Download PDF
Thromb Haemost 2007; 97(04): 566-572
DOI: 10.1160/TH06-01-0021
Blood Coagulation, Fibrinolysis and Cellular Haemostasis
Schattauer GmbH

Incidence and distribution of lower extremity deep venous thrombosis at indirect computed tomography venography in patients suspected of pulmonary embolism

Alain Nchimi   *
1   Department of Medical Imaging, University Hospital of Liège, Liege, Belgium
,
Benoît Ghaye
1   Department of Medical Imaging, University Hospital of Liège, Liege, Belgium
,
Charlemagne T. Noukoua
1   Department of Medical Imaging, University Hospital of Liège, Liege, Belgium
,
Robert F. Dondelinger
1   Department of Medical Imaging, University Hospital of Liège, Liege, Belgium
› Author Affiliations
Further Information

Publication History

Received 13 January 2006

Accepted after resubmission 09 February 2007

Publication Date:
24 November 2017 (online)

    Permissions and Reprints

Summary

Indirect computed tomography (CT) venography reportedly provides high accuracy for detection of venous thrombosis in patients suspected of pulmonary embolism (PE). Nevertheless, the extent of the scanning range for lower limb and abdominal veins remains to be determined. It was the objective of this study to investigate the distribution of venous thrombosis in order to identify the most appropriate extent of scanning range when using CT venography. We reviewed 1,408 combined CT pulmonary angiographies (CTPA) and indirect CT venographies of the lower limbs, performed in patients suspected of PE. Percentage of venous thromboembolism (VTE), which includes PE and/or venous thrombosis was calculated. Location and the upper end of clots were recorded in 37 venous segments per patient from calf to diaphragm. PE, venous thrombosis and VTE, were found respectively in 272 (19.3%), 259 (18.4%) and 329 (23.4%) patients. Addition of CT venography to CTPA increased depiction of VTE in 17.3%.The upper end of venous thrombosis was located below the knee in 48%, between knee and inguinal ligament in 36% of the patients, and above the inguinal ligament in 15%.Ninety-six patients had thrombosis in a single vein, of which none occured above the iliac crests in a patient without PE at CTPA. In conclusion, when added to CTPA, optimal scanning of CT venography should extent from calves to the iliac crests in patients suspected of VTE.

Keywords

Pulmonary embolism - computed tomography (CT) - venography - angiography - veins - thrombosis - thromboembolism

* Current address: Dept of Medical Imaging, Clinique Saint Joseph, Rue de Hesbaye, 52, B-4000 Liège, Belgium.


 

