Acute Versus Chronic DVT Imaging in the Vascular Lab Heather Gornik, MD, RVT, RPVI

Transcription

1 Acute Versus Chronic DVT Imaging in the Vascular Lab Heather Gornik, MD, RVT, RPVI Cleveland Clinic Heart and Vascular Institute

2 Heather L. Gornik, MD has the following relationships to disclose: CVR Global Research support FMD Society of America: Member, Medical Advisory Board IAC-Vascular testing: Member, Board of Directors

3 An Illustrative Case 46 year-old woman seen in consultation in vascular medicine clinic for coumadin failure 1997: Right popliteal DVT while on OCPs treated with anticoagulation therapy x 6 months 1999: Right popliteal DVT + pulmonary embolism after minor GYN surgery. On warfarin x 12 months. 2010: History of recurrent Right popliteal DVT. On warfarin ever since with very good INR control 8/2011: Right leg aches after playing 18 holes of golf. Goes to local ER Partially occlusive thrombus in the right popliteal vein

4 Is this.. What s Going On Here?! A. Really a new popliteal DVT? B. The same popliteal DVT reimaged by a different lab in a patient with the postthrombotic syndrome (PTS)? C. New thrombus on top of old thrombus? D. Who knows!

5 What is the Post-thrombotic Syndrome (PTS)? Recognized complication of deep vein thrombosis (DVT) Pathophysiology: venous obstruction (thrombus) and reflux (damaged vein valves) Key role of acute and chronic inflammation in pathophysiology of PTS Extremity pain, swelling, itching, cramping Generally develops within 2 years of the acute DVT Severe form of PTS leads to venous stasis ulcers (~25%) Costly and associated with substantial morbidity Symptoms of PTS can mimic acute DVT % 17% 1 year 2 years 5 years 8 years Arch Intern Med 2004; 164; Kahn SR, et al. Circulation ;1636.

6 Prevalence of Post-Thrombotic Syndrome in DVT Series Author/Yr N Journal 2-yr PTS Prandoni Ann Intern Med 23% Brandjes Lancet 23% Prandoni Ann Intern Med 25% Partsch Int Angiol 46% Van Dongen J Thromb Haemost 30% Table courtesy Dr. Suresh Vedantham, Washington Univ. St. Louis

7 How Can the Vascular Lab Help Us Age a DVT?

8 Classic Duplex Findings in Acute vs. Chronic DVT Acute DVT Dilated vein Non-compressible vein Occlusive thrombus with absent or near absent flow Hypoechoic thrombus (same echo characteristics as blood) Chronic DVT Vein not dilated Vein partially noncompressible Hyperechoic thrombus Stringy, linear thrombus adherent to vein wall Fibrous strands, webs Vein wall thickening Recanalization of flow Valvular incompetency (reflux) may be present

9 26 year-old Woman with Acute Left Leg Swelling: Acute Iliofemoral DVT

10 Acute Occlusive Left Iliofemoral DVT Unilateral DVT CIV Common Iliac Artery Common Iliac Vein CFV EIV

11 Acute Calf DVT Posterior Tibial DVT Gastrocnemius DVT Soleal DVT

12 Classic Duplex Findings in Acute vs. Chronic DVT Acute DVT Dilated vein Non-compressible vein Occlusive thrombus with absent or near absent flow Hypoechoic thrombus (same echo characteristics as blood) Chronic DVT Vein not dilated Vein partially noncompressible Hyperechoic thrombus Stringy, linear thrombus adherent to vein wall Fibrous strands, webs, synechiae Vein wall thickening Recanalization of flow Valvular incompetency (reflux) may be present

13 Classic Chronic Femoropopliteal DVT

14 Classic Chronic Internal Jugular DVT

15 Pitfall: Determining Acute vs. Chronic DVT on a Duplex Examination is Not Always so Easy!

16 How Would You Report This Case? Indication: Lower Extremity Swelling

17 How Would You Report This Case? Indication: Lower Extremity Swelling

18 How would you report this case? 1. Acute DVT 2. Subacute DVT 3. Chronic DVT 4. Age indeterminate DVT 5. My lab does not even try to report DVT age Can the ultrasound literature help us make this decision in any way?

19 Natural History of Ultrasound Features of DVTs in the Vascular Lab Murphy TP, Cronan JJ Radiology :543. N=46 patients with acute femoropopliteal DVT followed with serial duplex studies at baseline, 1 month, 3 months, 6 months (141 ultrasounds) 100% isolated popliteal DVTs resolved completely 28% femoropopliteal DVTs resolved completely Ultrasound features of 6 month old vs. day 0 DVTs No significant difference in clot echogenicity over time and echogenicity highly variable Highly significant difference in vein diameter Femoral vein 12.5 mm vs. 7.8 mm at 6 M (P<.005) Popliteal vein 9.6 mm vs. 6.8 mm at 6 M (P<.005) Authors conclude Vein diameter helpful in aging DVT Echogenicity does not appear to be a reliable criterion in assessment of clot age Determination of clot age with ultrasound may be enigmatic

20 For Future Research? Grayscale Median for Aging DVT Cassou-Birckholz M, et al. Ultrasound Quarterly :55-61: Int Angiol 2011;30:79-87.

21 For Future Research? Elastography for Aging DVT Basic premise chronic DVT is harder, less elastic, and has lower strain coefficients Acute DVT is more elastic and has higher strain coefficients Could potentially be used to complement assessment of echogenicity for aging DVT Acute DVT squares=acute DVT diamonds=chronic DVT Chronic DVT Rubin, JM, et al. J Ultrasound Med 2006; 25:1179.

22 Hot off the Presses! April 3, 2018 Recommendation: Chronic postthrombotic change is the preferred term for the material that persists on ultrasound after acute DVT. Recommendation: Abnormalities should be classified into acute venous thrombosis, chronic postthrombotic change, or indeterminate (equivocal). Recommendation: The term subacute thrombus does not have a unique ultrasound appearance and should rarely be used. It should be reported for a follow-up study only if (1) there is a previous u/s demonstrating acute thrombus weeks earlier and (2) the new study shows a change in the appearance of the thrombosis that is not typical of chronic postthrombotic change.

23 Take Home Points: Acute vs. Chronic DVT in the Vascular Lab In many cases timing of symptoms and classic ultrasound findings make diagnosis of acute DVT vs. chronic postthrombotic change easy In other cases, especially in the setting of the patient with prior DVT and new symptoms, this is challenging New DVT vs. post thrombotic syndrome Use ultrasound features as best as possible Vein dilatation probably most reliable parameter Better to hedge and say age indeterminate or equivocal than just call an acute DVT or chronic postthrombotic change

24 Take Home Points: Acute vs. Chronic DVT in the Vascular Lab Aging of DVT with ultrasound clearly an area in need of additional research D-dimer may be helpful clinically in some cases to determine acute DVT reoccurrence (data free zone) Very helpful but only if it is normal Consider obtaining a post treatment baseline duplex ultrasound for select DVT patients: Extensive proximal DVT Patients at high risk for recurrence (e.g., unprovoked DVT) For new symptoms and suspected DVT recurrence, try to obtain the venous duplex in the same vascular laboratory

25 Follow-up on my golfer with leg pain I tracked down the outside hospital images Ultrasound read as popliteal DVT, but findings actually improved compared to prior scans Symptoms felt to be consistent with the post thrombotic syndrome Not a coumadin failure though ultimately switched to DOAC for convenience She has done well with graduated elastic compression stockings, weight loss, and exercise