‘The prevalence of deep vein ‘thrombosis (DVT) and ut- monary embolism isa public heath car crisis in the United ‘State today, and the imaging sciences playa crucial role in diagnosing and treating these conditions. Professional radiographers must have a thorough understanding of the risk factors, diease proceses,requied diagnostic studies, treatment options and prophylaxis for these cond tions to provide safe, quality patient care. In addition, interoentional technologists ‘must continually expand their ‘professional sls 0 heap pace swith nw tecmologies used to treet DVT. This article is a Directed Reading Sete eee a. DIRECTED READING Venous Thromboembolism CATHERINE M. STEVENS, RT.(R) EUGEN MUNTEAN, R-T.(R)(VI) After completing this article, the r . Desribe the causes of venous thromboembolism. dor should be able tor fine te population at righ for dep vein thrombasis (DVT) and pulmonary enbolisn (PE). Discus the symptoms associated with venous thronboombelisn. I Explain the imaging studies used to diagnose DVT and PE. W Desrbe the therapies used to treat DVT. 1 Specify factor to consider in caring forthe patent with DVT and associated posiproceduve management Discuss options for proventing DVT. ood clots inside veins found deep in the extremities or ody cavities are a common disorder known as deep vein thrombosis (DVT)! DVT ‘and its complication, pulmonary embotisin (PE), make up one of the nation’s leading. causes of death? Collectively, DVT and PE. are known as venous thromboembolism (VTE) More people die in the United States from PE than breast cancer and AIDS combined.* Both DVT and PE are preventable and prophylaxis is the key t0 saving Hves#* When prevention fail, howey- cr, carly diagnosis and treatment are essen- tial to prevent complications. Imaging per- sonnel provide critical diagnostic studies and vital treatment options for those affected by DVT. DVT occurs in approximately 2 mil- lion Americans per year! and 1 out of every 100 people who develop DVT dies because of PE.’ Unfortunately, only about half of the people who develop DVT experience recognizable symptoms that allow early detection or prevention of PE.'In some circumstances, DVT also, ‘may contribute to other serious medical problems such as heart attack and stroke.” DVTis an under-ecognized clinical con- RADIOLOGIC TECHNOLOGY Mareh/Aprid 2007, Vl. 78/No. 4 dition affecting patients without regard to race or economic status and ean occur in either the upper or lover extremities. DVT in the arms now accounts for about 896 of all DVT cases in the United States.” ing Awareness ‘Many celebrities personally affected by DVT or PE have begun campaigns to edt cate the public and raise awareness about this condition. Several tragic cases of fatal PE have received widespread media cover- age. In 2000 a 28:year-old woman who had been a spectator at the Sydney Olympics collapsed and die of PE after deplaning in London. In 2008 reporter David Bloom of NBC News, who was embedded with a US. infantry anit during the Second Gulf War, complained of leg discomfort for several ays and then died suddenly of a pulmo- xnaty embolus. These events, coupled with a public awareness campaign, "Killer Legs,” have raised unprecedented interest in this previously overlooked but common condi- tion. Eyen 50, and in spite of thousands ‘of publications on the diagnosis and treat ‘ment of DVT, 74% of Americans have litle ‘or no awareness of the problem, accor- ing to a national survey sponsored by the “American Public Health Association?” 309ete ee Sars In February 2008, more than 60 organizations assembled at the Public Health Leadership Conference (on Deep Vein Thrombosis in Washington, D.G.,to di cuss the urgent need to make DVT a major US. public health priority. Conference participants formed the Coalition to Prevent Deep Vein Thrombosis, which is committed to educating the public and the health care community about DVT A key outcome of an Angust 2003 coalition meeting was to sponsor DVT ‘Awareness Month, a campaign to bring DVT into the public eye on a national and local level. The inangural DVT Awareness Month took place in March 2004.” In February 2005, Melanie Bloom, widow of the late ‘NBC Neus reporter, joined the coalition asits national spokesperson to further raise awareness and make DVT a national health priority? In a September 27, 2004 news release, the Joint Commission on Accreditation of Healthcare ‘Organizations (JOAHO) and the National Quality Forum announced a joint project to develop and stan- dardize performance measures for the prevention and care of DVT among inpatients. The Joint Commission Steering Gommitice and Technical Advisory Panel was charged with creating the DVT performance mea- sure set, a8 well as the specifications