J.
Steven
Perlin,
MD
Pulmonary Us ofthe
Embolism during Lower Extremity’
To the author’s knowledge, occurrence of pulmonary embolism during performance of compression ultrasound (US) of the lower extremity has not previously been reported in the radiology literature. The author describes a case in which pulmonary embolism was witnessed during compression US of yenous thrombosis in a superficial fernoral vein of a 64-year-old man. The embolism was documented with perfusion
lung
scanning.
pher,
who
reported
superficial
was pler
Compression
thrombus
femoral
vein.
in the
No
by the sonographer. US was then performed
thor.
Initially,
slightly
by the
an enlarged,
compressible
Radiology
Arteries, 60.72
superficial
1992;
within
distal
possibility
to the
original
compression
compression was applied. material was observed denly migrate proximally out field of view. The transducer returned to the original site,
184:165-166
compressibility
C
ultrasound
OMPRESSION
(US)
of the
lower extremity for evaluation of deep venous thrombosis has gained widespread acceptance and, in many institutions,
has
venography
as the primary
diagnosis
(1-4).
supplanted Several
contrast
means
reports
of
have
dealt with potential pitfalls and confounding factors, but, to my knowledge, no serious complications have been reported (5,6). Herein, I report a case in which a pulmonary embolism occurred during compression US of the lower extremity. CASE
REPORT
A 64-year-old man presented with acute right lower extremity swelling days
after
farction, aspirin. ity
was
128 unit
a 5-MHz equipped Doppler technique outlined
left
hemisphere
cerebral
10 in-
which was treated only with Compression US of the extremperformed with an Acuson (Mountain View, Calif) with linear-array transducer with both spectral and color capabilities. The examination was based on the methods by Cronan et al (1) and ManUS was
the right
extremity
lower
performed
on
by a sonogra-
1 From the Department of Radiology, Mercy Hospital, Springfield, Mass. Received December 17, 1991; revision requested January 21, 1992; revision received February 24; accepted March 5. Address reprint requests to the author, Radiology Group, PC, 136 Sherman Aye, New Hayen, CT 06511. © RSNA, 1992
of the
would
site,
Echoto sudof the was then where full
superficial
sivety
dyspneic
over
the
next
hours
after
preted
the
as high
US study,
probability
was
8
inter-
for pulmo-
nary embolism (Fig 3). Heparin therapy was begun, and the patient became less
dyspneic by the next morning. The patient continued to improve until the 4th hospital day, when he experienced acute recurrence of dyspnea at ambulation. A repeat perfusion lung scan was obtamed and showed new perfusion defects nary
consistent embolism.
with ongoing Inferior vena
interruption was performed of a transjugular approach Greenfield
entific,
filter
pulmocaval
Watertown,
Mass).
continued
Sa-
The
patient’s
to deteriorate,
seem
fact
that
was
with
not
performed.
Complications of contrast venograare well known (7,8). However,
of
being
the
in-
thrombus
was
found
iso-
vein lends
were
Alternatively,
the
developed vein and
confined thrombus
to the thigh. could
have
in the superficial femoral undergone the majority of from the performed,
vein wall before with compression
itself
possibilities.
to
the
producing the final disruption. Finally, the possibility that the compression provided
the
prime
impetus
for embolism should be considered. The patient’s subsequent clinical course would seem to favor the first
DISCUSSION phy
the
thromboses
study
autopsy
type
tated in the superficial femorat without popliteal involvement
5th
An
This
nonocciusive thrombus (9). Unfortunately, embolization occurred before Doppler study could be performed. Had this information been obtained, it might have been useful in determining whether the procedure played a role in causing the embolism or whether it merely documented an embolism in progress. The thrombus may have originated more distally within the leg, embolized, and become temporarily lodged within the superficial femoral vein, only to become dislodged with compression. The
separation study was
day.
flow.
