Venous Doppler Sonography of the Extremities: A Window to Pathology of the Thorax, Abdomen, and Pelvis

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1 Vascular and Interventional Radiology linical Perspective Selis and Kadakia Doppler Sonography of the Extremities Vascular and Interventional Radiology linical Perspective Downloaded from by on 12/24/17 from IP address opyright RRS. For personal use only; all rights reserved James E. Selis 1 Saumil Kadakia Selis JE, Kadakia S Keywords: Doppler sonography, duplex sonography, extremity, phasicity, pulsatility, pulsed-wave sonography, venous sonography DOI: /JR Received February 24, 2009; accepted after revision pril 28, oth authors: Department of Diagnostic Radiology, Providence Hospital and Medical enters, W 9 Mile Rd., Southfield, MI ddress correspondence to J. E. Selis (selisjames@yahoo.com). JR 2009; 193: X/09/ merican Roentgen Ray Society Venous Doppler Sonography of the Extremities: Window to Pathology of the Thorax, bdomen, and Pelvis OJETIVE. Swelling of an extremity may be a sign of peripheral deep venous thrombosis but may occasionally be due to more proximal or central venous obstruction. Venous Doppler sonography of the extremities is a commonly performed procedure to evaluate for the presence of deep venous thrombosis. Pulsed-wave Doppler sonography is performed as part of this procedure to evaluate for the presence of cardiac pulsatility or respiratory phasicity. The importance of information provided by the pulsed-wave Doppler waveform must not be undervalued. Thus, the purpose of this article is to discuss the pathology of the thorax, abdomen, and pelvis that can be discovered by identifying abnormal waveforms in the veins of the extremities. ONLUSION. bnormal waveforms provide information for compression or obstruction of the proximal venous system in the thorax, abdomen, and pelvis. When these waveforms are abnormal, previous imaging should be reviewed or additional imaging performed to discover the cause. I t is estimated that more than 500,000 duplex venous sonography examinations are performed in the United States to evaluate for deep venous thrombosis of the lower extremities [1]. Often, the examination is obtained to evaluate the cause of swelling of an extremity. In addition to deep venous thrombosis, there are other causes for swelling. s part of the examination, pulsed-wave Doppler sonography of the veins should be performed. This can be done with augmentation, in which the extremity is squeezed distally and the vein is insonated proximally using pulsed-wave Doppler sonography. rapid change in the venous waveform provides indirect evidence of patency of the vein between those two points. Pulsed-wave Doppler sonography in a proximal vein in the extremity is also performed to evaluate the waveform for the presence of respiratory phasicity or cardiac pulsatility [2, 3]. normal waveform provides indirect evidence for patency of the proximal venous system between the point of insonation and the diaphragm and heart. If a normal waveform is obtained in the subclavian or jugular veins, the proximal brachiocephalic vein and superior vena cava are patent. If a normal waveform is obtained in the common femoral vein, the proximal iliac veins and inferior vena cava are patent. If a normal waveform is obtained from these veins but a nonphasic or nonpulsatile (flat) waveform is obtained more distally, a venous occlusion between the points of insonation should be investigated. There is tremendous variability in the appearance of normal venous waveforms between individuals because of differences in depth and rate of respiration, right heart function, tricuspid regurgitation, intravascular volume [4], body habitus, and other physiologic differences. In addition, for a given individual, the amplitude of the waveform decreases as the distance from the heart increases. To obtain an internal standard, the contralateral extremity can often be used. n abnormal waveform in one upper extremity or jugular vein should prompt pulsedwave Doppler sonography of the veins of the contralateral upper extremity for comparison. If it is determined that the waveforms lack phasicity or pulsatility in one extremity, the ipsilateral brachiocephalic vein should be further evaluated by additional imaging for compression or obstruction. n abnormal waveform of both upper extremities or both jugular veins should prompt evaluation of both brachiocephalic veins and the superior 1446 JR:193, November 2009