and testing for these measures.” Joint commission meetings began in January 2005. At an initial meeting, members decided that the project should encompass DVT and PE, result ing in a name revision to the National Consensus Standards for the Prevention anel Care of Venous Thromboembolism project. ight performance measures were finalized during the summer of 2006 and recommended for pilot test ing, (See Table 1, In Janvary 2007, a 6-xmonth pilot test of the measures began in $5 randomly selected volunteer hospitals across the country." One initiae tive the Joint Commission might employ to support these strategies isa disease-specific care certification program, This approach aims to increase the use of evidence-based medicine as a focal point for disease- specific patient care services or programs, Asa strategy {0 improve clinical outcomes for patients with DVT, this certification offers a framework for practitioners to implement practice guidelines for DVT: Some experts {ge the JCAHO to considera stronger siep beyond certification and make DVT prevention a component ‘of accreditation.’ n addition, The American Medical ‘Association Physician Consortium for Performance Improvement aims to become a leading source for ‘evidence-based performance measures and outcomes 310 coe Meee US un Ly Laat “RISK Assessmient/Prophylexis VTE risk assessment/prophlaxs within 24 hours of hospital acission, 1m VTE risk assessmentiprophylaxis within 24 hours of transfer to ICU. 'M_Documentation of inferior vena cava fitrinciation VTE patients with overlap therapy. VTE patients receiving untractionate heparin with platelet count monitoring, |m VTE patients receiving unfractionated heparin man- agement by nomogram/protocol. VTE discharge Instructions. 2 Outcome IB Incidence of potentially preventable hospital ‘soquired VTE. reporting tools and has offered its assistance in devel: oping tools for DVT prevention.? Venous vs Arterial Thrombus ‘Venous thrombi are different from arterial thrombi, ‘not only in terms of the sites where they form but also in |. their appearance and make-up. Compared with the pale- ‘colored, plateletrich arterial thrombi, venous thrombi are less compact and contain many red blood cells trapped in a fibrin network.” Venous and arterial thrombi also pres- ‘ent ery different symptoms, A venous thrombus, chaugh 2 serious condition, often is not considered immediately life threatening, exceptin the case of PE, Arterial thrombi, on the other hand, are considered emergent conditions and ‘often present with more severe signs or symptoms, such as a transient ischemic attack or stroke, myocardial infarc- tion, a cold extremity or gangrene. DVT Mechanisms and Risk Factors ‘At highest risk for thrombus development are individu- als with an identified risk factor: The elderly and obese are most susceptible to lower-extremity thrombus, and increased use of eentral venous catheters is at least par- tially responsible for the increased frequency of DVT in ‘the upper extremities” Two forms of DVT in the upper extremities are effort induced thrombosis (Pagetwon March/April 2007, Vo. 78/No. 4 RADIOLOGIC TECHNOLOGYSchrétter syndrome) and secondary thrombosis." ldiopathic clots in the upper extremities ae rare and should raise concern for occult carcinoma.” Effortinduced thrombosis accounts for a quarter of upper-extremity DVT cases and in its primary form is described as an underlying chronic venous compressive abnormality caused by the musculoskeletal structures in| the costoclavicular space at the thoracic inet, outlet or both, Secondary thrombosis occurs in three quarters of patients with upper-extremity DVT, and important con- lributing factors ae hypercoagulability and indwelling central venous catheters.’ Etiologies of secondary venous thrombosis in the upper extremities include: Use of central venous catheters. Use of permanent cardiac pacers, I Hypercoagulable states. ME Reduced Sand C protein levels, MI Mediastinal tumors or nodes. HE Mediastinal radiation and surgery. Wi Trauma (eg, fractured claviete)’” Inimal injury is likely to be more important than other factars in the etiology of upper-extremity DVT. ‘This is particularly true of thrombosis in the axillosub: clavian vein compared with thrombus in other large veins. Because ofits relatively fixed position in the tho- racic inlet or outlet, the axillosubclavian vein is exposed. to repeated trauma with arm movement. This repetitive ‘trauma and compression in the fixed costocavicutar space leads to intimal hyperplasia and venous sten Susceptibility and risk factors for thrombi in the lower extremities are much more thoroughly document- ced, perhaps dine to the higher incidence of this condi- tion. Individuals older than 40 years are more suscep- tible