6%) of these 59 limbs had venographic evidence of deep venous thrombosis. Doppler ultrasound evaluation for augmented venous sounds was performed in 49 limbs (Table 1). All ofthese limbs subsequently underwent venographic evaluation, and 19 were found to have deep venous thrombosis. The evaluation of augmented venous sounds correctly diagnosed the presence or absence of deep venous thrombosis found on venography in 38 of these limbs (77.6%). In only two limbs did Doppler ultrasound examination yield a false negative result when compared to the venogram. In the 69 limbs evaluated using the segmental plethysmograph, venography revealed deep venous
Clinical signs of deep venous thrombosis were present in 59 of the limbs examined, yet only 21 (35.6%) had venographic evidence of thrombosis. The results of others confirm the inaccuracy of clinical examination in this disease process. Cranley found clinical signs of deep venous thrombosis to be present with an equal frequency in two groups, one with and one without venographic evidence of deep venous thrombosis.4 Barnes noted objective confirmation of the clinical diagnosis of acute venous thrombosis in only 37% of 527 patients.3 Haeger found venographic confirmation of the clinical diagnosis of acute venous thrombosis in less than half of the 72 patients in the series he reported.6 It is data such as these that lead one to suggest the need for objective confirmation of venous thrombosis. Doppler ultrasound analysis and segmental plethysmography are used by many clinical vascular laboratories to more clearly define abnormal venous hemodynamics. Sigel outlined an extensive technique for evaluating venous hemodynamics with doppler ultrasound.10 The presence of augmented Doppler sounds in response to limb compression allows one to define patency as well as value function in the segment being tested. Yao et al. examined 162 patients and found the Doppler ultrasound technique to be 82.9%o accurate.12 Alexander et al. noted a 93% accuracy of this technique in the 166 patients they evaluated.1 The Doppler ultrasound technique has several limitations. 10 Examination of a leg that has been drained of blood either by recent elevation or external compression may yield erroneous results. Errors related to the disease process are also possible. In the presence of only tributary or calf clots and in the presence of extensive collateralization, ultrasound results may be misleading. Indeed, Sigel reported 39Wo false negative results with
TABLE 1. Doppler Ultrasound Accuracy in Detecting Deep Venous Thrombosis as Determined by Venography
TABLE 2. Segmental Plethysmographic Accuracy in Detecting Deep Venous Thrombosis as Determined by Venography
50
z
LUJ
C-)
LUJ ci
l
_
1001 0
1
2
3
4
5
TIME (sec.)
FIG. 1. Normal maximum venous outflow. Proximal venous occlusion cuff deflated at time 0. Normal venous outflow is greater than 50o decrease in segmental volume in two seconds.
Results
Result
No.
Percent
Result
No.
Percent
Correct Incorrect false positive false negative Total
38
77.6
57
11 9 2
22.4 18.4 4.0 100
Correct Incorrect false positive false negative Total
82.6 17.4 14.5 2.9 100
49
12 10 2 69
Vol. 186 . No. 2
215
THROMBOSIS DIAGNOSIS
Doppler ultrasound if only leg vein thrombosis was seen on venography.10 Even with these limitations, Barnes was able to accurately diagnose calf deep venous thrombosis in 84% of 55 limbs they studied.2 In the 49 patients examined by Doppler ultrasound, the diagnosis was correct in 38 at 77.6%. Although 11 were incorrectly diagnosed, it is important that in only two (4%) was the test a false negative. Thus, the presence of a normal Doppler ultrasound examination is excellent evidence that deep venous thrombosis is not present. Segmental plethysmography is also useful in evaluating limb hemodynamics. Alterations in limb volume are reflected in changes in limb impedance or pressure changes in an air-filled cuff placed on the limb. A variety