deep venous thrombosis to raise concerns about of an embolism
oxygen pressure of 46 mm Hg and arterial oxygen percent saturation of 83% with a 100% nonrebreather mask. The patient died of respiratory failure on the hospital
venous
some credence to a noncausat role of US. In the study by Browse and LeaThomas (10), only 14% of deep venous
by means with a
(Medi-tech/Boston
attribut-
is, whether it was a nonocclusive thrombus. It has been suggested that an embolism is more likely to occur with a
several
and
complications
duced as a result of the examination. In this case, however, no free-floating head was observed. The thrombus abutted the venous wall along its entire length. It would be interesting to know whether color Doppler interrogation would have revealed peripheral flow around the edges of the thrombus, that
femo-
hours, with accompanying deterioration of arterial blood gas levels. A perfusion lung scan was obtained approximately
the
free-floating
rat vein was demonstrated (Fig 2). Doppler interrogation was not performed before this event. Doppler examination performed after embolism occurred demonstrated normat venous flow characteristics. The patient did not have any symptoms at this time. However, he became progres-
condition
toni (3). Compression
only femoral
vein, with a mildly echogenic intraluminat thrombus, was visualized (Fig 1). The transducer was then moved 3-4 cm
genic
US, 921.1298 #{149} Embo#{149} Veins, US, 931.1298
au-
round,
knowledge,
able to compression US have not been described. In this case, a thrombus that appeared to completely fill the lumen embolized during compression. It is rare that a thrombus is visualized in which the proximal edge or head is tapered and can clearly be seen to undulate
detected in the popliteal vein. Dopinterrogation was not performed
and Index terms: lism, pulmonary,
my
thrombus
The
onset
rent dyspnea during worsening perfusion
of acute
ambulation lung scan
two
recur-
and a are sug165
2.
1. Figures 1, 2. (1) Initial US images vein (arrowheads) consistent with (2) Transverse US images obtained a normally compressible vein. A
=
obtained without (left) and with (right) compression (C) demonstrate deep venous thrombosis. Arrows = superficial femoral artery, TRANS after embolism occurred without (left) and with (right) compression superficial femoral artery, V = superficial femoral vein.
noncompression
RT FEM
(COMP)
of superficial femoral right femoral. at a higher level than 1 show
transverse
gestive, if not proof, of recurrent embolism. This might lead one to suspect that
the patient
was
at risk for spontaneous
embolism initially and dental in this regard.
In summary,
that
this case
US was
mci-
demonstrates
that compression US studies may not entirety without complications. Although not proved by the events re-
ported perform
herein, it may be prudent to Doppler interrogation immedi-
atety when a noncompressibte vein vein containing echogenic material demonstrated. This wilt elucidate
whether
the deep
occlusive. as
to
be
venous
If nonocclusive,
whether
there
tation in the force pression is raised.
should
or a is
thrombosis the be
is
question any
limi-
of subsequent cornHowever, given the
apparent rarity of the described event and the uncertainty as to whether cornpression
US was
a direct
cause
a
b.
Figure 3. (a) Right lateral lower lobes. P = posterior, fects
2.
3.
aration
and Roger
Thanks to Tim Reid, Fagnant for manuscript prepManahan, MLS, for research
4.
assistance.
References 1.
Cronan JJ, Dorfman GS, Scola FH, Schepps B, Alexander J. Deep venous thrombosis: US assessment using vein compression. Radiology 1987; 162:191-194.
5.
6.
166
#{149} Radiology
multiple
segments
in each
lung.
L
=
defects involving the right middle and perfusion lung scan demonstrates deleft, R = right.
of the
embolism, it is doubtful that any alteration to the current method is in order. #{149} Acknowledgments: RDMS, and Diane
involving
perfusion lung scan shows A = anterior. (b) Posterior
Lensing AWA, Prandoni P, Brandjes D, et al. Detection of deep-vein thrombosis by real-time B-mode ultrasonography. N EngI I Med 1989; 320:342-345. Mantoni M. Diagnosis of deep venous thrombosis by duplex sonography. Acta Radiol 1989; 30:575-579. Cronan JJ, Dorfman GS, GrusmarkJ. Lower-extremity deep venous thrombosis: further experience with and refinements of US assessment. Radiology 1988; 168:101107. Quinn KL, Vandeman FN. Thrombosis of a duplicated superficial femoral vein. J UItrasound Med 1990; 9:235-238. Cronan JJ, Leen V. Recurrent deep yenous thrombosis: limitations of US. Radiology 1989; 170:739-742.
7.
8.
9.
10.
Lea-Thomas M, MacDonald LM. Complications of ascending phlebography of the leg. Br Med J 1978; 2:317-318. Harmon B. Deep vein thrombosis: a perspective on anatomy and venographic analysis. I Thorac Imaging 1989; 4:15-19. Norris CS, Greenfield U, Herrmann JB. Free-floating iliofemoral thrombus. Arch Surg 1985; 120:806-808. Browse NL, Lea-Thomas M. Source of non-lethal pulmonary emboli. Lancet 1974; 1:258-2.59.
