Evaluation of Two-Point Compression Ultrasound as a Screening Tool for Lower Extremity Deep Venous Thrombosis in a Neurocritical Care Unit: Insights from a Single-Center Study

Abstract

Background

Deep venous thrombosis (DVT) is an important cause of morbidity and mortality in the intensive care unit (ICU) and it is often missed in the neurocritical care unit (NCCU) as patients might not manifest with obvious symptomatology. Screening of these patients may provide a preventive benefit. The routine use of formal lower extremity venous Doppler (LEVD) scan, which is done by a vascular laboratory technician and comprises the imaging of the entire lower extremity venous system plus Doppler imaging, can be resource intensive. Alternatively, the two-point compression ultrasound (2-CUS), which consists of the imaging and compression at the common femoral vein and popliteal fossa, is quick and can be done by the clinician at bedside with minimal training. The aim of this study is to evaluate the use of 2-CUS as a screening tool for all patients in the NCCU.

Methods

We performed a retrospective analysis of prospectively collected data for consecutive patients admitted to the NCCU at Baylor College of Medicine between August 2020 and February 2021. A 2-CUS scan was performed by neurocritical care fellows, evaluating the bilateral common femoral veins and popliteal veins without color Doppler, on admission and every third day. An LEVD scan was performed in all NCCU patients every 7 days and sooner if 2-CUS scan was positive. The inclusion criteria were patients admitted to the neurocritical care service and age ≥18 years. The exclusion criteria were expected length of stay (LOS) of less than 48 hours, known recent DVT, or positive test for COVID-19.

Results

A total of 298 patients were admitted to the NCCU. 2-CUS was done in 256 patients, while 64 patients underwent both 2-CUS and an LEVD scan. The overall incidence rate of lower extremity DVTs was 10.1%. Nine patients undergoing 2-CUS were positive, of whom six were confirmed by LEVD, and three were false positives (positive predictive value = 66.7%). Two patients had false-negative 2-CUS (negative predictive value = 96.6%). When compared with LEVD, the sensitivity of 2-CUS was 75% (6/8) and the specificity was 95% (57/60). The sensitivity for proximal DVTs was 100%. The two DVTs missed were in the posterior tibial veins not scanned with 2-CUS.

Conclusion

This is the first study to evaluate the use of 2-CUS as a screening tool for lower extremity DVTs. An incidence of 10.6% was found on patients with a LOS ≥7 days. With a sensitivity of 100% for proximal DVT, a specificity of 95%, and a diagnostic accuracy of 95%, the authors conclude that 2-CUS is a feasible, easily learnt, quick and cost-effective tool for screening DVT in NCCU patients.

Keywords

point-of-care ultrasonography - venous dopplers - critical care - deep venous thrombosis

^* All authors were affiliated with Baylor College of Medicine when this work was conducted. Muhammad U. Hafeez is currently affiliated with the Department of Neurology, University of Texas Medical Branch, Galveston, Texas. Ivan Cuesta is affiliated with the Department of Neurology, Advocate General Lutheran Hospital, Chicago, Illinois. Aaron A. Desai is currently affiliated with the Department of Neurology, University of South Florida, Tampa, Florida.

^# Muhammad U. Hafeez and Ivan Cuesta are the first co-authors.

