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RT: Case of the swollen Leg. Cimi Achiam MD, DTMH, FRCPC. First visit: Sept 14, 2011. 12:25: 50 yr male cc: L leg swelling 6 days of L leg swelling Transient SOBOE w / mildly pleuritic chest pain yesterday, but completely resolved on presentation PMHx : L DVT Jan 2011

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rt case of the swollen leg

RT: Case of the swollen Leg

Cimi Achiam


first visit sept 14 2011
First visit: Sept 14, 2011
  • 12:25:
    • 50 yr male cc: L leg swelling
      • 6 days of L leg swelling
      • Transient SOBOE w/ mildly pleuritic chest pain yesterday, but completely resolved on presentation
    • PMHx:
      • L DVT Jan 2011
        • Precipitated by flight to Hawaii
        • Tx w/ 6/12 of Warfarin D/C in mid June
    • No meds currently
    • Family Hx: nil
visit 1
Visit 1
  • O/E:

T37.2 HR 70 BP 145/78 RR20 Sat 96% RA

    • Chest: GAEBL, clear
    • CVS: S1S2 N, no murmur
    • Abdo: Soft NT, not distended
    • Neuro: Normal
    • L Leg: proximal swelling
vist 1 investigations
Vist 1 Investigations
  • 6 Pack: -
  • D dimer: 646
  • Troponin: -
visit 1 imaging
Visit 1: Imaging
  • CTPA:
    • no PE, mildly prominent R hilar node of uncertain clinical significance
  • CT Abdo/Pelvis:
    • No large pelvic mass causing obstruction of veins
    • No acute intra-abdominal abnormality
    • Questionable narrowing of the left common iliac vein at the level of the overlying right common illiac artery ? May-Thurner syndrome.
      • Recommend Interventional Radiology consult. If there is still significant clinical concern, an MRV could be attempted or a CTV could be reattempted with a longer delay between contrast and imaging
  • Doppler US:
    • - DVT, deep venous system widely patent
    • No residual thrombus identified
    • Normal waveforms, phasicity, augmentation, and compression were obtained
visit 11
Visit 1
  • Given high clinical concern for DVT, case was discussed with radiologist and plan was made for MR venogram next day
  • Pt was tx in the mean time with Enoxaparin 1.5mg/kg SC
visit 2 sept 16 2011
Visit 2: Sept 16, 2011
  • 13:42: Return for MRI results
    • Patient’s leg re-examined: Pt looks well, no pedal swelling, good circulation to L foot
    • MR Venogram of Pelvis & Thighs:
      • Negative MR venogram with no evidence of DVT in the pelvis and LE to just above the knees
  • Pt instructed to return on an as needed basis
visit 3 sept 20 2011
Visit 3: Sept 20, 2011
  • Patient represented with progressive swelling of his L leg, non- painful, no paraesthesias. No CP or SOB currently or since last evaluation
  • O/E:
    • Abdomen: Soft NT, no masses or inguinal lymphadenopathy
    • LE: non-pitting edema from foot to mid thigh, no erythema, normal pedal pulses and motor exam
visit 3
Visit 3
  • Given multiple investigations on previous visits case was discussed with radiology
      • Repeat Doppler U/S planned
      • Doppler U/S report:
        • Occlusive thrombus seen within the left external iliac vein
        • Non-occlusive thrombus within one branch of both of the duplicated superficial femoral, and popliteal veins
        • ? May Thurner’s syndrome
visit 31
Visit 3
      • On suggestion of radiology, interventional radiology consulted re: possibility of thrombolysis/stenting
        • Was informed would have to consult vascular surgery and that they would consult IR if required
  • Vascular surgery consult
      • Pt was admitted and anticoagulated with IV heparin protocol
  • Sept 21/11:
    • Pt underwent thrombolysis & stenting of his left iliac vein
    • Pt advised to restart IV heparin and continue coumadinx 6 mo minimum
may thurner syndrome
May Thurner Syndrome
  • Most commonly seen in women between 20-50yrs
  • Episodes of DVT may be recurrent and/or poorly responsive to treatment with anticoagulation alone
    • May require:
      • Catheter-directed thrombolysis
      • Venous angioplasty and/or intravascular stenting
  • Visualization of a clot this high in the pelvis may be difficult to detect using ultrasound of LE
    • If DVT is strongly suspected, further testing should be performed
diagnosis of suspected dvt of le
Diagnosis of Suspected DVT of LE
  • Only a minority of patients (17 and 32 % in two large series) actually have the disease
  • Accurate diagnosis is essential
    • Potential risk of fatal PE in untreated proximal LE DVTs
    • Potential risk of fatal bleeding due to anticoagulating a patient who does not have a DVT

Birdwell BG, et al. Ann Intern Med 1998; 128:1-5

Huisman MV, et alNEngl J Med 1986; 314:823

diagnosis of suspected le dvt
Diagnosis of Suspected LE DVT
  • Pre-test probability:
    • Modified Well’s Score
  • Imaging:
    • “Doppler” Compression U/S
      • Abnormal compressibility of the vein
      • Abnormal Doppler color flow
      • The presence of an echogenic band
      • Abnormal change in diameter during valsalva maneuver
        • Non-compressibility is 95% Sens & Spec for a proximal DVT
diagnostic imaging modalities beyond u s
Diagnostic Imaging Modalities: Beyond U/S
  • Contrast Venography
  • Non-invasive Tests:
    • Impedance Plethysmography
      • Sensitivity 91%; Specificity 96 %
    • MRI Venography
      • Sens 100%; Spec 96%
    • CT Venography
at rch high suspicion doppler u s
At RCH: High suspicion & - Doppler U/S
  • Options:
      • Order D-dimer: if positive bring patient back for repeat U/S in 5-7 days
      • Order more imaging:
        • CT Venogram
          • May be best option to rule out causes of pelvis compression ie mass and to assess iliac vessels
        • MR Venogram
        • Repeat U/S in 1 week without D-dimer
management of dvts beyond anticoagulation
Management of DVTs: Beyond anticoagulation
  • Thrombolytics
  • Surgical thrombectomy
  • Percutaneous mechanical thrombectomy
  • Potential indications:
    • Hemodynamically unstable PE
    • Massive iliofemoral thrombosis
    • May Thurner syndrome
  • May result in more rapid and complete lysis of LE DVT & less post-thrombotic syndrome
  • However, seldom used because:
    • Clinical relevance of achieving earlier relief of venous obstruction is uncertain
    • Increased risk of major bleeding
    • Low risk of death and early recurrence if anticoagulants are started promptly at an appropriate dose
    • Increased risk of catastrophic bleeding may not be worth preventing post-thrombotic syndrome
  • Indications:
    • Massive proximal LE or iliofemoral thrombosis PLUS
      • Severe symptomatic swelling or
      • Limb-threatening ischemia (phlegmasiaceruleadolens)
take home points
Take Home points
  • In patients with recurrent left sided DVT consider May Thurner syndrome
  • In patients with a high probability of DVT a single negative U/S study may be insufficient
    • Repeat the U/S in 5-7 days or
    • Consider adding a D-dimer at the time of the initial workup or
    • Consider other imaging modalities ie CT venogram