July 1992
Steven
Perlin,
MD
Pulmonary Us ofthe
Embolism during Lower Extremity’
To the author’s knowledge, occurrence of pulmonary embolism during performance of compression ultrasound (US) of the lower extremity has not previously been reported in the radiology literature. The author describes a case in which pulmonary embolism was witnessed during compression US of yenous thrombosis in a superficial fernoral vein of a 64-year-old man. The embolism was documented with perfusion
lung
scanning.
pher,
who
reported
superficial
was pler
Compression
thrombus
femoral
vein.
in the
No
by the sonographer. US was then performed
thor.
Initially,
slightly
by the
an enlarged,
compressible
Radiology
Arteries, 60.72
superficial
1992;
within
distal
possibility
to the
original
compression
compression was applied. material was observed denly migrate proximally out field of view. The transducer returned to the original site,
184:165-166
compressibility
C
ultrasound
OMPRESSION
(US)
of the
lower extremity for evaluation of deep venous thrombosis has gained widespread acceptance and, in many institutions,
has
venography
as the primary
diagnosis
(1-4).
supplanted Several
contrast
means
reports
of
have
dealt with potential pitfalls and confounding factors, but, to my knowledge, no serious complications have been reported (5,6). Herein, I report a case in which a pulmonary embolism occurred during compression US of the lower extremity. CASE
REPORT
A 64-year-old man presented with acute right lower extremity swelling days
after
farction, aspirin. ity
was
128 unit
a 5-MHz equipped Doppler technique outlined
left
hemisphere
cerebral
10 in-
which was treated only with Compression US of the extremperformed with an Acuson (Mountain View, Calif) with linear-array transducer with both spectral and color capabilities. The examination was based on the methods by Cronan et al (1) and ManUS was
the right
extremity
lower
performed
on
by a sonogra-
1 From the Department of Radiology, Mercy Hospital, Springfield, Mass. Received December 17, 1991; revision requested January 21, 1992; revision received February 24; accepted March 5. Address reprint requests to the author, Radiology Group, PC, 136 Sherman Aye, New Hayen, CT 06511. © RSNA, 1992
of the
would
site,
Echoto sudof the was then where full
superficial
sivety
dyspneic
over
the
next
hours
after
preted
the
as high
US study,
probability
was
8
inter-
for pulmo-
nary embolism (Fig 3). Heparin therapy was begun, and the patient became less
dyspneic by the next morning. The patient continued to improve until the 4th hospital day, when he experienced acute recurrence of dyspnea at ambulation. A repeat perfusion lung scan was obtamed and showed new perfusion defects nary
consistent embolism.
with ongoing Inferior vena
interruption was performed of a transjugular approach Greenfield
entific,
filter
pulmocaval
Watertown,
Mass).
continued
Sa-
The
patient’s
to deteriorate,
seem
fact
that
was
with
not
performed.
Complications of contrast venograare well known (7,8). However,
of
being
the
in-
thrombus
was
found
iso-
vein lends
were
Alternatively,
the
developed vein and
confined thrombus
to the thigh. could
have
in the superficial femoral undergone the majority of from the performed,
vein wall before with compression
itself
possibilities.
to
the
producing the final disruption. Finally, the possibility that the compression provided
the
prime
impetus
for embolism should be considered. The patient’s subsequent clinical course would seem to favor the first
DISCUSSION phy
the
thromboses
study
autopsy
type
tated in the superficial femorat without popliteal involvement
5th
An
This
nonocciusive thrombus (9). Unfortunately, embolization occurred before Doppler study could be performed. Had this information been obtained, it might have been useful in determining whether the procedure played a role in causing the embolism or whether it merely documented an embolism in progress. The thrombus may have originated more distally within the leg, embolized, and become temporarily lodged within the superficial femoral vein, only to become dislodged with compression. The
separation study was
day.
flow.
