"Ms. Davis" awoke this morning to find the pain in her right leg had increased to a high degree from the day before. She is a 35-year-old female with a 20 pack year history of cigarette smoking and currently is physically inactive. She also has been on hormonal birth control for a number of years and her current weight is 205 lbs. As she gets out of bed to examine her right leg she notices it has become red and swollen in the posterior calf region. The area is noticeably much more painful than it was the prior evening, before she went to bed. "Ms. Davis" recalls that her aunt had a similar event last year and was diagnosed with "blood clots" in her leg. This resulted in her aunt being hospitalized and treated for a blood clot that moved to her lung.
Concerned that this maybe a similar event, she calls her primary care physician and reviews her symptoms the doctor. Fearing she may have developed a Deep Vein Thrombosis (DVT), "Dr. Spencer" tells her to come right in to the medical center clinic for an examination. Upon arrival to the physician's clinic office, "Ms. Davis" is brought to an examination room. "Dr. Spencer" notices that as "Ms. Davis" makes her way down the hall, she is limping somewhat on the right side and has become easily short of breath as she makes her way to the examination room.
Physical examination reveals complaints of increased pain in her lower right extremity, accompanied by pain, tenderness and swelling in her left calf area. Her past medical and surgical history is relatively benign and she has not been to the primary care office on a regular basis. She continues to smoke and is sexually active, with no children or pregnancies. Heart and lung auscultation review a regular heart rate of 98 beat per minute a blood pressure of 186/90. Her lung sounds are clear but somewhat diminished at the bases, with a respiratory rate of 26 breaths per minute. Fearing a deep vein thrombosis (DVT) the doctor places an order for an Ultrasound scan of the lower extremities to rule out DVT. "Ms. Davis" is escorted to the Radiology department for the Ultrasound examination.
What is DVT?
DVT, or deep vein thrombosis, is the formation of a blood clot in a deep vein, usually in a calf or thigh muscle. DVT can partly or completely block blood flow, causing chronic pain and swelling. It may damage valves in blood vessels, making it difficult for you to get around. A blood clot can also break free and travel through your body's blood stream to major organs, such as your lungs or heart. There, it may cause significant damage to tissue affected by the obstructed blood flow. In severe cases, death can occur within hours.
Signs and Symptoms of DVT
DVT cases cause little to no symptoms depending on the severity of the blood clot. Some of the hall mark signs and symptoms of a Deep Vein Thrombosis can include but not be limited to:
- Swelling in one or both legs
- Pain or tenderness in one or both legs, which may occur only while standing or walking
- Warmth in the skin of the affected leg
- Red or discolored skin in the affected leg
- Visible surface veins
- Leg fatigue
When a blood clot breaks free in the lower extremities and travels to the lungs, its clinical disposition is a pulmonary embolism, which can be fatal. Pulmonary embolism symptoms can produce sudden coughing, which may cause the patient to bring up blood, experience sharp chest pain, rapid breathing or shortness of breath, or experience severe lightheadedness.
To diagnose DVT, examination to determine current and past health history is essential. Medical history, and symptoms, as well as performing a physical exam will aid the medical team in diagnosing this event. However, because DVT symptoms are shared by many other conditions, one or more special tests are needed to rule out other problems or to confirm a diagnosis. Of significance is the use of Ultrasound guided imaging.
Most ultrasound imaging of the lower extremity venous system involves a full examination of the deep veins' patency by compressing the veins in a transverse approach approximately every centimeter from the groin to the calf 1. To successfully complete the scan, the patient should ideally be placed in the reverse Trendelenburg position, wherein the legs are tilted downward to fully distend the veins in the leg. The patient is instructed to relax the leg being imaged and to externally rotate the leg slightly.
