Lower extremity not to treat?
calf thrombosis:
Joann M. L&r, MD, Thomas M. Kerr, MD, Robert D. Cranley, MD, Katherine Spirtoff, Cincinnati, Ohio
Kenneth S. Lutter, BS, RVT, and John
To treat or MD, J. Cranley,
MD,
Seventy-five patients with isolated calf vein thrombi were prospectively monitored with sequential duplex scans at 3- to 4-day intervals. Twenty-four patients (32%) propagated and 11 of these 24 (46%) into the popliteal or larger veins of the thigh. Sex, age, obesity, trauma, estrogen use, malignancy, varicose veins, smoking, surgery, and activity level were not predictive for proximal propagation. Proximal soleal vein thrombi had the highest incidence in both propagating and nonpropagating groups. Thrombus extent and bilateral involvement were not predictive of propagation. Five percent (4 of 75 patients) had highly probable ventilation perfusion scans as their initial indication for duplex scanning. Deep vein thrombosis isolated to the calf is not a benign problem. If anticoagulant therapy is contraindicated, the progress of the thrombus can be followed by duplex scanning. (J VAX SURC 1991;14:618-23.)
Duplex scanning of the peripheral vessels was introduced in I974 by Barber et al.’ Venous duplex scanning was introduced in 1982 by Talbot? and has become the standard method of diagnosing deep venous thrombosis (DVT) of the lower extremities. More than 16,000 lower extremities have been examined in this laboratory over the past 10 years. We have become convinced,3-5 as many others have,6-i3 that duplex scanning is the preferred method of diagnosis of venous thrombosis of the lower (or upper) extremity. Review of phlebograms and duplex scans at this laboratory showed that when the phlebogram was positive the duplex scan had a sensitivity of 96 O AI.I4 The false-negative rate is slightly higher with the phlebogram than with the duplex scan. For pelvic and subclavian venous thrombosis phlebography remains the “gold standard.” However, with the addition of color scanning this may change. Not all instruments are of sufficient sensitivity to permit visualization of the veins of the distal leg or of the soleal sinuses. But as more sensitive instruments become available, others report the same accuracy as we have. Prandoni and Lensing report a sensitivity and specificity of 91% and 93%, respecFrom the John J. Cranky Vascular Laboratory, Good Samaritan Hospital, Cincinnati. Presented at the Third Annual Meeting of the American Venous Forum, Ft. Lauderdale, Fla., Feb. 21-22, 1991. Reprint requests: Joann M. Lohr, MD, John J. Cranley Vascular Laboratory, Good Samaritan Hospital, 3217 Clifton Ave., Cincinnati, OH 45220
24/l/33057 618
tively, for the detection of thrombi including involvement of the calf veins. Habscheid et al9 found ultrasonography to have a 93% sensitivity for thrombosis of the calf veins and a 98% sensitivity for thrombosis involving the popliteal veins. They experienced no cases of false-positive results and had an overall specificity of 100%. METHODS
FromMar. 13,1990, to Dec. 9,1990,75 patients with DVT isolated to the calf veins on initial duplex scanning were evaluated prospectively. Serial scans were obtained at 3-day intervals to determine propagation of thrombus. Thrombi were managed with varied treatment protocols at the discretion of the attending physician. This laboratory has previously published its technique as described by Karkow et al5 Whenever possible, the same technician performed the duplex scanning. The Biosound Phase II machine (Biosound Inc., Indianapolis, Ind.) with the 10 mHz phased linear array probe was used for all studies. The most proximal extent of thrombus was documented with use of zone 5 as an imaginary line passing from midpatella to the popliteal crease. Zone 8 corresponds to a line drawn from midmedial malleolus to the midlateral malleolus. The calfwas subdivided into three equal zones. Patients were included in the study only if their initial thrombus did not extend into the popliteal vein and was distal to wne 5 (Fig. 1).
Volume 14 Number 5 November 1991
Lower extremity calf thvumbi
619
Table I. Patient characteristics Propqatms n := 24 Male Female Age range Mean age Symptomatic Asymptomatic Inpatients Outpatients
10 (42%)
14 (58%) 33-86 55.46 f 16.11 18 (75%) 6 (25%) 15 (63%) 9 (37%)
Nonpop~aturs II = 51 23 (45%) 28 (55%) 29-103 58.35 k 17.29 44 (86%) 7 (14%) 24 (47%) 27 (53%)
Short sections of the anterior tibial veins were not visualized with our current technique. The entire posterior tibial veins were imaged, and normally they were paired, and at times three veins were present. The peroneal veins were visualized from the tibial peroneal trunk distally. Gastrocnemius and soleal veins were considered together and were referred to as all being soleal veins in this laboratory. Parametric statistical analysis was done with the Student t test, whereas nonparametric comparisons were done by the chi-square method. A p value of less than 0.05 was taken to represent a significant difference.