to lower-extremity thrombus, and DVT in the lower extremities occurs more commonly in women than men, The risks for DVT are not simply additive and ean more than double with the presence of 2 risk factors." Table 2 Tiss risk factors for lower-extremity DVT. ‘Nurnerous medical Conditions that affect or damage vessels may likewise contribute to the formation of DVT. ‘Varicose veins result from incompetent valves in the blood vessels that cause blood to pool, thus producing vessel enlargement in the superficial leg veins. Venous stasis, thrombophlebitis and thrombus formation can. tors are analyzed and discussed in Table 3. ise vein compression syndrome, also know as May- Thurner syndrome, Cockett syndrome or iliocaval syndrome, causes stenosis, venous stasis and collateral venous formation in the iliae vein. May:Thurner isa RADIOLOGIC TECHNOLOGY Manch/April 2007, Vol. 78/No. 4 result from this condition, Selected DVT and PE risk fac~_ DIRECTED READING coo os a ec RC biscuit oa) = Familial Heteditary Risk Factors Prior history, especialy bofore age 35, or family history of DVT. Inherited predisposition for abnormal eating “Medical Risk Factors Recont surgery/postoperative slate. Malignancy. ‘Coagulation abnormalities; innerited or acquited _Predispositon to clotting, Orthopadie procedures of joint replacements. Pregnancy or postpartum state, Varicose veins. History of inflammatory bows! disease. Having a central venous catheter. “© Other Risk Factors Immobilization (og, bed resto: long trips). Smoking. Limb trauma. 1M Decreased oxygen. |W Hormone replacement therapy or oral contraceptive “use. 1 Obesity. 1 Cramped seating in some aircraft!**" congenital anatomie variant in which the right common iliac artery overlies and compresses the upper left com- ‘mon iliac vein against the lumbosacral spine or pelvie 0. This compression and resulting stenosis can result in extensive iliofemoral DVT. Along with the physical compression of the vein, there is also chronic, repetitive trauma to the venous endothelium from adjacent arte- rial pulsation. The trauma results in an accumutation of collagen and elastin at the point of contact, referred to asa “spue" of contact.” i Clinically, patients present with left leg symptoms, Extrinsic compression ofthe left common iliac vein is considered to cause 3 to 8 times more cases of iliofemo- ral DVT on the left side than on the right.” The ili: femoral thrombus is less likey to spontaneously resolve att cEene and usually requives more invasive therapies than other clots. May-Thurner syndrome is assoctated with greater morbidity than conventional DVT, and there is up to a 73% lifetime chance of reeu* rent thrombosis with this syndrome despite standard courses of an coagulation.” Although many consid er ilae vein compression syndrome a rare finding toiay, some physicians believe improved imag. ing technologies like 5-D spiral computed tomog raphy (CT) could more frequently identify these lesions. Other recent Titerature indicates this anatomical variant might be a normal finding in as much as one third of the general population.” In July 2001, the National Aeronautics and Space Administration (NASA) Occupational Health described a unique health condition called “flightrelated deep ‘cin thrombosis” or “ecomomy class syndzome." NASA cited increasing evidence that immobilization in an air- Tine seat for long flights puts people at risk for DVT and also prevents early medical intervention. These findings place greater importance on disease prevention.’ core Pregnancy Malignancy | Central venous catheters Pathophysiology and Symptoms Decreased circulation due to iliness, injury oF inne tivity can cause blood to accumulate o: pool, which provides an ideal setting for clot formation.” Researchers agree that the pathophysiology of DVT, described by Rudolf Virchow in 1851, is significant in understanding the disease process. Virchow characterized DVT by a classic ria of conditions: endothelial injury (eg, trau- ma or surgery), stasis of blood flow (due to ienmabiliy, obesity or congestive heat failure) and hypercoagutable states (such as those caused by oral contraceptives or hormone replacement therapy).