Publikationsverlauf

Artikel online veröffentlicht:
12. Mai 2025

• References

• 1 Cook D, Crowther M, Meade M. et al. Deep venous thrombosis in medical-surgical critically ill patients: prevalence, incidence, and risk factors. Crit Care Med 2005; 33 (07) 1565-1571
• 2 Attia J, Ray JG, Cook DJ, Douketis J, Ginsberg JS, Geerts WH. Deep vein thrombosis and its prevention in critically ill adults. Arch Intern Med 2001; 161 (10) 1268-1279
• 3 Moser KM, LeMoine JR, Nachtwey FJ, Spragg RG. Deep venous thrombosis and pulmonary embolism. Frequency in a respiratory intensive care unit. JAMA 1981; 246 (13) 1422-1424
• 4 Cade JF. High risk of the critically ill for venous thromboembolism. Crit Care Med 1982; 10 (07) 448-450
• 5 Kapoor M, Kupfer YY, Tessler S. Subcutaneous heparin prophylaxis significantly reduces the incidence of venous thromboembolic events in the critically ill. Crit Care Med 1999; 27 (12) A69
• 6 Fraisse F, Holzapfel L, Couland JM. et al; The Association of Non-University Affiliated Intensive Care Specialist Physicians of France. Nadroparin in the prevention of deep vein thrombosis in acute decompensated COPD. Am J Respir Crit Care Med 2000; 161 (4, Pt 1): 1109-1114
• 7 Ibrahim EH, Iregui M, Prentice D, Sherman G, Kollef MH, Shannon W. Deep vein thrombosis during prolonged mechanical ventilation despite prophylaxis. Crit Care Med 2002; 30 (04) 771-774
• 8 Cook D, Meade M, Guyatt G. et al; PROTECT Investigators for the Canadian Critical Care Trials Group and the Australian and New Zealand Intensive Care Society Clinical Trials Group. Dalteparin versus unfractionated heparin in critically ill patients. N Engl J Med 2011; 364 (14) 1305-1314
• 9 Yang T, Wei G, Zhu C, Pan A. Incidence and risk factor analysis of deep venous thrombosis in patients with severe traumatic brain injury. Zhonghua Wei Zhong Bing Ji Jiu Yi Xue 2019; 31 (02) 182-186
• 10 Eck RJ, Hulshof L, Wiersema R. et al. Incidence, prognostic factors, and outcomes of venous thromboembolism in critically ill patients: data from two prospective cohort studies. Crit Care 2021; 25 (01) 27
• 11 Schultz DJ, Brasel KJ, Washington L. et al. Incidence of asymptomatic pulmonary embolism in moderately to severely injured trauma patients. J Trauma 2004; 56 (04) 727-731 , discussion 731–733
• 12 Ciuti G, Grifoni E, Pavellini A. et al. Incidence and characteristics of asymptomatic distal deep vein thrombosis unexpectedly found at admission in an internal medicine setting. Thromb Res 2012; 130 (04) 591-595
• 13 Shimabukuro N, Mo M, Hashiyama N. et al. Clinical course of asymptomatic isolated distal deep vein thrombosis of the leg: a single-institution study. Ann Vasc Dis 2019; 12 (04) 487-492
• 14 Rose SC, Zwiebel WJ, Miller FJ. Distribution of acute lower extremity deep venous thrombosis in symptomatic and asymptomatic patients: imaging implications. J Ultrasound Med 1994; 13 (04) 243-250
• 15 De Martino RR, Beck AW, Edwards MS. et al. Impact of screening versus symptomatic measurement of deep vein thrombosis in a national quality improvement registry. J Vasc Surg 2012; 56 (04) 1045-51.e1
• 16 Skrifvars MB, Bailey M, Presneill J. et al; EPO-TBI investigators and the ANZICS Clinical Trials Group. Venous thromboembolic events in critically ill traumatic brain injury patients. Intensive Care Med 2017; 43 (03) 419-428
• 17 Allen CJ, Murray CR, Meizoso JP. et al. Surveillance and early management of deep vein thrombosis decreases rate of pulmonary embolism in high-risk trauma patients. J Am Coll Surg 2016; 222 (01) 65-72
• 18 Samuel S, Patel N, McGuire MF, Salazar M, Nguyen T. Analysis of venous thromboembolism in neurosurgical patients undergoing standard versus routine ultrasonography. J Thromb Thrombolysis 2019; 47 (02) 209-215
• 19 Arabi YM, Burns KEA, Alsolamy SJ. et al; Saudi Critical Care Trials Group. Surveillance or no surveillance ultrasonography for deep vein thrombosis and outcomes of critically ill patients: a pre-planned sub-study of the PREVENT trial. Intensive Care Med 2020; 46 (04) 737-746
• 20 Malhotra AK, Goldberg SR, McLay L. et al. DVT surveillance program in the ICU: analysis of cost-effectiveness. PLoS One 2014; 9 (09) e106793
• 21 Dickerson JC, Harriel KL, Dambrino RJ. et al. Screening duplex ultrasonography in neurosurgery patients does not correlate with a reduction in pulmonary embolism rate or decreased mortality. J Neurosurg 2019; 132 (05) 1589-1597
• 22 Kearon C, Julian JA, Newman TE, Ginsberg JS. Noninvasive diagnosis of deep venous thrombosis. McMaster Diagnostic Imaging Practice Guidelines Initiative. Ann Intern Med 1998; 128 (08) 663-677
• 23 Kory PD, Pellecchia CM, Shiloh AL, Mayo PH, DiBello C, Koenig S. Accuracy of ultrasonography performed by critical care physicians for the diagnosis of DVT. Chest 2011; 139 (03) 538-542
• 24 Palareti G, Cosmi B, Lessiani G. et al. Evolution of untreated calf deep-vein thrombosis in high risk symptomatic outpatients: the blind, prospective CALTHRO study. Thromb Haemost 2010; 104 (05) 1063-1070
• 25 Utter GH, Dhillon TS, Salcedo ES. et al. Therapeutic anticoagulation for isolated calf deep vein thrombosis. JAMA Surg 2016; 151 (09) e161770
• 26 Robert-Ebadi H, Righini M. Management of distal deep vein thrombosis. Thromb Res 2017; 149: 48-55
• 27 Caronia J, Sarzynski A, Tofighi B. et al. Resident performed two-point compression ultrasound is inadequate for diagnosis of deep vein thrombosis in the critically III. J Thromb Thrombolysis 2014; 37 (03) 298-302
• 28 Roberts L, Rozen T, Murphy D. et al. A preliminary study of intensivist-performed DVT ultrasound screening in trauma ICU patients (APSIT study). Ann Intensive Care 2020; 10 (01) 122-122
• 29 Misra M, Roitberg B, Ebersole K, Charbel FT. Prevention of pulmonary embolism by combined modalities of thromboprophylaxis and intensive surveillance protocol. Neurosurgery 2004; 54 (05) 1099-1102 , discussion 1102–1103
• 30 Shackford SR, Cipolle MD, Badiee J. et al. Determining the magnitude of surveillance bias in the assessment of lower extremity deep venous thrombosis: a prospective observational study of two centers. J Trauma Acute Care Surg 2016; 80 (05) 734-739 , discussion 740–741
• 31 Haut ER, Noll K, Efron DT. et al. Can increased incidence of deep vein thrombosis (DVT) be used as a marker of quality of care in the absence of standardized screening? The potential effect of surveillance bias on reported DVT rates after trauma. J Trauma 2007; 63 (05) 1132-1135 , discussion 1135–1137