RESULTS There were 42 female patients ranging in age from 29 to 103 years, with a mean age of 60.64 & 18.43 years. Fourteen women propagated thrombus, and 28 did not propagate thrombus. Thirty-three men were evaluated ranging in age from 33 to 82 years with a mean age of 53.33 + 13.85 years. Ten male patients propagated and 23 did not propagate. Female patients in either the propagating or nonpropagating groups were slightly older than the respective male patients (Table I). A total of 24 (32%) patients propagated their initial thrombus to a more proximal level, 11 (46%) to involve the popliteal vein or larger veins, whereas 13 (54%) propagated to a more proximal level but did not involve the popliteal vein. Of the entire 75 patients studied 15% propagated to involve the popliteal or larger veins, whereas 17% of the 75 propagated proximally but did not involve the popliteal vein. Six of these propagated and seven did not. Symptoms of pain, swelling, tenderness, discoloration, and mass were analyzed. No positive predictive factor could be identified (Table II). Risk factors were analyzed including obesity, trauma, estrogen use, malignancy, varicose veins, smoking, surgery, and activity level. No statistically significant difference was observed between the
Fig. 1. Zones of reference for upper extremity venous scanning: midline = 1.0, acromion = 3.0, elbow = 5.0, wrist = 8.0, and fingertips = 9.0. propagating and nonpropagating groups in any of these categories (Table III). Forty-nine patients in the study population underwent a surgical procedure. No significant difference occurred in any procedure group when comparing propagators to nonpropagators. Seven of the 17 patients who were propagators had undergone an orthopedic procedure, four underwent a neurosurgical procedure, one had a coronary artery bypass gratting, one had a urologic procedure, and four underwent vascular procedures. Seventeen of the 32 patients with DVT who did not propagate had undergone an orthopedic procedure, four underwent a neurosurgical procedure, two had cardiothoracic procedures, one had a urologic procedure, four underwent vascular procedures, and four had general surgical procedures. No surgical procedure could be identified as statistically prognostic for propagation. When analyzing patients who propagated with single vein segment involvement, a total of 13 patients were evaluated. The proximal soleal vein was the most frequently involved vein. Nonpropagators who were admitted with single venous segment involvement likewise most frequently had involvement of the proximal soleal vein (Table IV). Multiple vein segment involvement was seen in 11 of 24 patients (46%) who propagated, whereas 18 of 51 patients (32%) who did not propagate had multiple venous segment involvement (Fig. 2). No pattern of venous involvement could be identified. In
Journal of VASCULAR SURGERY
620 L&r et al.
Table II. Symptoms
Table IV. Single vein segment involvement Propagaturs n = 24
Nonpropa~ators n = 51
Se-rat
involved
Propagators Pain Swelling Tenderness Discoloration Mass
Table III.
16 (67%) 13 (54%) 11(46%) 0 (0%) 0 (0%)
30 26 19 5 2
(59%) (51%) (37%) (10%) (4%)
DSOL PM-V DPTV Nonpropagators PSOL DSOL PPTV DPTV PPER
Risk factors for DVT PrqDqators n = 24
Obesity Trauma Estrogen use Malignancy Varicose veins Smoking Sww
1(4%) 2 (8%) 1(4%)
3 2 4 17
Nonpropagatm II = 51 2 (4%) 8 (16%) 1(2%) 3 (6%) 7 (14%)
(12%) (8%) (17%) (71%)
32 (63%)
15 (63%) 3 (12%) 6 (25%)
44 (86%) 1(2%) 6 (12%)
11(22%)
ACtiVity
walking Chair Bedrest
PSOL
the groups with multisegment involvement, no statistically significant difference could be identified as prognostic for propagation or nonpropagation. Three patients who propagated were admitted with bilateral calf vein involvement, whereas only one nonpropagator had bilateral involvement. This approaches, but does not achieve, statistical significance. The incidence of vein involvement was evaluated in both propagator and nonpropagator groups. No prognostically significant vein segment involvement was isolated for either group. However, proximal soleal vein thrombus was identified most frequently in both groups (Table V). An interesting subgroup of the study population actually was admitted with pulmonary symptoms. These four patients (5%) had highly suspicious ventilation perfusion scans and were referred to the vascular laboratory in an attempt to identify the source of emboli. None of these patients had pulmonary angiograms at the discretion of their attending physician. These patients had sequential scans, revealing that two had propagated and two had not. An unanswered question is whether these patients had more extensive thrombi that had embolized before study. Propagation involving the popliteal or larger veins of the thigh occurred in 11 patients. Four of the propagations were to the common femoral vein level. Seven patients had involvement of the popliteal
PSOL, Proximal soleal vein; DSOL, proximal posterior tibial vein; DPTV, PPER, proximal peroneal vein.
Patients n = 13 7 (54%) 4 (31%) 1(8%) 1(8%) n = 33 15 (45%) 4 (15%) 6 (18%) 3 (9%) 5 (15%)
distal soleal vein; PPTV, distal posterior tibial vein;
vein. Six were inpatients and five were outpatients. Two of the inpatients and four of the outpatients were receiving no treatment. Two patients were in compression boots, one was receiving aspirin and was in elastic stockings, one patient was on subcutaneous heparin, and one outpatient was in elastic stockings only. Thirteen patients propagated their thrombus proximally but without popliteal vein involvement. Eight of the 13 were inpatients and five were outpatients. Six patients were receiving no treatment. One patient was on subcutaneous heparin, and one was receiving therapeutic intravenous heparin. Three patients were on aspirin, one patient was in elastic stockings, and one patient was in compression boots. Fifty-one patients were in the nonpropagating group. Twenty-four of the 51 were inpatients and 27 were outpatients. Thirty-two patients were not treated. Four patients were treated with elastic stockings, two patients were in compression devices, two patients received dipyridamole (Persantine), eight patients received aspirin alone, two patients received aspirin and Persantine, and one patient received subcutaneous heparin.
DISCUSSION Much has been made of calfveins having a benign course and not being the source of emboli. The natural history of calf muscle vein thrombosis has been used to suggest that observation is a viable treatment alternative to anticoagulation. Kistner et al.15 reported that pulmonary emboli occurred in 75% of patients as a silent event. He stated that pulmonary emboli occurred frequently from clots at all sites in the lower extremity including the tibial veins. Twenty-nine percent of the patients in his study with only tibial vein involvement had emboli.
Volume 14 Number 5 November 1991
Lower extremity calf thvumbi
x
PGSV -
y$yl~
DGSV-.
X
PPTV -.
A A
A A
A
A
A
A
A
DPTV -. PPER -. DPER-.
621
000
l
2
II
00
4
0
0000
6
7'
n
000000
.