2 Doppler Sonography of the Extremities Downloaded from by on 12/24/17 from IP address opyright RRS. For personal use only; all rights reserved vena cava by additional imaging. There have been numerous published reports of proximal venous obstructions in the thorax that were discovered by the absence of pulsatility or phasicity [5 9]. n abnormal waveform present in one of the lower extremities should prompt pulsedwave Doppler sonography of the veins of the Fig. 1 Normal venous waveforms obtained from healthy volunteers. R = right, V = vein, FV = common femoral vein. and, Normal venous waveforms in 27-year-old woman show cardiac pulsatility in subclavian vein () and FV ()., Normal venous waveform from FV in 25-year-old woman shows pulsatility with much lower amplitude. There is significant variability in amplitude between individuals. Fig. 2 Normal venous waveform in 40-year-old woman healthy volunteer shows respiratory phasicity. FV = common femoral vein. contralateral lower extremity for comparison. If it is determined that the waveforms lack phasicity or pulsatility in one extremity, the ipsilateral iliac vein should be further evaluated by additional imaging for compression or obstruction. n abnormal waveform present in both lower extremities should prompt evaluation of both iliac veins and the inferior vena cava. There has been a report of venous occlusion of an iliac vein because of lym phadenopathy that was discovered due to lack of a normal waveform [10]. However, abnormalities of the abdomen and pelvis have not been as well recognized as abnormalities of the thorax. There is much pathology in the thorax, abdomen, and pelvis that can be discovered from identifying abnormal waveforms in the veins of the extremities. Materials and Methods To examine the upper extremity, real-time images (Logiq 9, GE Healthcare) of the axillary and brachial veins before and after compression were obtained. olor and pulsed-wave Doppler sonography of the internal jugular, subclavian, axillary, and brachial veins was also performed. If an abnormal pulsed-wave Doppler waveform was present, attempts were made to evaluate the brachiocephalic vein by real-time and color Doppler imaging. T of the thorax to evaluate the brachiocephalic vein and superior vena cava was also performed. For the lower extremity, real-time images of the common femoral, deep femoral, femoral, and popliteal veins were obtained before and after compression. olor and pulsed-wave Doppler sonography also was performed. If an abnormal pulsed-wave Doppler waveform was present, realtime images and Doppler sonograms of the iliac veins and inferior vena cava were obtained. If available, previous T scans were reviewed. T was also performed if needed. waveform obtained by pulsed-wave Doppler sonography was interpreted as normal if cardiac pulsatility (Fig. 1) or respiratory phasicity (Fig. 2) was shown. waveform was interpreted as abnormal if there was a flat or nearly flat waveform. If there was any uncertainty about the appearance of the waveform, pulsed-wave Doppler sonography Fig year-old woman with non-hodgkin s lymphoma. and, Pulsed-wave Doppler sonograms of right internal jugular vein (IJV) () and right subclavian vein (SUL V) show low-amplitude pulsatile waveforms., T scan of thorax shows severe compression of superior vena cava due to lymphadenopathy. JR:193, November

3 Selis and Kadakia Downloaded from by on 12/24/17 from IP address opyright RRS. For personal use only; all rights reserved Fig year-old woman with hepatic metastases., Pulsed-wave Doppler sonogram of right common femoral vein (FV) shows low-amplitude phasic waveform. similar waveform was obtained in left FV (not shown)., oronal reconstructed image of T scan of abdomen and pelvis shows compression of intrahepatic inferior vena cava (arrows) from metastases. of the contralateral extremity was performed to provide comparison with a normal waveform. ll waveforms were interpreted with the patient breathing normally. Respiratory maneuvers, such as panting or Valsalva maneuver, were not used. In all cases, the interpreter of the duplex venous examination was unaware of the results of any previous imaging examinations at the time of the interpretation. The cause of the thoracic, abdominal, or pelvic pathology was discovered on respective review of previous T scans or after performing additional imaging using ultrasound or T. Results Patient 1 was a 51-year-old woman who presented with swelling of the head and upper extremities. Pulsed-wave Doppler sonography revealed low-amplitude pulsatile wave forms in the right internal jugular (Fig. 3) and subclavian (Fig. 3) veins. Review of a recent T scan (Fig. 3) showed severe compression of the superior vena cava from lymphadenopathy due to non-hodgkin s lymphoma. Patient 2 was a 65-year-old woman who was found to have liver metastases on initial T of the abdomen. Subsequently, she was referred for imaging because of bilateral lower extremity