The sonographer evaluates the patency of the external iliac vein and follows the vessel down displaying compression of the greater saphenous vein, common femoral vein, profunda femoris vein, and the femoral vein in proximal, mid, and distal locations. The popliteal vein is then evaluated as well as interrogating the popliteal fossa for the presence of a Baker's cyst, which is a collection of synovial fluid that may sometimes accumulate behind the knee, causing pain, tightness or stiffness, and sometimes a palpable lump. The posterior tibial veins and peroneal veins may also be evaluated using the described method if the patient shows signs and/or symptoms such as "Ms. Davis" has shown in this case study. If a vein is partially compressible or non-compressible, a DVT is indicated. Frequently, an echogenic clot and/or vein distention is visualized.2,3 If a clot is not visualized and all veins completely compress, the sonographer then returns to the groin and interrogates the veins once again to demonstrate flow, employing a method known as augmentation. It is important to note that if a DVT has been identified or is suspected, augmentation is not utilized and only respiratory phasicity is evaluated. While there has been some debate as to the significance of completing augmentation procedures to aid in diagnosing the absence of a DVT, it is still a widely used and common occurrence in most hospitals and facilities today.
Treatment and Follow-up after Diagnosis
With the Ultrasound images obtained, the clinical sonographer reviews the images with the radiologist reading Ultrasound scans for that day. Review of the imaging indicates that thrombosis formation has been identified in the posterior tibal vein through the popliteal vein and into the central femoral vein. Concerned with the findings, the radiologist calls "Dr. Spencer" to review the case and discuss a plan of treatment for "Ms. Davis." "Dr. Spencer reviews the risks and benefits with "Ms. Davis" of an inpatient admission, to treat the clinical findings.
Remembering the incident that occurred with her aunt, "Ms. Davis" understands that if left untreated she could develop a possible life-threating condition. She agrees to be admitted to the inpatient medical surgical floor for intravenous anticoagulation therapy and monitoring of blood coagulation levels.
Once "Ms. Davis" is admitted she is started on a continuous intravenous anticoagulant infusion with perriodic (every 6 hour) monitoring of her blood's activated partial thromboplastin time (aPTT). With these lab values "Dr. Spencer" can adjust and titrate the intravenous anticoagulant infusion to a therapeutic level. The clinical effect of the anticoagulation treatment will significantly reduce the continued formation of thrombosis as the body begins to dissolve the existing thrombus in her right leg. "Dr. Spencer" then turns his attention to the factors which may have been contributory to the clot formation. During her 5-day admission she is seen by members of the multi-disciplinary team to discuss dietary and smoking related issues. "Ms. Davis" and the team reviewed and discussed the effects of obesity, lack of physical exercise and the long and short term effects of cigarette smoking.
As the treatment course drew to a close, "Ms. Davis" was transitioned to an oral blood thinner, which overlapped the existing infusion therapy. Before she was discharged an Ultrasound scan of the lower extremities was completed. When compared to the previous scan, this demonstrated significant reduction in the thrombus size and content. She was discharged to home with a 7 day follow up appointment at "Dr. Spencer's" office for examination and blood work. Over the next six months she remained on the oral blood thinner with blood level monitoring and repeated Ultrasound imaging of the lower extremities.
Positive Health Results
Incidentally, "Ms. Davis" was also successful in smoking cessation and adopted a dietary pattern that allowed for a 40-pound weight reduction in combination with light transitional exercise. At her six month follow- up appointment Ultrasound imaging revealed the thrombus was completely resolved and she was moving toward move active forms of physical exercise. The oral blood thinner medication was discontinued and she was scheduled for another follow-up appointment in six months.
In Ms. Davis' case she was fortunate to have responded to a conservative form of treatment. Complications from a DVT can be severe and life threating. In some severe cases placement of Inferior Vena Cava filters with systemic thrombolysis medication may be required. For "Ms. Davis", the outcomes were very good, due in part to early diagnosis and advanced ultrasonography imaging. These actions provided her with the ability to improve her overall physical condition for a life time of prevention.
1. Deep Vein Thrombus: Symptoms, Diagnosis, Treatment and NIH Research. http://www.nlm.nih.gov/medlineplus
2. DiVittorio, R. MD, Bluth, E. MD, Sullivan, M. MD. Deep Vein Thrombosis: Diagnosis of a Clinical Problem. Department of Radiology , Ochsner Clinic Foundation, New Orleans, LA. 2002, 4 (1) 14-17 The Ochsner Journal.
3. Zweibel, William MD. Introduction to Vascular Ultrasonography, 3rd ed. Philadelphia, PA, Saunders, 1992, pp 255-263.
Douglas Sutton works at the Radiology / Ultrasound department at the University of Vermont Medical Center. Deborah L. Szigeti is Program Director, DMS at American Institute.