5
AA
A
n
l
3
A
AA
0
PSOL -. 0 0 0
1
AA
n
n
DSOL-,
A
0
6' 9'
10 11 12 13 14 15 16 17 16 19'20
m 0
*a
l
21 22 23 24 25 26 27 26 29
Patients PGSV: Proximal greater saphenous vein DGSV: Distal greater saphenous vein PPTV: Proximal posterior tibia1 vein DPTV: Distal posterior tibia1 vein
PPER. Proximal peroneal vein DPER: Distal peroneal vein PSOL, Proximal soleal vein DSOL: Distal soleal vein
Fig. 2. Inpatients and outpatients with multiple vein segments involved. Patients 1 to 9 were inpatients who propagated, patients 10 to 11 were outpatients who propagated, patients 12 to 19 were inpatients who did not propagate, and patients 20 to 29 were outpatients who did not propagate. Patients with bilateral involvement are indicated with an astffisk.
Sevitt and Gallagher,16 in an autopsy series, investigated 74 cases of death from pulmonary embolus. The rate of fatal pulmonary emboli from thrombi in the deep veins of the calf in this study was 15% (11 of 74 patients). In a retrospective study, Giachino17 documented 13% of fatal pulmonary emboli originating from only calf DVT. Since the incidence of asymptomatic DVT, as well as the incidence of asymptomatic pulmonary emboli, and the incidence of emboli that are fatal, are all unknown, it is impossible to determine the relationship of calf vein thrombosis and pulmonary emboli at this time.” Some authors advocate treatment of calf vein thrombi,19-27 and others do not.28*29 Hirsh et a13’ believe that if one chooses not to treat calf vein thrombosis, a patient must be followed up clinically as 20% of these thrombi extend into the thigh. Long-term sequelae of deep venous insufficiency occurs after calf vein thrombosis as often as it occurs after more proximal DVT as reported by Lindhagen et a131 Lindner et al.32 found that 5 to 10 years after lower extremity DVT, 80% of patients will have both symptoms and abnormal venous hemodynamic studies regardless of the initial site of thrombosis. Rollins et al.33 report asymptomatic calf thrombosis as a common occurrence and confirms this as a risk factor
Table V. Incidence of vein involvement propatratm Vin
sepnt
n = 24
Distal greater saphenous Proximal posterior tibial Distal posterior tibial Proximal peroneal
2 (8%)
Distal
2 (8%)
peroneal
Anterior tibial Proximal soleal
7 (29%) 3 (13%) 4 (17%)
0 (0%) 14 (58%)
Nonjwopagatm
n = 51
0 (0%)
14 7 13 7
(27%) (14%) (25%) (14%)
0 (0%)
soleal
5 (21%)
25 (49%) 13 (25%)
Lesser saphenous
0 (0%)
0 (0%)
Distal
for recurrent DVT. Browse et al.% report a 20% incidence of moderate to severe postphlebitic symptoms 5 to 10 years after symptomatic distal DVT. Lawrence and KakkaP report 41% mild to moderate and 14% severe abnormalities when assessedby foot volumetry 2 years after DVT. One patient had a recurrent DVT in our study population on repeat scan 3 months after his original thrombus was identified.
CONCLUSION From our patient data it is clear that 32% (24 of 75 patients) of calfvein thrombi propagate. Forty-six
Journal
622
Lobr
et al.
percent of propagation was into the popliteal or larger veins, whereas 54% of propagation was to a more proximal level but did not involve the popliteal vein. In addition, in this study, calfvein thrombi were associated with a 5% (4 of 75 patients) incidence of high probability ventilation perfusion scans. Comparing the 32% risk of propagation with the 4% to 10% risk of anticoagulation,36-38 the option of doing nothing with calf vein thrombi seems illogical and poorly contemplated. In patients at high risk for anticoagulation, repeat duplex scanning is an acceptable surveillance mode. The significance of thrombus propagation when it does not extend to involve the popliteal vein remains unknown. However, we are unable to identify risk factors that identify patients with calf vein thrombi who will go on to have deep venous involvement or pulmonary emboli. Therefore we feel all calf vein thrombi should be treated with anticoagulation. If at high risk for complications of anticoagulation, then serial duplex scanning is an alternative. Deep venous thrombosis isolated to the calf veins is not a benign problem. The authors acknowledge staffs of the John J. Cranley research staff of the Clinical Samaritan Hospital, Cincinnati,
of
VASCULAR SURGERY
the support
provided Laboratory,
11.
12.
13.
14.
15.
16.
17.
18.
by the
Vascular Laboratory and the Support Ohio.
10.
19.
Good
REFERENCES 1. Barber FE, Baker DW, Strandness DE Jr, et al. Duplex scanner II for simultaneous imaging of artery tissues and flow, IEEE publication 1974, Ultrasonic Symposium Proceedings 1974. 2. Talbot SR. Use of real-time imaging in identifying deep venous obstruction. A preliminary report. Bruit 1982;6:41-2. 3. Cranley JJ. Diagnosis of deep venous thrombosis. In: Bemstein EF, ed. Recent advances in noninvasive diagnostic techniques in vascular disease. St. Louis: CV Mosby, 1990: 207-12. 4. Cranley JJ. Seeing is believing: a clot is a clot, on a duplex scan or a phlebogram. Echocard 1987;4:423. 5. Karkow WS, Ruoff BA, Cranley J J. B-mode venous imaging. In: Kempczinski RF, Yao JST, eds. Practical noninvasive vascular diagnosis. Chicago: Year Book Medical Publishers, 1987464-85. 6. Prandoni P, Lensing AW. New developments in noninvasive diagnosis of deep vein thrombosis of the lower limbs. Ric Clin Lab 1990;20:11-7. 7. Cavaye D, Kelly AT, Graham JC, Appleberg M, Briggs GM. Duplex ~ultrasound diagnosis of lower limb deep venous thrombosis. Aust N Z J Surg 1990;60:283-8. 8. Elias A, L&c&G, Bouvier JL, Benichou M, Serradimigni A. Value of real-time B-mode ultrasound imaging in the diagnosis of deep vein thrombosis of the lower limbs. Int Angiol 1987;6:175-82. 9. Habscheid W, Hohmann M, Wilhelm T, Epping J. Real-time ultrasound in the diagnosis of acute deep venous thrombosis of the lower extremity. Angiology 1990;41:559-608.