swelling. On pulsed-wave Doppler sonography, she had low-amplitude respiratory waveforms in the common femoral veins bilaterally (Fig. 4). Review of the previous T scan (Fig. 4) showed that the metastases compressed the intrahepatic inferior vena cava, which had not been previously recognized. Patient 3 was a 22-year-old woman who was referred for left lower extremity swelling. Pulsed-wave Doppler sonography revealed a normal or low-amplitude phasic waveform in the common femoral vein (Fig. 5) and a flat waveform in the femoral vein (Fig. 5). There was no thrombus or venous occlusion between the two points of insonation. Therefore, a proximal venous abnormality was suspected. The right common femoral vein also was examined, which showed a low-amplitude phasic waveform. T scan (Fig. 5) was then obtained that revealed absence of the right kidney and inferior vena cava, with numerous collateral veins in the subcutaneous fat. The patient then provided additional history of having had a right nephrectomy with ligation of the inferior vena cava shortly after birth for treatment of a malignant tumor of the kidney. Patient 4 was a 79-year-old woman who had swelling of both lower extremities. Pulsed-wave Doppler sonography of the left (Fig. 6) and right (Fig. 6) common femoral veins revealed flat or low-amplitude waveforms. T of the abdomen (Fig. 6) revealed a small or absent inferior vena cava of unknown cause, with a collateral dilated left ovarian vein. Patient 5 was a 21-year-old man with end-stage renal disease. Pulsed-wave Doppler sonography of the left common femoral vein revealed a flat waveform (Fig. 7). T of the abdomen and pelvis (Fig. 7) revealed a large, loculated fluid collection that Fig year-old woman who underwent right nephrectomy and ligation of inferior vena cava as infant for treatment of right renal cancer. and, Pulsed-wave Doppler sonogram of left common femoral vein () shows normal to low-amplitude phasic waveform, and pulsed-wave Doppler sonogram of left femoral vein () shows flat waveform. There was no thrombus between these two points of insonation to explain this abnormality, so proximal pathology was suspected. Pulsed-wave Doppler sonography of right common femoral vein was also of low amplitude (not shown)., On T scan, nonvisualization of inferior vena cava below left renal vein with presence of numerous superficial collateral veins was noted. History of previous treatment was obtained only after T was performed JR:193, November 2009

4 Doppler Sonography of the Extremities Downloaded from by on 12/24/17 from IP address opyright RRS. For personal use only; all rights reserved Fig year-old woman with small or absent inferior vena cava. and, Pulsed-wave Doppler sonograms of left () and right () common femoral veins (FV) show flat or low-amplitude waveforms., T scan of abdomen shows small or absent inferior vena cava (arrow) with collateral dilated left ovarian vein (arrowhead). Fig year-old man with end-stage renal disease., Pulsed-wave Doppler sonogram of left common femoral vein (FV) shows flat waveform. Note that velocity range is set very low, which spuriously creates appearance of pulsatility., T scan of pelvis shows large, loculated fluid collection that compresses right and left common iliac arteries and left common iliac vein as it courses between right common iliac artery and lumbar spine. Iliac vein was dilated below this level (not shown). Fig year-old woman who underwent radical hysterectomy for endometrial carcinoma 7 months previously. Flat venous waveform from right common femoral vein was obtained (not shown). T scan shows right common iliac vein is compressed by lymphocele that was subsequently drained, after which, right lower extremity swelling resolved. compressed the left common iliac vein as it coursed between the right common iliac artery and the lumbar spine. The left iliac vein was dilated below this level. Patient 6 was an 85-year-old woman who underwent radical hysterectomy for endometrial carcinoma 7 months previously. flat venous waveform from the right common femoral vein was obtained. Sonography of the pelvis revealed a mass. T (Fig. 8) revealed that the right common iliac vein was compressed by a lymphocele. The lymphocele was drained, and swelling in the right lower extremity resolved. Patient 7 was an 80-year-old man with prostate cancer. Pulsed-wave Doppler sonography of the left common femoral vein (Fig. 9) revealed a flat waveform. Subsequent T of the pelvis (Fig. 9) revealed a lack of visualization of the left external iliac vein, most likely from previous thrombosis. Patient 8 was an 83-year-old woman with peritoneal metastases. bnormal waveforms in the right and left common femoral veins were obtained. olor Doppler