  • References

  • 1 National Institutes Of Health. Prevention of venous thrombosis and pulmonary embolism. Progr Cardiovasc Dis 1986; 256: 744-749.
    PubMedGoogle Scholar
  • 2 Dalen JE, Alpert JS. Natural history of pulmonary embolism. Progr Cardiovasc Dis 1975; 17: 259-270.
    CrossrefPubMedGoogle Scholar
  • 3 Dalen JE, Alpert JS. Writing Group for the Christopher Study Investigators. Effectiveness of managing suspected pulmonary embolism using an algorithm combining clinical probability, D-Dimer testing and computed tomography. J Am Med Assoc 2006; 295: 172-179.
    CrossrefPubMedGoogle Scholar
  • 4 Moser KM. Venous thromboembolism. Am Rev Respir Dis 1990; 141: 235-249.
    CrossrefPubMedGoogle Scholar
  • 5 Value of the perfusion/ventilation lung scan in acute pulmonary embolism: results of the prospective investigation of pulmonary embolism diagnosis (PIOPED)- The PIOPED investigators. J Am Med Assoc 1990; 263: 2753-2759.
    CrossrefPubMedGoogle Scholar
  • 6 Musset D, Parent F, Meyer G. et al. Diagnostic strategy for patients with suspected pulmonary embolism: a prospective multicentre outcome study. Lancet 2002; 360: 1914-1920.
    CrossrefPubMedGoogle Scholar
  • 7 Schoepf UJ, Costello P. CT angiography for diagnosis of pulmonary embolism: state of the art. Radiology 2004; 230: 329-337.
    CrossrefPubMedGoogle Scholar
  • 8 Loud PA, Grossman ZD, Klippenstein DL. et al. Combined CT venography and pulmonary angiography: a new diagnostic technique for suspected thromboembolic disease. Am J Roentgenol 1988; 170: 951-954.
    PubMedGoogle Scholar
  • 9 Loud PA, Katz DS, Klippenstein DL. et al. Combined CT venography and pulmonary angiography in suspected thromboembolic disease: diagnostic accuracy for deep venous evaluation. Am J Roentgenol 2000; 174: 61-65.
    CrossrefPubMedGoogle Scholar
  • 10 Loud PA, Katz DS, Bruce DA. et al. Deep venous thrombosis with suspected pulmonary embolism: detection with combined CT venography and pulmonary angiography. Radiology 2001; 219: 498-502.
    CrossrefPubMedGoogle Scholar
  • 11 Ghaye B, Szapiro D, Willems V. et al. Combined CT venography of the lower limbs and spiral CT angiography of pulmonary arteries in acute pulmonary embolism: preliminary results of a prospective study. JBR-BTR 2000; 83: 271-278.
    PubMedGoogle Scholar
  • 12 Garg K, Kemp JL, Wojcik D. et al. Thromboembolic disease: comparison of combined CT pulmonary angiography and venography with bilateral leg sonography in 70 patients. Am J Roentgenol 2000; 175: 997-1001.
    CrossrefPubMedGoogle Scholar
  • 13 Coche EE, Hamoir XL, Hammer FD. et al. Using dual-detector helical CT angiography to detect deep venous thrombosis in patients with suspicion of pulmonary embolism: diagnostic value and additional findings. Am J Roentgenol 2001; 176: 1035-1039.
    CrossrefPubMedGoogle Scholar
  • 14 Cham MD, Yankelevitz DF, Shaham D. et al. Deep venous thrombosis: detection by using indirect CT venography. Radiology 2000; 216: 744-751.
    CrossrefPubMedGoogle Scholar
  • 15 Richman PB, Wood J, Kasper DM. et al. Contribution of indirect computed tomography venography to computed tomography angiography of the chest for the diagnosis of thromboembolic disease in two United States emergency departments. J Thromb Haemost 2003; 1: 652-657.
    CrossrefPubMedGoogle Scholar
  • 16 Cham MD, Yankelevitz DF, Henschke I C. Thromboembolic disease detection at indirect CT venography versus CT pulmonary angiography. Radiology 2005; 234: 591-594.
    CrossrefPubMedGoogle Scholar
  • 17 Revel MP, Petrover D, Hernigou A. et al. Diagnosing pulmonary embolism with four-detector row helical CT: prospective evaluation of 216 outpatients and inpatients. Radiology 2005; 234: 265-273.
    CrossrefPubMedGoogle Scholar
  • 18 Stein PD, Fowler SE, Goodman LR. et al. PIOPED II Investigators. Multidetector computed tomography for acute pulmonary embolism. N Engl J Med 2006; 354: 2317-2327.
    CrossrefPubMedGoogle Scholar
  • 19 Bounameaux H, Righini M, Perrier A. Diagnosing deep vein thrombosis: the case for compression ultrasonography limited to the proximal veins. J Thromb Haemost 2004; 2: 2260-2261.
    CrossrefPubMedGoogle Scholar
  • 20 Walsh G, Redmond S. Does addition of CT pelvic venography to CT pulmonary angiography protocols contribute to the diagnosis of thromboembolic disease?. Clin Radiol 2002; 57: 462-465.
    CrossrefPubMedGoogle Scholar
  • 21 Maki DD, Kumar N, Nguyen B. et al. Distribution of thrombi in acute lower extremity deep venous thrombosis: implications for sonography and CT and MR venography. Am J Roentgenol 2000; 175: 1299-1301.
    CrossrefPubMedGoogle Scholar
  • 22 Katz DS, Loud PA, Bruce D. et al. Combined CT venography and pulmonary angiography: a comprehensive review. Radiographics 2002; 22: 3S-19S.
    CrossrefPubMedGoogle Scholar
  • 23 Ghaye B, Remy J, Remy-jardin M. Non-traumatic thoracic emergencies: CT diagnosis of acute pulmonary embolism : the first ten years. Eur Radiol 2002; 12: 1886-1905.
    CrossrefPubMedGoogle Scholar