20. 21. 22.
23. 24.
25. 26.
27.
28.
29.
30. 31.
Rollins DL, Semrow CM, Friedell ML, Lloyd WE, Buchbinder D. Origin of deep vein thrombi in an ambulatory population. Am J Surg 1988;156:122-5. Krupski WC, Bass A, Dilley RB, Bernstein EF, Otis SM. Propagation of deep venous thrombosis identified by duplex ultrasonogmphy. J VASC SURG 1990;12:467-75. Flinn WR, Sandager GP, Cerullo LJ, Harvey RJ, Yao JST. Duplex venous scanning for the prospective surveillance of perioperative venous thrombosis. Arch Surg 1989;124: 901-5. Lensing AWA, Prandoni P, Brandjes D, et al. Detection of deep-vein thrombosis by real-time B-mode ulaasonography. N Engl J Med 1989;320:342-5. Cranley JJ, Higgins RF, Berry RE, et al. Near parity in the final diagnosis of deep venous thrombosis by duplex scan and phlebogreaphy. Phlebology 1989;4:714. Kismer RL, Bail JJ, Nordyke RA, Freeman GC. Incidence of pulmonary embolism in the course of thrombophlebitis of the lower extremities. Am J Surg 1972;124:169-76. Sevitt S, Gallagher N. Venous thrombosis and pulmonary embolism. A clinico-pathological study in injured and burned patients. Br J Surg 1961;48:475-89. Giachino A. Relationship between deep-vein thrombosis in the calf and fatal pulmonary embolism. Can J Surg 1988;31: 129-30. Merli GJ. Prophylaxis for deep vein thrombosis and pulmonaty embolism in the geriatric patient undergoing surgery. Clin Geriat Med 1990;6:531-42. Lisbona R, Rush C, Lepanto L. Technetium-99m red blood cell venography of the lower limb in symptomatic pulmonary embolization. Clin Nucl Med 1987;12:93-8. Strandness DE. Thrombus propagation and level of anticoagulation. J VASC SKJRG 1990;12:497-8. Moreno-Cabral R, Kismer RL, Nordyke RA. Importance of calf vein thrombophlebitis. Surgery 1976;80:73542. Lagerstedt CI, Olsson CG, Fagher BO, Cqvist BW, Albrechtsson U. Need for long-term anticoagulant treatment in symptomatic calf-vein thrombosis. Lancet 1985;2:515-8. Philbrick JT, Becker DM. Calf deep venous thrombosis. A wolfin sheep’s clothing? Arch Intern Med 1988;148:2131-8. Cade JF, Clegg EA, Westlake GW. Prophylaxis of venous thrombosis after major thoracic surgery. Aust N Z J Surg 1983;53:301-4. Du Toit DF, McCormich M, Laker L. Deep-vein thrombosis in pregnancy. A case report. S Afr Med J 1985;67:781-2. Doyle DJ, Turpie AGG, Hirsh J, et al. Adjusted subcutaneous heparin or continuous intravenous heparin in patients with acute deep vein thrombosis. Ann Intern Med 1987;107: 441-5. Barnes RW, Nix ML, Barnes CL, et al. Perioperative asymptomatic venous thrombosis: role of duplex scanning versus venography. J VASC SURG 1989;9:251-60. Meibers DJ, Baldridge ED, Ruoff BA, Karkow WS: Cranley JJ. The significance of calf muscle venous thrombosis. J Vast Tech 1988;12:143-8. Menzoian JO, Sequeira JC, Doyle JE, et al. Therapeutic and clinical course of deep vein thrombosis. Am J Surg 1983; 146:581-5. Hirsh J, Genton E, Hull R. Venous thromboembolism. New York: Grune and Stratton, 1981. Lindhagen A, Bergqvist D, Hallbook T, Efsing HO. Venous function five to eight years after clinically suspected deep venous thrombosis. Acta Med Stand 1985;217:389-95.
Volume 14 Number 5 November 1991
her
32.
Lindner DJ, Edwards JM, Phinney ES, Taylor LM, Porter JM. Long-term hemodynamic and clinical sequelae of lower extremity deep vein thrombosis. J VASC SIJRC 1986;4:43642. 33. Rollins DL, Semrow CM, FriedeLI ML, Calligaro KD, Buchbinder D. Progress in the diagnosis of deep venous thrombosis: the efficacy of real-time B-mode ultrasonic imaging. J VASC SURG 1988;7:63841. 34. Browse NL, Clemenson G, Thomas ML. Is the postphlebitic leg always postphlebitic? Relation between phlebographic appearances of deep-vein thrombosis and late sequelae. BMJ 1980;281:1167-70.
BOUND
VOLUMES
extremity calf tbrd
35.
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Lawrence D, Kakkar W. Post-phlebitic syndrome-a functional assessment. Br J Surg 1980;67:686-9. 36. Kapsch DN, Silver D. Complications of anticoagulant therapy. In: Bernhard VM, Towne JB, eds. Complications in vascular surgery. New York: Grime and Stratton 1985%X. 37. Coon WW, Willis PW III. Hemorrhagic complications of anticoagulant therapy. Arch Intern Med 1974;133:386-92. 38. Coon WW. Anticoagulant therapy. Am J Surg 1985;150: 45-9.
