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Rule in DVT

Introduction

•Background

•Evidence

•System of examination

•Diagnoses & Variants

•Final actions

•Limitation of the examination

BACKGROUND

•Common presentation

•Influence initial management

•NICE Guidelines

EVIDENCE

EXAMINATION, DIAGNOSIS &

LIMITATION

Rule-In DVT Minimum Equipment

•Ultrasound machine• B-mode ultrasound system

• Regularly safety checked and serviced

•Probe• Frequencies of 3MHz and greater

• High frequency = better resolution = use for small legs

• Linear (small legs) and curvilinear (bigger legs) transducers should be available

Anatomy - CFV

CFA

SFA

DFA CFV

SFV

LSV

SFJ

CFV SFJ

LSVSFV

CFA

DFA

SFA

Anatomy - SFV

CFA CFV

SFJ

LSV

DFA

SFA SFV

Anatomy - PV

PAPV

SSV

PV

LSV

SSV

Per. V

PA

ATV

PTV

LSV

Rule-In DVT Pre-scanning preparation

•Introduction

•Set up machine• Confirm patient’s identity e.g. full name and date of birth

•Explanation to patient (if possible)• Why?

• Exam process

• Expected duration

•Verbal consent

•Expose exam area • groin to below knee

•Positioning• Supine position

• Head tilt if possible (encourages leg vein distension)

• Hip: externally rotated

• Knee: slight flexion

First, Find Mickey Mouse

Left Leg

‘Mickey Mouse Sign’

SFVSFV

LSVLSV CFA

CFA

Left Leg

SFJSFJ

Evidence for ‘Mickey Mouse Sign’Anatomical Variation at the Sapheno-Femoral Junction

Kimihiro Igari, Masayuki Hirokawa, Hidetoshi Uchiyama, Takahiro

Toyofuku, Toshifumi Kudo, Masatoshi Jibiki, Nobuhisa Kurihara,

Yoshinori Inoue

Ann Vasc Dis Vol. 6, No. 4; 2013; pp 702–705 ©2013 Annals of

Vascular Diseases. Online November 15, 2013

DOI:10.3400/avd.oa.13-00087

Duplex Ultrasound Investigation of the Veins in Chronic Venous

Disease of the Lower Limbs — UIP Consensus Document. Part I.

Basic Principles

P. Coleridge-Smith, N. Labropoulos, H. Partsch, K. Myers, A.

Nicolaides, A. Cavezzi

European Journal of Vascular and Endovascular Surgery.

Volume 31, Issue 1, Pages 83-92 (January 2006) DOI:

10.1016/j.ejvs.2005.07.019

Transverse view of common femoral vein and artery in the right groin: ‘Mickey Mouse’ view;

CFA, common femoral artery; CFV, common femoral vein; SFJ, sapheno–femoral junction (from the archive of PCS).

Normal anatomy at the sapheno-femoral junction (transverse view).

It is called “Mickey mouse sign”. GSV: great saphenous vein;

CFA: common femoral artery; FV: femoral veinUltrasound-guided central venous

access

Christopher P Gale, Andrew R

Bodenham

The British Journal of Cardiology.

January 2008 Br J Cardiol 2008;15:51-

4Cross-sectional images of the right

common femoral vessels just below the

inguinal ligament, showing the ‘Mickey

Mouse sign’. The femoral artery (FA) is

depicted on the left and the femoral vein

(FV) on the right. The sapheno-femoral

junction (SFJ) comprises the long

saphenous vein (LSV) and the FV

Anatomy Reminder - CFV

CFA

SFA

DFA CFV

SFV

LSV

SFJ

CFV SFJ

LSVSFV

CFA

DFA

SFA

Finding Mickey Mouse

Slide Probe Up

To

From

If this

is your first image...

Zone 1 – CFV

NO COMPRESSION COMPRESSION

Zone 2 – SFV

NO COMPRESSION COMPRESSION

Zone 3 – PV

NO COMPRESSION COMPRESSION

FAMUS: 3 point, Rule-In DVT Scanning

processFind CFV/SFJ

(Mickey Mouse)

CFV/SFJ - Compress (Zone 1)

Move probe down medial thigh to Mid SFV(compress along vessel as you move between zones)

Mid SFV – Compress (Zone 2)

Move probe down medial thigh and posteriorly towards PV

(compress along vessel as you move zones) (often cannot compress vessel as it goes posterior)

Identify PV trification – Just distal to popliteal fossa

Move probe proximally until a single vessel (PV) appears

PV – Compress (Zone 3)

Colour Flow

Colour Flow

Colour Flow

Normal Variant – Bifid venous system

Main diagnosis (DVT Rule IN)

Zone 1

Main diagnosis (DVT Rule IN)

Zone 2

Main diagnosis (DVT Rule IN)

Zone 2

Main diagnosis (DVT Rule IN)

Zone 2

Main diagnosis (DVT Rule IN)

Zone 3

Other pathology of significance –

SFJ Incompetence

Other pathology of significance –

Oedema

Other pathology of significance –

Oedema

Other pathology of significance –

Lymph nodes

Other pathology of significance –

Lymph nodes

Other pathology of significance –

Bakers cyst

Other pathology of significance –

Bakers cyst (?Ruptured)

Other pathology of significance –

Haematoma

Other pathology of significance –

Phlebitis

Other pathology of significance –

Phlebitis

Other pathology of significance –

Aneurysm

Other pathology of significance –

Aneurysm

Final 3 Actions

• Store ALL images

• Ensure good clinical governance

• Formally Report ALL Scans

• Ideal – Local PACS system

• Minimum – Reporting Template

secured in patients notes

• Act on information obtained

•Incorporate scan information into

effective management plan

•Refer for departmental scan as

needed

Limitation of Rule-In study

•Compared to Society of Vascular Technology (SVT) DVT

Professional Performance Guidelines of October 2012

(Our Standard) – FAMUS scans use 1 (main thrombus

detection tool) of the 3 DVT assessment tools• SVT Guidelines suggest

• B-mode should be used to image the vein and its contents; using compression of the vein in

the transverse plane

• Spectral Doppler should be used to determine direction of flow and detect abnormal flow

patterns

• Colour Doppler maybe used to detect thrombus as an aid to the B-mode procedure; it is an

essential requirement for the assessment of the abdominal veins.

•Hence, FAMUS Scans cannot formally rule-out DVT• Provides good sensitivity for rule-in DVT detection

QUESTIONS?