  • 24 Ghaye B, Dondelinger RF. Non-traumatic thoracic emergencies: CT venography in an integrated diagnostic strategy of acute pulmonary embolism and venous thrombosis. Eur Radiol 2002; 12: 1906-1921.
    CrossrefPubMedGoogle Scholar
  • 25 Stein PD, Fowler SE, Goodman LR. et al. PIOPED II Investigators. Multidetector computed tomography for acute pulmonary embolism. N Engl J Med 2006; 1: 2317-2327.
    PubMedGoogle Scholar
  • 26 van Rossum AB, van Houwelingen HC, Kieft GJ. et al. Prevalence of deep vein thrombosis in suspected and proven pulmonary embolism: a meta-analysis. Br J Radiol 1998; 71: 1260-1265.
    CrossrefPubMedGoogle Scholar
  • 27 Hull RD, Hirsh J, Carter CJ et al. Pulmonary angiography, ventilation lung scanning, and venography for clinically suspected pulmonary embolism with abnormal perfusion lung scan. Ann Intern Med 1983; 98: 891-899.
    CrossrefPubMedGoogle Scholar
  • 28 Girard P, Musset D, Parent F. et al. High prevalence of detectable deep venous thrombosis in patients with acute pulmonary embolism. Chest 1999; 116: 903-908.
    CrossrefPubMedGoogle Scholar
  • 29 Barrellier MT C, Lezin B, Landy S. et al. Prevalence of duplex ultrasonography detectable venous thrombosis in patients with suspected or acute pulmonary embolism. J Mal Vasc 2001; 26: 23-30.
    PubMedGoogle Scholar
  • 30 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: 243-250.
    CrossrefPubMedGoogle Scholar
  • 31 Ouriel K, Green RM, Greenberg RK. et al. The anatomy of deep venous thrombosis of the lower extremity. J Vasc Surg 2000; 31: 895-900.
    CrossrefPubMedGoogle Scholar
  • 32 Kerr TM, Cranley JJ, Johnson JR. et al. Analysis of 1084 consecutive lower extremities involved with acute venous thrombosis diagnosed by duplex scanning. Surgery 1990; 108: 520-527.
    PubMedGoogle Scholar
  • 33 Markel A, Manzo RA, Bergelin RO. et al. Pattern and distribution of thrombi in acute venous thrombosis. Arch Surg 1992; 127: 305-309.
    CrossrefPubMedGoogle Scholar
  • 34 Mattos MA, Melendres G, Sumner DS. et al. Prevalence and distribution of calf vein thrombosis in patients with symptomatic deep venous thrombosis: a color-flow duplex study. J Vasc Surg 1996; 24: 738-744.
    CrossrefPubMedGoogle Scholar
  • 35 Cogo A, Lensing AW, Koopman MM. et al. Compression ultrasonography for diagnostic management of patients with clinically suspected deep vein thrombosis: prospective cohort study. Br Med J 1998; 316: 17-20.
    CrossrefPubMedGoogle Scholar
  • 36 Baldt MM, Zontsich T, Stumpflen A. et al. Deep venous thrombosis of the lower extremity: efficacy of spiral CT venography compared with conventional venography in diagnosis. Radiology 1996; 200: 423-428.
    CrossrefPubMedGoogle Scholar
  • 37 Birdwell BG, Raskob GE, Whitsett TL. et al. The clinical validity of normal compression ultrasonography in outpatients suspected of having deep venous thrombosis. Ann Intern Med 1998; 128: 1-7.
    CrossrefPubMedGoogle Scholar
  • 38 Elias A, Colombier D, Victor G. et al. Diagnostic performance of complete lower limb venous ultrasound in patients with clinically suspected acute pulmonary embolism. Thromb Haemost 2004; 91: 187-195.
    Article in Thieme ConnectPubMedGoogle Scholar
  • 39 Lohr JM, Kerr TM, Lutter KS. et al. Lower extremity calf thrombosis: to treat or not to treat?. J Vasc Surg 1991; 14: 618-623.
    CrossrefPubMedGoogle Scholar
  • 40 Philbrick JT, Becker DM. Calf deep venous thrombosis. A wolf in sheep's clothing?. Arch Intern Med 1988; 148: 2131-2138.
    CrossrefPubMedGoogle Scholar
  • 41 Passman MA, Moneta GL, Taylor Jr LM. et al. Pulmonary embolism is associated with the combination of isolated calf vein thrombosis and respiratory symptoms. J Vasc Surg 1997; 25: 39-45.
    CrossrefPubMedGoogle Scholar
  • 42 Ghaye B, Nchimi A, Noukoua CT. et al. Does multidetector row CT pulmonary angiography reduce the incremental value of indirect CT venography compared with single-detector row CT pulmonary angiography?. Radiology 2006; 240: 256-262.
    CrossrefPubMedGoogle Scholar
  • 43 Begemann PG, Bonacker M, Kemper J. et al. Evaluation of the deep venous system in patients with suspected pulmonary embolism with multi-detector CT: a prospective study in comparison to Doppler sonography. J Comput Assist Tomogr 2003; 27: 399-409.
    CrossrefPubMedGoogle Scholar
  • 44 Wildberger JE, Mahnken AH, Sinha AM. et al. A differentiated approach to the diagnosis of pulmonary embolism and deep venous thrombosis using multislice CT. Fortschr Röntgenstr 2002; 174: 301-307.
    Article in Thieme ConnectPubMedGoogle Scholar
  • 45 Rademaker J, Griesshaber V, Hidajat N. et al. Combined CT pulmonary angiography and venography for diagnosis of pulmonary embolism and deep vein thrombosis: radiation dose. J Thorac Imaging 2001; 16: 297-299.
    CrossrefPubMedGoogle Scholar
  • 46 Greess H, Wolf H, Suess C. et al. Automatic exposure control to reduce the dose in subsecond multislice spiral CT: phantom measurements and clinical results. Fortschr Röntgenstr 2004; 176: 862-869.
    Article in Thieme ConnectPubMedGoogle Scholar