Submitted
AVAILABLE
Apr. 19, 1991; accepted Aug. 12, 1991.
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calf thrombosis:
Joann M. L&r, MD, Thomas M. Kerr, MD, Robert D. Cranley, MD, Katherine Spirtoff, Cincinnati, Ohio
Kenneth S. Lutter, BS, RVT, and John
To treat or MD, J. Cranley,
MD,
Seventy-five patients with isolated calf vein thrombi were prospectively monitored with sequential duplex scans at 3- to 4-day intervals. Twenty-four patients (32%) propagated and 11 of these 24 (46%) into the popliteal or larger veins of the thigh. Sex, age, obesity, trauma, estrogen use, malignancy, varicose veins, smoking, surgery, and activity level were not predictive for proximal propagation. Proximal soleal vein thrombi had the highest incidence in both propagating and nonpropagating groups. Thrombus extent and bilateral involvement were not predictive of propagation. Five percent (4 of 75 patients) had highly probable ventilation perfusion scans as their initial indication for duplex scanning. Deep vein thrombosis isolated to the calf is not a benign problem. If anticoagulant therapy is contraindicated, the progress of the thrombus can be followed by duplex scanning. (J VAX SURC 1991;14:618-23.)
Duplex scanning of the peripheral vessels was introduced in I974 by Barber et al.’ Venous duplex scanning was introduced in 1982 by Talbot? and has become the standard method of diagnosing deep venous thrombosis (DVT) of the lower extremities. More than 16,000 lower extremities have been examined in this laboratory over the past 10 years. We have become convinced,3-5 as many others have,6-i3 that duplex scanning is the preferred method of diagnosis of venous thrombosis of the lower (or upper) extremity. Review of phlebograms and duplex scans at this laboratory showed that when the phlebogram was positive the duplex scan had a sensitivity of 96 O AI.I4 The false-negative rate is slightly higher with the phlebogram than with the duplex scan. For pelvic and subclavian venous thrombosis phlebography remains the “gold standard.” However, with the addition of color scanning this may change. Not all instruments are of sufficient sensitivity to permit visualization of the veins of the distal leg or of the soleal sinuses. But as more sensitive instruments become available, others report the same accuracy as we have. Prandoni and Lensing report a sensitivity and specificity of 91% and 93%, respecFrom the John J. Cranky Vascular Laboratory, Good Samaritan Hospital, Cincinnati. Presented at the Third Annual Meeting of the American Venous Forum, Ft. Lauderdale, Fla., Feb. 21-22, 1991. Reprint requests: Joann M. Lohr, MD, John J. Cranley Vascular Laboratory, Good Samaritan Hospital, 3217 Clifton Ave., Cincinnati, OH 45220
24/l/33057 618
tively, for the detection of thrombi including involvement of the calf veins. Habscheid et al9 found ultrasonography to have a 93% sensitivity for thrombosis of the calf veins and a 98% sensitivity for thrombosis involving the popliteal veins. They experienced no cases of false-positive results and had an overall specificity of 100%. METHODS
FromMar. 13,1990, to Dec. 9,1990,75 patients with DVT isolated to the calf veins on initial duplex scanning were evaluated prospectively. Serial scans were obtained at 3-day intervals to determine propagation of thrombus. Thrombi were managed with varied treatment protocols at the discretion of the attending physician. This laboratory has previously published its technique as described by Karkow et al5 Whenever possible, the same technician performed the duplex scanning. The Biosound Phase II machine (Biosound Inc., Indianapolis, Ind.) with the 10 mHz phased linear array probe was used for all studies. The most proximal extent of thrombus was documented with use of zone 5 as an imaginary line passing from midpatella to the popliteal crease. Zone 8 corresponds to a line drawn from midmedial malleolus to the midlateral malleolus. The calfwas subdivided into three equal zones. Patients were included in the study only if their initial thrombus did not extend into the popliteal vein and was distal to wne 5 (Fig. 1).
Volume 14 Number 5 November 1991
Lower extremity calf thvumbi
619
Table I. Patient characteristics Propqatms n := 24 Male Female Age range Mean age Symptomatic Asymptomatic Inpatients Outpatients
10 (42%)
14 (58%) 33-86 55.46 f 16.11 18 (75%) 6 (25%) 15 (63%) 9 (37%)
Nonpop~aturs II = 51 23 (45%) 28 (55%) 29-103 58.35 k 17.29 44 (86%) 7 (14%) 24 (47%) 27 (53%)
Short sections of the anterior tibial veins were not visualized with our current technique. The entire posterior tibial veins were imaged, and normally they were paired, and at times three veins were present. The peroneal veins were visualized from the tibial peroneal trunk distally. Gastrocnemius and soleal veins were considered together and were referred to as all being soleal veins in this laboratory. Parametric statistical analysis was done with the Student t test, whereas nonparametric comparisons were done by the chi-square method. A p value of less than 0.05 was taken to represent a significant difference.