*" AA venous thrombus isa chump or clot of blood cells, platelets and fibrin that attaches to the inside wall ofa vein and can grow and break off to travel downstream, I the clot stays localized, it can cause swelling and vein 12. Chance of BVT increases with age and doubles with each decade of fe over the age of 40. Men are £0% more kaly than wornen to have another biood Clot alos having a fist DVT episode. im Pregnant women are & times mare ily than nnpregnant women to develop DVT. Risk increases in the thts triostor and immediatly aftr delivery. Cancer paints undergoing susical procedures have atleast, {nico the risk of doveloping postoperative DVT and more than 9 tes tho risk of fatal PE than patents without cancer undergoing imitar prooedures. ‘lot ragrente are found in up io 60% of patients with eg Having a central venous catheter accounts for almost 10% of DVT cases. irritation, If part of the clot breaks off, it can develop into a blockage downstream or travel to the lungs, caus- ing a PE that can result in serious ilIness or even death ‘As mentioned earlier, in some circumstances DVT also ‘an contribute to other serious medical problems such as heart attack and stroke! DVT usually originates in the deep veins of the lower legs, These veins lie near the center of the leg and are surrounded by powerful muscles that contract and force ‘deoxygenated blood back to the heart and lungs. One- ‘way valves prevent the backflow of blood between con- tractions and assist infighting gravitational pull.” Left ‘untreated, in about 20% of cases this type of DVT can spread to invole the deep veins at the knee and thigh.” ‘Venous thrombosis in the Jeg ean involve the superfi- , posteitor and lateral heads of the scalenus ‘muscle and the third rib. i anterior head of the brachial muscle and the second rib. 4. subclavius musele, the clavicle and the firstrib. PE and superior vena cava syndrome are ‘considered major complications of: a. lowerextremity DVT. Db. upper-extremity DVT. ¢.postthrombotie syndrome, 4. thoracic inlet syndrome, ‘More than people suffer from PE and of those who develop PE, up to__will die each year ‘8, 100000, 30000 b. 200.000, 100.000 e. 600000, 200 000 4. 900.000, 600.000 ‘What may be the most common preventable cause of hospital death in the United States? a. DVT b. PE economy class syndrome 4. iliceaval syndrome RADIOLOGIC TECHNOLOGY March/Aprit 2007, Vol. 78/No. 4 18 uM 6, v. Post-thromboric syndrome can manifest itself i within nonths of developing a DVT, a 2 db 8 4 45 ‘Whatis considered the gold standard examination for diagnosing DVI? a. computed tomography (CT) b. contrast venography fe. sonography 4d. magnetic resonance (MR) imaging Which of the following isa diagnostic criterion for a DVT demonstrated on ultrasound? a, easy compressibility visualization of hyperechoic material ¢. reduced visualization of echogenic material 4. altered blood flow patterns ‘Which type of venography is performed to assess valvular damage associated with postthrombotic syndrome? a. legascending b._ legedescending c. flow-directed 4. pulse-directed, Grades and are considered normal wh fying valvular incompetence. a 01 db 12 23 a 34 Continued on next page18, 19, 20, 2 28, 330 Directed Reading Con Which finaging technique is considered superior to venography for evaluating extrinsic compression ofthe iliac vein? GT venography (CTY) b. sonography ©. MR venography (MRV) 4. nuclear vascular imaging -MRY principally has been used for evaluating the a. upperextremity b, lowerextremity pelvic a calf ‘The D-dimer test measures: ‘a, fibrin degradation products. b. anticoagulants. c._thrombolytics. d._ platelets. All of the following are thrombolytics except a, Jowsmolecularveight heparins. b. streptokinase, ce alteplase tissue plasminogen activator, “Clovbusting” drugs also are called: a. warfarins, >, drombolytics. anticoagulants, , antiplatelet agents. Catheter-divected thrombolysis is designed to rapidly remove the clot and: a, preserve valve function, bb. decrease blood flow. aid in restenosis, allow Sor contrast administration, inuing Education Quiz 24, Which of the following is a category of thrombectomy recirculation devices? a. doublelumen b, intermittent infusion e.restoration 4, rotational 25, Anew pharmacomechanical thrombolysis system uses 2 oceluding balloons to: 1, provide an isolated treatment zone. prevent pieces of clot from traveling to other parts ofthe body, 3, decrease che chances of excessive bleeding. a land? b. Land3 © 2and3 a. 1,2and3 26, Stent placement can contribute to thrombus formation, a ue be false 27, An intravascular device designed to prevent pul- monary embolism isa: AL stent. », “balloon. sheath, vena cwa filter, 28, Howson should temporary vena cava filters be removed following insertion? a. 310d days b, Tio Qweeks & 8to4 months 4. Tt Qyears Continued on next page ‘March/April 2007, Vol. 78/No. 4 RADIOLOGIC TECHNOLOGY29, Patients with acute DVT should be advised not to: a, levate the affected limb, b. apply heat. c. rub the affected area, a. use intermittent pneumatic pressure stockings. 80, One suggestion for preventing economy class syndrome isto before boarding a plane. a. dink 2 t0 3 cups of coffee , havea high-protein snack : © takeashort nap 4. walk for 30 minutes RADIOLOGIC TECHNOLOGY Mench/Aprit 2007, Vol 78/No. 4 331