deep venous thrombosis to raise concerns about of an embolism
oxygen pressure of 46 mm Hg and arterial oxygen percent saturation of 83% with a 100% nonrebreather mask. The patient died of respiratory failure on the hospital
venous
some credence to a noncausat role of US. In the study by Browse and LeaThomas (10), only 14% of deep venous
by means with a
(Medi-tech/Boston
attribut-
is, whether it was a nonocclusive thrombus. It has been suggested that an embolism is more likely to occur with a
several
and
complications
duced as a result of the examination. In this case, however, no free-floating head was observed. The thrombus abutted the venous wall along its entire length. It would be interesting to know whether color Doppler interrogation would have revealed peripheral flow around the edges of the thrombus, that
femo-
hours, with accompanying deterioration of arterial blood gas levels. A perfusion lung scan was obtained approximately
the
free-floating
rat vein was demonstrated (Fig 2). Doppler interrogation was not performed before this event. Doppler examination performed after embolism occurred demonstrated normat venous flow characteristics. The patient did not have any symptoms at this time. However, he became progres-
condition
toni (3). Compression
only femoral
vein, with a mildly echogenic intraluminat thrombus, was visualized (Fig 1). The transducer was then moved 3-4 cm
genic
US, 921.1298 #{149} Embo#{149} Veins, US, 931.1298
au-
round,
knowledge,
able to compression US have not been described. In this case, a thrombus that appeared to completely fill the lumen embolized during compression. It is rare that a thrombus is visualized in which the proximal edge or head is tapered and can clearly be seen to undulate
detected in the popliteal vein. Dopinterrogation was not performed
and Index terms: lism, pulmonary,
my
thrombus
The
onset
rent dyspnea during worsening perfusion
of acute
ambulation lung scan
two
recur-
and a are sug165
2.
1. Figures 1, 2. (1) Initial US images vein (arrowheads) consistent with (2) Transverse US images obtained a normally compressible vein. A
=
obtained without (left) and with (right) compression (C) demonstrate deep venous thrombosis. Arrows = superficial femoral artery, TRANS after embolism occurred without (left) and with (right) compression superficial femoral artery, V = superficial femoral vein.
noncompression
RT FEM
(COMP)
of superficial femoral right femoral. at a higher level than 1 show
transverse
gestive, if not proof, of recurrent embolism. This might lead one to suspect that
the patient
was
at risk for spontaneous
embolism initially and dental in this regard.
In summary,
that
this case
US was
mci-
demonstrates
that compression US studies may not entirety without complications. Although not proved by the events re-
ported perform
herein, it may be prudent to Doppler interrogation immedi-
atety when a noncompressibte vein vein containing echogenic material demonstrated. This wilt elucidate
whether
the deep
occlusive. as
to
be
venous
If nonocclusive,
whether
there
tation in the force pression is raised.
should
or a is
thrombosis the be
is
question any
limi-
of subsequent cornHowever, given the
apparent rarity of the described event and the uncertainty as to whether cornpression
US was
a direct
cause
a
b.
Figure 3. (a) Right lateral lower lobes. P = posterior, fects
2.
3.
aration
and Roger
Thanks to Tim Reid, Fagnant for manuscript prepManahan, MLS, for research
4.
assistance.
References 1.
Cronan JJ, Dorfman GS, Scola FH, Schepps B, Alexander J. Deep venous thrombosis: US assessment using vein compression. Radiology 1987; 162:191-194.
5.
6.
166
#{149} Radiology
multiple
segments
in each
lung.
L
=
defects involving the right middle and perfusion lung scan demonstrates deleft, R = right.
of the
embolism, it is doubtful that any alteration to the current method is in order. #{149} Acknowledgments: RDMS, and Diane
involving
perfusion lung scan shows A = anterior. (b) Posterior
Lensing AWA, Prandoni P, Brandjes D, et al. Detection of deep-vein thrombosis by real-time B-mode ultrasonography. N EngI I Med 1989; 320:342-345. Mantoni M. Diagnosis of deep venous thrombosis by duplex sonography. Acta Radiol 1989; 30:575-579. Cronan JJ, Dorfman GS, GrusmarkJ. Lower-extremity deep venous thrombosis: further experience with and refinements of US assessment. Radiology 1988; 168:101107. Quinn KL, Vandeman FN. Thrombosis of a duplicated superficial femoral vein. J UItrasound Med 1990; 9:235-238. Cronan JJ, Leen V. Recurrent deep yenous thrombosis: limitations of US. Radiology 1989; 170:739-742.
7.
8.
9.
10.
Lea-Thomas M, MacDonald LM. Complications of ascending phlebography of the leg. Br Med J 1978; 2:317-318. Harmon B. Deep vein thrombosis: a perspective on anatomy and venographic analysis. I Thorac Imaging 1989; 4:15-19. Norris CS, Greenfield U, Herrmann JB. Free-floating iliofemoral thrombus. Arch Surg 1985; 120:806-808. Browse NL, Lea-Thomas M. Source of non-lethal pulmonary emboli. Lancet 1974; 1:258-2.59.
July 1992