sonography of the right iliac vein revealed absence of flow (Fig. 10), consistent with thrombosis. The inferior vena cava was shown to be occluded on T. Patient 9 was a 29-year-old pregnant woman. She had swelling of the right lower extremity. She was found to have a flat venous waveform in the right common femoral vein (Fig. 11) because of compression of the iliac vein by the enlarged gravid uterus. Patient 10 was a 49-year-old man who suffered rupture of an aneurysm of the anterior cerebral artery. Several days later, he developed swelling of both lower extremities. Pulsed-wave Doppler sonography of the right and left common femoral veins (Fig. 12) revealed low-amplitude waveforms. Sonography of the pelvis (Fig. 12) then revealed an overdistended bladder that compressed the external iliac veins bilaterally. The patient was immediately catheterized and 1,500 ml of urine was recovered. fter catheterization, repeat pulsed-wave Doppler sonography of the common femoral veins (Fig. 12) revealed normalized waveforms because of lack of compression of the external iliac veins by the bladder. Table 1 provides more details on study participants and results. Discussion Swelling of an extremity may be a sign of peripheral deep venous thrombosis but may JR:193, November

5 Selis and Kadakia Downloaded from by on 12/24/17 from IP address opyright RRS. For personal use only; all rights reserved occasionally be caused by more proximal venous obstruction. Duplex venous sonography of the extremities is a commonly performed procedure to evaluate for this possibility. s a part of this examination, pulsed-wave Doppler sonography is used to evaluate for augmentation that provides evidence of venous patency between the levels that the extremity is squeezed and the point of insonation. Pulsed-wave Doppler sonography is also used in the most proximal vein of an extremity. normal waveform with cardiac pulsatility or respiratory phasicity provides indirect evidence of venous patency between the levels of the heart or diaphragm and the point of insonation. The importance of this finding Fig year-old man with prostate cancer., Pulsed-wave Doppler sonogram of left common femoral vein (FV) shows flat waveform., T scan of pelvis shows lack of visualization of left external iliac vein (arrow) that was most likely from previous thrombosis. Fig year-old pregnant woman. Sonogram shows flat venous waveform in right common femoral vein (RT FV) because of compression of iliac vein by enlarged gravid uterus. should not be underestimated because it creates a window through which the brachiocephalic veins and superior vena cava can be evaluated when examining the veins of the neck or upper extremities. When examining the lower extremities, it creates a window through which the iliac veins and inferior vena cava can be evaluated. lthough deep venous thrombosis may cause extremity swelling, there are many other conditions that can occur proximal to the affected extremity that may cause the patient s symptoms. areful analysis of the waveform should be made to discover an intrathoracic, intraabdominal, or intrapelvic cause for the swollen extremity or extremities. Fig year-old woman with peritoneal metastases. bnormal waveforms in right and left common femoral veins (not shown) were obtained. olor Doppler sonogram of right iliac vein (RT IL VN) shows absence of flow (arrow). Normal flow was seen in adjacent iliac artery (RT). T scan (not shown) revealed occlusion of inferior vena cava. Fig year-old man with ruptured aneurysm of anterior cerebral artery., Pulsed-wave Doppler sonography of left (LT) and right (not shown) common femoral veins (FV) shows lowamplitude waveforms. Sonography of pelvis revealed overdistended bladder that compressed external iliac veins bilaterally. normal waveform in more proximal right common iliac vein (not shown) was seen. Patient was catheterized immediately and 1,500 ml of urine was recovered., fter catheterization, repeat pulsed-wave Doppler sonogram of left and right (not shown) FV revealed normalized waveforms because of lack of compression of external iliac veins by bladder. When interpreting the waveform, there are several important points to keep in mind. First, physiologic reasons cause considerable variability in the appearance of a normal venous waveform. The contralateral upper or lower extremity can often be used as an internal standard to determine what is normal for a given patient s venous waveform. Second, if the velocity range for pulsed-wave Doppler sonography is set very low, the waveform may falsely appear to have normal pulsatility or phasicity (Fig. 7). Third, if the velocity range for the pulsed-wave Doppler sonography is set very high then the waveform may falsely appear to be flat (nonphasic, nonpulsatile). Fourth, even if there is obstruction 1450 JR:193, November 2009