of respiratory maneuvers as well as proximal venous compression are used to produce fluctuations in limb volume. The use of respiratory mechanics to alter limb volume as originally outlined by Mullick et al.9 has been found by others to be an insensitive indicator of venous thrombosis.7'8 Improved accuracy can be achieved if one uses proximal venous occlusion with quantitation of subsequent venous outflow from the extremity being examined.8 Johnston found the maximum rate of venous emptying to be the most sensitive index of deep venous thrombosis. This technique also overcomes many of the shortcomings encountered when one depends upon respiratory maneuvers requiring patient cooperation. The accuracy of maximum venous outflow determination is limited by the inability to detect tributary and calf thrombi that are so clearly demonstrated with 1125 fibrinogen techniques. Extensive venous collateralization in limbs with chronic venous occlusive disease will also cause errors in diagnosis. In the 69 limbs we examined, the correct diagnosis was made in 57 (82.6%) when compared to venography. Segmental plethysmographic results were incorrect in 12 limbs, but in only two (2.9Wo) was a false negative result obtained. Thus, an examination finding normal results for maximum venous outflow is strong evidence for the absence of deep venous thrombosis. Only in those patients with classic phlegmasia can one feel assured as to the correctness of the clinical
diagnosis without obtaining more objective data. At the present time, Doppler ultrasound and segmental plethysmography are recommended for all patients with clinical signs of deep venous thrombosis. Altough noninvasive clinical vascular laboratory testing has not been able to achieve the accuracy obtained with venography in the detection of deep venous thrombosis, it is clear that results obtained surpass those achieved on the basis of clinical examination alone. If one is going to institute anticoagulation with its attendant risks, inconvenience, and expense, objective data obtained in the clinical vascular laboratory is useful to confirm the clinical impression. References 1. Alexander, R. H., Folse, R., Pizzorne, J., and Conn, R.: Thrombophlebitis and Thromboembolism. Ann. Surg., 180: 883, 1974. 2. Barnes, R. W., Russell, H. E., Wu, K. K., and Hoak, J. C.: Accuracy of Doppler Ultrasound in Clinically Suspected Venous Thrombosis of the Calf. Surg. Gynecol. Obstet., 143: 425, 1976. 3. Barnes, R. W., Wu, K. K., and Hoak, J. C.: Fallibility of the Clinical Diagnosis of Venous Thrombosis. JAMA, 234:605, 1975. 4. Cranley, J. L., Canos, A. J., and Sull, W. J.: Phleborheographic Technique for Diagnosing Deep Venous Thrombosis of the Lower Extremities. Surg. Gynecol. Obstet., 141:331, 1975. 5. Freiman, D., Suyemoto, J., and Wissler, S.: Frequency of Pulmonary Thromboembolism in Man. N. Engl. J. Med., 272: 1278, 1965. 6. Haeger, K.: Problems of Acute Deep Venous Thrombosis I: The Interpretation of Signs and Symptoms. Angiology, 20:219, 1969. 7. Harris, W. H., Sara, S. M., Salzman, E. W., et al.: Impedance Phlebography: A Correlation with Lower Limb Venography in the Diagnosis of Deep Vein Thrombosis. Surgery, 74:385, 1973. 8. Johnston, K. W. and Kakkar, V. V.: Plethysmographic Diagnosis of Deep Vein Thrombosis. Surg. Gynecol. Obstet., 139: 41, 1974. 9. Mullick, S. C., Wheeler, H., and Sheperd, M. H.: Diagnosis of Deep Venous Thrombosis by Measurement of Electrical Impedance. Am. J. Surg., 119:417, 1970. 10. Sigel, B., Felix, W. R., Popky, G. L., and Ipsen, J.: Diagnosis of Lower Limb Venous Thrombosis by Doppler Ultrasound Technique. Arch. Surg., 104:174, 1972. 11. Steer, M. L., Spotnitz, A. J., Cohen, S. I., et al.: Limitation of Impedance Phlebography for Diagnosis of Venous Thrombosis. Arch. Surg., 106:44, 1973. 12. Yao, J. S., Henkin, R. E., and Bergan, J. L.: Venous Thromboembolic Disease: Evaluation of New Methodology in Treatment. Arch. Surg., 109:664, 1974.