RESULTS There were 42 female patients ranging in age from 29 to 103 years, with a mean age of 60.64 & 18.43 years. Fourteen women propagated thrombus, and 28 did not propagate thrombus. Thirty-three men were evaluated ranging in age from 33 to 82 years with a mean age of 53.33 + 13.85 years. Ten male patients propagated and 23 did not propagate. Female patients in either the propagating or nonpropagating groups were slightly older than the respective male patients (Table I). A total of 24 (32%) patients propagated their initial thrombus to a more proximal level, 11 (46%) to involve the popliteal vein or larger veins, whereas 13 (54%) propagated to a more proximal level but did not involve the popliteal vein. Of the entire 75 patients studied 15% propagated to involve the popliteal or larger veins, whereas 17% of the 75 propagated proximally but did not involve the popliteal vein. Six of these propagated and seven did not. Symptoms of pain, swelling, tenderness, discoloration, and mass were analyzed. No positive predictive factor could be identified (Table II). Risk factors were analyzed including obesity, trauma, estrogen use, malignancy, varicose veins, smoking, surgery, and activity level. No statistically significant difference was observed between the
Fig. 1. Zones of reference for upper extremity venous scanning: midline = 1.0, acromion = 3.0, elbow = 5.0, wrist = 8.0, and fingertips = 9.0. propagating and nonpropagating groups in any of these categories (Table III). Forty-nine patients in the study population underwent a surgical procedure. No significant difference occurred in any procedure group when comparing propagators to nonpropagators. Seven of the 17 patients who were propagators had undergone an orthopedic procedure, four underwent a neurosurgical procedure, one had a coronary artery bypass gratting, one had a urologic procedure, and four underwent vascular procedures. Seventeen of the 32 patients with DVT who did not propagate had undergone an orthopedic procedure, four underwent a neurosurgical procedure, two had cardiothoracic procedures, one had a urologic procedure, four underwent vascular procedures, and four had general surgical procedures. No surgical procedure could be identified as statistically prognostic for propagation. When analyzing patients who propagated with single vein segment involvement, a total of 13 patients were evaluated. The proximal soleal vein was the most frequently involved vein. Nonpropagators who were admitted with single venous segment involvement likewise most frequently had involvement of the proximal soleal vein (Table IV). Multiple vein segment involvement was seen in 11 of 24 patients (46%) who propagated, whereas 18 of 51 patients (32%) who did not propagate had multiple venous segment involvement (Fig. 2). No pattern of venous involvement could be identified. In
Journal of VASCULAR SURGERY
620 L&r et al.
Table II. Symptoms
Table IV. Single vein segment involvement Propagaturs n = 24
Nonpropa~ators n = 51
Se-rat
involved
Propagators Pain Swelling Tenderness Discoloration Mass
Table III.
16 (67%) 13 (54%) 11(46%) 0 (0%) 0 (0%)
30 26 19 5 2
(59%) (51%) (37%) (10%) (4%)
DSOL PM-V DPTV Nonpropagators PSOL DSOL PPTV DPTV PPER
Risk factors for DVT PrqDqators n = 24
Obesity Trauma Estrogen use Malignancy Varicose veins Smoking Sww
1(4%) 2 (8%) 1(4%)
3 2 4 17
Nonpropagatm II = 51 2 (4%) 8 (16%) 1(2%) 3 (6%) 7 (14%)
(12%) (8%) (17%) (71%)
32 (63%)
15 (63%) 3 (12%) 6 (25%)
44 (86%) 1(2%) 6 (12%)
11(22%)
ACtiVity
walking Chair Bedrest
PSOL
the groups with multisegment involvement, no statistically significant difference could be identified as prognostic for propagation or nonpropagation. Three patients who propagated were admitted with bilateral calf vein involvement, whereas only one nonpropagator had bilateral involvement. This approaches, but does not achieve, statistical significance. The incidence of vein involvement was evaluated in both propagator and nonpropagator groups. No prognostically significant vein segment involvement was isolated for either group. However, proximal soleal vein thrombus was identified most frequently in both groups (Table V). An interesting subgroup of the study population actually was admitted with pulmonary symptoms. These four patients (5%) had highly suspicious ventilation perfusion scans and were referred to the vascular laboratory in an attempt to identify the source of emboli. None of these patients had pulmonary angiograms at the discretion of their attending physician. These patients had sequential scans, revealing that two had propagated and two had not. An unanswered question is whether these patients had more extensive thrombi that had embolized before study. Propagation involving the popliteal or larger veins of the thigh occurred in 11 patients. Four of the propagations were to the common femoral vein level. Seven patients had involvement of the popliteal
PSOL, Proximal soleal vein; DSOL, proximal posterior tibial vein; DPTV, PPER, proximal peroneal vein.
Patients n = 13 7 (54%) 4 (31%) 1(8%) 1(8%) n = 33 15 (45%) 4 (15%) 6 (18%) 3 (9%) 5 (15%)
distal soleal vein; PPTV, distal posterior tibial vein;
vein. Six were inpatients and five were outpatients. Two of the inpatients and four of the outpatients were receiving no treatment. Two patients were in compression boots, one was receiving aspirin and was in elastic stockings, one patient was on subcutaneous heparin, and one outpatient was in elastic stockings only. Thirteen patients propagated their thrombus proximally but without popliteal vein involvement. Eight of the 13 were inpatients and five were outpatients. Six patients were receiving no treatment. One patient was on subcutaneous heparin, and one was receiving therapeutic intravenous heparin. Three patients were on aspirin, one patient was in elastic stockings, and one patient was in compression boots. Fifty-one patients were in the nonpropagating group. Twenty-four of the 51 were inpatients and 27 were outpatients. Thirty-two patients were not treated. Four patients were treated with elastic stockings, two patients were in compression devices, two patients received dipyridamole (Persantine), eight patients received aspirin alone, two patients received aspirin and Persantine, and one patient received subcutaneous heparin.
DISCUSSION Much has been made of calfveins having a benign course and not being the source of emboli. The natural history of calf muscle vein thrombosis has been used to suggest that observation is a viable treatment alternative to anticoagulation. Kistner et al.15 reported that pulmonary emboli occurred in 75% of patients as a silent event. He stated that pulmonary emboli occurred frequently from clots at all sites in the lower extremity including the tibial veins. Twenty-nine percent of the patients in his study with only tibial vein involvement had emboli.
Volume 14 Number 5 November 1991
Lower extremity calf thvumbi
x
PGSV -
y$yl~
DGSV-.
X
PPTV -.