6 Doppler Sonography of the Extremities TLE 1: Study Participants and Results Downloaded from by on 12/24/17 from IP address opyright RRS. For personal use only; all rights reserved Patient No. ge (y) Sex Underlying ondition Veins Examined Diagnosis 1 51 F Non-Hodgkin s lymphoma Right internal jugular and subclavian veins Superior vena syndrome 2 65 F Liver metastases Right and left common femoral veins ompression of intrahepatic inferior vena cava 3 22 F Remote treatment of renal cancer Left and right common and left femoral veins Ligation of inferior vena cava 4 79 F Swelling of lower extremities Right and left common femoral veins bsent or small inferior vena cava 5 21 M End-stage renal disease Left common femoral vein Fluid-filled pelvic mass 6 85 F Metastatic endometrial cancer Right common femoral vein Right iliac lymphocele 7 80 M Prostate cancer Left common femoral vein Occlusion of left iliac vein 8 83 F Peritoneal metastases Right and left common femoral veins Thrombosis of inferior vena cava and right iliac vein 9 29 F Pregnant Right common femoral vein Enlarged gravid uterus M Ruptured cerebral aneurysm Right and left common femoral veins Overdistended bladder or compression of the vein proximally, the pulsed-wave Doppler waveform cannot be expected to be perfectly flat because there still may be some preservation of pulsatility or phasicity due to well-developed collateral flow or partial patency of the affected vein. Fifth, the pulsed-wave Doppler waveform should be assessed during quiet respiration. Do not use extraordinary respiratory maneuvers, such as the Valsalva maneuver, to decide whether there is normal respiratory variation because these maneuvers may transmit large-amplitude waveforms via collateral veins and give false evidence of patency. Sixth, if the pulsed-wave Doppler waveform in an extremity appears normal but more distal waveforms appear abnormal and there is no thrombus or occlusion between those levels of insonation, a more proximal venous abnormality should still be suspected (Figs. 5 and 5). Seventh, if there is a deep venous thrombosis in an extremity, the pulsedwave Doppler waveforms more distally will be nonphasic and nonpulsatile. To evaluate for proximal or central venous obstruction or compression, additional pulsed-wave Doppler sonography should be performed on a vein proximal to the thrombosed vein in that extremity. Finally, for pulsed-wave Doppler sonography, angle correction is not necessary because it is the waveform rather than the absolute velocity that is important. In conclusion, peripheral venous duplex sonography is commonly performed to evaluate the cause of swelling of an extremity. Peripheral deep venous thrombosis is frequently the cause. However, the swelling may occasionally be due to central pathology in the chest, abdomen, and pelvis. nalysis of the pulsed-wave Doppler waveforms provides the key to discover the central pathology. cknowledgment We thank our entire staff of ultrasound technologists for their dedication and enthusiasm. References 1. irdwell G, Raskob GE, Whitsett TL, et al. The clinical validity of normal compression ultrasonography in outpatients suspected of having deep venous thrombosis. nn Intern Med 1998; 128: merican ollege of Radiology. R practice guideline for the performance of peripheral venous ultrasound examination. In: R practice guidelines and technical standards. Reston, V: merican ollege of Radiology, 2007: Zwiebel WJ, Pellerito JS. Introduction to vascular ultrasonography, 5th ed. Philadelphia, P: Elsevier Saunders, 2005: Shelley KH, Dickstein M, Shulman SM. The detection of peripheral venous pulsation using the pulse oximeter as a plethysmograph. J lin Monit 1993; 9: hin EE, Zimmerman PT, Grant EG. Sonographic evaluation of upper extremity deep venous thrombosis. J Ultrasound Med 2005; 24: Patel M, erman LH, Moss H, McPherson SJ. Subclavian and internal jugular veins at Doppler US: abnormal cardiac pulsatility and respiratory phasicity as a predictor of complete central occlusion. Radiology 1999; 211: Nazarian GK, Foshager M. olor Doppler sonography of the thoracic inlet veins. Radio- Graphics 1995; 15: Longley DG, Yedlicka JW, Molina EJ, Schwabacher S, Hunter DW, Letourneau JG. Thoracic outlet syndrome: evaluation of the subclavian vessels by color duplex sonography. JR 1992; 158: Longley DG, Finlay DE, Letourneau JG. Sonography of the upper extremity and jugular veins. JR 1993; 160: llison SJ, Merton D, Needleman L, Polak JF. Peripheral vascular system. In: McGahan JP, Goldberg, eds. Diagnostic ultrasound. New York, NY: Informa Healthcare, 2007:499 JR:193, November