A 36 yo female with no significant PMH presented to the ED with a chief complaint of left sided leg swelling for one week. The patient notes that this has never happened before and does not have a family history of clotting disorders. She notes that she takes birth control but denies any recent travel. She does state that she lives a sedentary lifestyle. All other ROS were unremarkable, and she denies symptoms such as chest pain, SOB, or hemoptysis. Physical exam revealed intact and symmetric pulses in all 4 extremities with left sided leg swelling.
What imaging study would be indicated at this time?
A lower extremity ultrasound was performed given the concern for a DVT.
What abnormalities can be seen in this 2-point lower extremity venous ultrasound?
Case Conclusion
The patient was diagnosed with a DVT, and the patient was started on heparin and admitted to the hospital. The patient was subsequently taken to the OR for thrombectomy given the extent of her clot.
Learning Points
1) When using POCUS in the ED to assess for a DVT, both the 2-point and 3-point compression tests have shown to have similar sensitivity and specificity. For the 3- point compression test you need to identify the saphenofemoral junction and compress 1-2 cm above and below this site. Next, you need to find the bifurcation of the common femoral vein into the deep femoral vein and superficial femoral vein, and compress 1-2 cm above and below this site. Lastly, you need to find the popliteal vein up to the trifurcation into the anterior tibial vein, posterior tibial vein, and the peroneal vein and compress 1-2 cm above and below this site. For the 2-point compression test, you only need to find the saphenofemoral junction and the popliteal vein up to the trifurcation. When compressing, the walls of the vein should completely collapse and touch. Again, studies have shown the 2-point compression test has similar sensitivity and specificity as the 3-point compression test.
2) If a DVT is identified at the level of the popliteal vein or higher, treatment is anticoagulation
3) When doing POCUS in the ED to look for DVT, we do not scan below the knee. However, when ordering a formal ultrasound they will scan the entirety of the leg. If a thrombus is noted in the tibial or peroneal vein below the knee and the patient is symptomatic or
high risk, then you should treat with anticoagulation. All other clots noted below the knee need to be follow-up up with an ultrasound in 2 weeks.
4) The treatment for superficial venous thrombosis is slightly more nuanced when compared to the treatment of a DVT. If an SVT is noted <3cm from the saphenofemoral junction or >5cm in length, then you should treat with anticoagulation.
5) If an SVT is noted >3cm from the saphenofemoral junction and <5 cm in length, then you can treat with NSAIDs, compression, and outpatient follow-up.