A A
A A
A
A
A
A
A
DPTV -. PPER -. DPER-.
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l
2
II
00
4
0
0000
6
7'
n
000000
.
5
AA
A
n
l
3
A
AA
0
PSOL -. 0 0 0
1
AA
n
n
DSOL-,
A
0
6' 9'
10 11 12 13 14 15 16 17 16 19'20
m 0
*a
l
21 22 23 24 25 26 27 26 29
Patients PGSV: Proximal greater saphenous vein DGSV: Distal greater saphenous vein PPTV: Proximal posterior tibia1 vein DPTV: Distal posterior tibia1 vein
PPER. Proximal peroneal vein DPER: Distal peroneal vein PSOL, Proximal soleal vein DSOL: Distal soleal vein
Fig. 2. Inpatients and outpatients with multiple vein segments involved. Patients 1 to 9 were inpatients who propagated, patients 10 to 11 were outpatients who propagated, patients 12 to 19 were inpatients who did not propagate, and patients 20 to 29 were outpatients who did not propagate. Patients with bilateral involvement are indicated with an astffisk.
Sevitt and Gallagher,16 in an autopsy series, investigated 74 cases of death from pulmonary embolus. The rate of fatal pulmonary emboli from thrombi in the deep veins of the calf in this study was 15% (11 of 74 patients). In a retrospective study, Giachino17 documented 13% of fatal pulmonary emboli originating from only calf DVT. Since the incidence of asymptomatic DVT, as well as the incidence of asymptomatic pulmonary emboli, and the incidence of emboli that are fatal, are all unknown, it is impossible to determine the relationship of calf vein thrombosis and pulmonary emboli at this time.” Some authors advocate treatment of calf vein thrombi,19-27 and others do not.28*29 Hirsh et a13’ believe that if one chooses not to treat calf vein thrombosis, a patient must be followed up clinically as 20% of these thrombi extend into the thigh. Long-term sequelae of deep venous insufficiency occurs after calf vein thrombosis as often as it occurs after more proximal DVT as reported by Lindhagen et a131 Lindner et al.32 found that 5 to 10 years after lower extremity DVT, 80% of patients will have both symptoms and abnormal venous hemodynamic studies regardless of the initial site of thrombosis. Rollins et al.33 report asymptomatic calf thrombosis as a common occurrence and confirms this as a risk factor
Table V. Incidence of vein involvement propatratm Vin
sepnt
n = 24
Distal greater saphenous Proximal posterior tibial Distal posterior tibial Proximal peroneal
2 (8%)
Distal
2 (8%)
peroneal
Anterior tibial Proximal soleal
7 (29%) 3 (13%) 4 (17%)
0 (0%) 14 (58%)
Nonjwopagatm
n = 51
0 (0%)
14 7 13 7
(27%) (14%) (25%) (14%)
0 (0%)
soleal
5 (21%)
25 (49%) 13 (25%)
Lesser saphenous
0 (0%)
0 (0%)
Distal
for recurrent DVT. Browse et al.% report a 20% incidence of moderate to severe postphlebitic symptoms 5 to 10 years after symptomatic distal DVT. Lawrence and KakkaP report 41% mild to moderate and 14% severe abnormalities when assessedby foot volumetry 2 years after DVT. One patient had a recurrent DVT in our study population on repeat scan 3 months after his original thrombus was identified.
CONCLUSION From our patient data it is clear that 32% (24 of 75 patients) of calfvein thrombi propagate. Forty-six
Journal
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Lobr
et al.
percent of propagation was into the popliteal or larger veins, whereas 54% of propagation was to a more proximal level but did not involve the popliteal vein. In addition, in this study, calfvein thrombi were associated with a 5% (4 of 75 patients) incidence of high probability ventilation perfusion scans. Comparing the 32% risk of propagation with the 4% to 10% risk of anticoagulation,36-38 the option of doing nothing with calf vein thrombi seems illogical and poorly contemplated. In patients at high risk for anticoagulation, repeat duplex scanning is an acceptable surveillance mode. The significance of thrombus propagation when it does not extend to involve the popliteal vein remains unknown. However, we are unable to identify risk factors that identify patients with calf vein thrombi who will go on to have deep venous involvement or pulmonary emboli. Therefore we feel all calf vein thrombi should be treated with anticoagulation. If at high risk for complications of anticoagulation, then serial duplex scanning is an alternative. Deep venous thrombosis isolated to the calf veins is not a benign problem. The authors acknowledge staffs of the John J. Cranley research staff of the Clinical Samaritan Hospital, Cincinnati,
of
VASCULAR SURGERY
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provided Laboratory,
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12.
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REFERENCES 1. Barber FE, Baker DW, Strandness DE Jr, et al. Duplex scanner II for simultaneous imaging of artery tissues and flow, IEEE publication 1974, Ultrasonic Symposium Proceedings 1974. 2. Talbot SR. Use of real-time imaging in identifying deep venous obstruction. A preliminary report. Bruit 1982;6:41-2. 3. Cranley JJ. Diagnosis of deep venous thrombosis. In: Bemstein EF, ed. Recent advances in noninvasive diagnostic techniques in vascular disease. St. Louis: CV Mosby, 1990: 207-12. 4. Cranley JJ. Seeing is believing: a clot is a clot, on a duplex scan or a phlebogram. Echocard 1987;4:423. 5. Karkow WS, Ruoff BA, Cranley J J. B-mode venous imaging. In: Kempczinski RF, Yao JST, eds. Practical noninvasive vascular diagnosis. Chicago: Year Book Medical Publishers, 1987464-85. 6. Prandoni P, Lensing AW. New developments in noninvasive diagnosis of deep vein thrombosis of the lower limbs. Ric Clin Lab 1990;20:11-7. 7. Cavaye D, Kelly AT, Graham JC, Appleberg M, Briggs GM. Duplex ~ultrasound diagnosis of lower limb deep venous thrombosis. Aust N Z J Surg 1990;60:283-8. 8. Elias A, L&c&G, Bouvier JL, Benichou M, Serradimigni A. Value of real-time B-mode ultrasound imaging in the diagnosis of deep vein thrombosis of the lower limbs. Int Angiol 1987;6:175-82. 9. Habscheid W, Hohmann M, Wilhelm T, Epping J. Real-time ultrasound in the diagnosis of acute deep venous thrombosis of the lower extremity. Angiology 1990;41:559-608.
