ARRS Case of the Week

ULTRASOUND: Vascular

Case Author: Deborah Rubens, MD, University of Rochester

History

55-year-old woman with left arm swelling.

Imaging Findings

Sagittal gray-scale ultrasound image of the left internal jugular vein (A) shows a slightly irregular hyperechoic linear echogenic band with posterior shadowing at the periphery of the vessel.

Sagittal color flow image through the left internal jugular vein (B) confirms flow in the vessel.

Transverse dual split-screen ultrasound images of the left internal jugular vein (C) at the same level as A obtained without (left) and with (right) compression show collapse of the vein (arrowheads) in response to compression. C = carotid artery.

Diagnosis

Chronic deep venous thrombosis

Teaching Points

Acute deep venous thrombosis (DVT) typically expands the vessel. Intraluminal material is usually hypoechoic. Clot fills the lumen and does not allow luminal coaptation with compression. Acute DVT requires consideration of anticoagulation therapy depending on the location of the clot and the other clinical findings. As it ages, the clot becomes more echogenic.

Chronic DVT is the sequela of an acute thrombotic event. The residual clot can calcify or be reduced to linear echogenic central bands or webs in the vessels. Vessel walls may thicken, but on compression, the lumen coapts completely. Chronic DVT does not require anticoagulation, and thus it is important to differentiate it from acute DVT to properly treat the patient.

Fibrin sheath can be recognized by its parallel walls and by a history of recent removal of an IV line from the vessel in question. A fibrin sheath requires no therapy.

Normal valves can be recognized by their thin, short structure, motion in real time, typical 30°–45° angle to the vessel wall, and paired configuration. The vein wall often balloons laterally at the site of the valve attachment.

Suggested Readings

Fraser JD, Anderson DR. Venous protocols, techniques and interpretations of the upper and lower extremities. Radiol Clin North America 2004; 42:279–296

Hamper UM, DeJong MR, Scoutt LM. Ultrasound evaluation of the lower extremity veins. Radiol Clin North Am 2007; 45:525–547

This page is updated with new content weekly. It was last updated on February 11, 2019.