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Rollins DL, Semrow CM, Friedell ML, Lloyd WE, Buchbinder D. Origin of deep vein thrombi in an ambulatory population. Am J Surg 1988;156:122-5. Krupski WC, Bass A, Dilley RB, Bernstein EF, Otis SM. Propagation of deep venous thrombosis identified by duplex ultrasonogmphy. J VASC SURG 1990;12:467-75. Flinn WR, Sandager GP, Cerullo LJ, Harvey RJ, Yao JST. Duplex venous scanning for the prospective surveillance of perioperative venous thrombosis. Arch Surg 1989;124: 901-5. Lensing AWA, Prandoni P, Brandjes D, et al. Detection of deep-vein thrombosis by real-time B-mode ulaasonography. N Engl J Med 1989;320:342-5. Cranley JJ, Higgins RF, Berry RE, et al. Near parity in the final diagnosis of deep venous thrombosis by duplex scan and phlebogreaphy. Phlebology 1989;4:714. Kismer RL, Bail JJ, Nordyke RA, Freeman GC. Incidence of pulmonary embolism in the course of thrombophlebitis of the lower extremities. Am J Surg 1972;124:169-76. Sevitt S, Gallagher N. Venous thrombosis and pulmonary embolism. A clinico-pathological study in injured and burned patients. Br J Surg 1961;48:475-89. Giachino A. Relationship between deep-vein thrombosis in the calf and fatal pulmonary embolism. Can J Surg 1988;31: 129-30. Merli GJ. Prophylaxis for deep vein thrombosis and pulmonaty embolism in the geriatric patient undergoing surgery. Clin Geriat Med 1990;6:531-42. Lisbona R, Rush C, Lepanto L. Technetium-99m red blood cell venography of the lower limb in symptomatic pulmonary embolization. Clin Nucl Med 1987;12:93-8. Strandness DE. Thrombus propagation and level of anticoagulation. J VASC SKJRG 1990;12:497-8. Moreno-Cabral R, Kismer RL, Nordyke RA. Importance of calf vein thrombophlebitis. Surgery 1976;80:73542. Lagerstedt CI, Olsson CG, Fagher BO, Cqvist BW, Albrechtsson U. Need for long-term anticoagulant treatment in symptomatic calf-vein thrombosis. Lancet 1985;2:515-8. Philbrick JT, Becker DM. Calf deep venous thrombosis. A wolfin sheep’s clothing? Arch Intern Med 1988;148:2131-8. Cade JF, Clegg EA, Westlake GW. Prophylaxis of venous thrombosis after major thoracic surgery. Aust N Z J Surg 1983;53:301-4. Du Toit DF, McCormich M, Laker L. Deep-vein thrombosis in pregnancy. A case report. S Afr Med J 1985;67:781-2. Doyle DJ, Turpie AGG, Hirsh J, et al. Adjusted subcutaneous heparin or continuous intravenous heparin in patients with acute deep vein thrombosis. Ann Intern Med 1987;107: 441-5. Barnes RW, Nix ML, Barnes CL, et al. Perioperative asymptomatic venous thrombosis: role of duplex scanning versus venography. J VASC SURG 1989;9:251-60. Meibers DJ, Baldridge ED, Ruoff BA, Karkow WS: Cranley JJ. The significance of calf muscle venous thrombosis. J Vast Tech 1988;12:143-8. Menzoian JO, Sequeira JC, Doyle JE, et al. Therapeutic and clinical course of deep vein thrombosis. Am J Surg 1983; 146:581-5. Hirsh J, Genton E, Hull R. Venous thromboembolism. New York: Grune and Stratton, 1981. Lindhagen A, Bergqvist D, Hallbook T, Efsing HO. Venous function five to eight years after clinically suspected deep venous thrombosis. Acta Med Stand 1985;217:389-95.
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her
32.
Lindner DJ, Edwards JM, Phinney ES, Taylor LM, Porter JM. Long-term hemodynamic and clinical sequelae of lower extremity deep vein thrombosis. J VASC SIJRC 1986;4:43642. 33. Rollins DL, Semrow CM, FriedeLI ML, Calligaro KD, Buchbinder D. Progress in the diagnosis of deep venous thrombosis: the efficacy of real-time B-mode ultrasonic imaging. J VASC SURG 1988;7:63841. 34. Browse NL, Clemenson G, Thomas ML. Is the postphlebitic leg always postphlebitic? Relation between phlebographic appearances of deep-vein thrombosis and late sequelae. BMJ 1980;281:1167-70.
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Lawrence D, Kakkar W. Post-phlebitic syndrome-a functional assessment. Br J Surg 1980;67:686-9. 36. Kapsch DN, Silver D. Complications of anticoagulant therapy. In: Bernhard VM, Towne JB, eds. Complications in vascular surgery. New York: Grime and Stratton 1985%X. 37. Coon WW, Willis PW III. Hemorrhagic complications of anticoagulant therapy. Arch Intern Med 1974;133:386-92. 38. Coon WW. Anticoagulant therapy. Am J Surg 1985;150: 45-9.
Submitted
AVAILABLE
Apr. 19, 1991; accepted Aug. 12, 1991.
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