Pulmonary Embolism As a Consequence of Ultrasonographic Examination of Extremities for Suspected Venous Thrombosis: A Systematic Review

Abstract

Ultrasonographic examination for deep vein thrombosis (DVT) appears to be a safe diagnostic method, but a theoretical concern has been raised for dislodgment of thrombi during examination. We conducted a systematic review of the literature to identify reports of possible or confirmed pulmonary embolism (PE) as a consequence of ultrasonographic assessment of extremities in patients with suspected DVT. We searched PubMed for studies published in English from January 1, 1960, to April 10, 2015. We included all cohort studies, case series, and case reports that described PE as a consequence of ultrasonographic assessment of extremities. We excluded studies that reported assessment of areas other than extremities. We screened 3,626 articles, 15 of which reported the issue of clot dislodgement and embolization following ultrasonographic examination of the extremities, including 8 original case reports (7 men and 1 woman). DVTs were in the lower extremities in all eight cases: five in right and three in left lower extremity. In six cases, the femoral veins were involved, and a free-floating thrombus was reported in two cases. Compression ultrasonography was used in all cases, with or without adjunct techniques. Overall, there were seven confirmed and one probable PE cases, two of which had fatal outcomes. Clot embolization is a rare but potential complication of ultrasonic examination for DVT that can lead into PE. Radiologists and clinicians should be aware of this potentially serious phenomenon and avoid excessive pressure when performing ultrasonographic studies of the extremities.

Keywords

pulmonary embolism - venous thrombosis - extremities - complications - ultrasonography

• References

• 1 Beckman MG, Hooper WC, Critchley SE, Ortel TL. Venous thromboembolism: a public health concern. Am J Prev Med 2010; 38 (4, Suppl): S495-S501
• 2 Gornik HL, Sharma AM. Duplex ultrasound in the diagnosis of lower-extremity deep venous thrombosis. Circulation 2014; 129 (8) 917-921
• 3 Divittorio R, Bluth EI, Sullivan MA. Deep vein thrombosis: diagnosis of a comon clinical problem. Ochsner J 2002; 4 (1) 14-17
• 4 Rollins DL, Semrow CM, Friedell ML, Calligaro KD, Buchbinder D. Progress in the diagnosis of deep venous thrombosis: the efficacy of real-time B-mode ultrasonic imaging. J Vasc Surg 1988; 7 (5) 638-641
• 5 Needleman L. Update on the lower extremity venous ultrasonography examination. Radiol Clin North Am 2014; 52 (6) 1359-1374
• 6 Katz DS, Hon M. Current DVT imaging. Tech Vasc Interv Radiol 2004; 7 (2) 55-62
• 7 Raghavendra BN, Horii SC, Hilton S, Subramanyam BR, Rosen RJ, Lam S. Deep venous thrombosis: detection by probe compression of veins. J Ultrasound Med 1986; 5 (2) 89-95
• 8 Liberati A, Altman DG, Tetzlaff J , et al. The PRISMA statement for reporting systematic reviews and meta-analyses of studies that evaluate healthcare interventions: explanation and elaboration. BMJ 2009; 339: b2700
• 9 Wood EH, Prentice CR. Clots and calf pressure. Lancet 1970; 1 (7655) 1056
• 10 Bracey DW. Hazard of ultrasonic detection of deep vein thrombosis. BMJ 1973; 1 (5850) 420
• 11 Brown JN, Polak A. Hazard of ultrasonic detection of deep vein thrombosis. BMJ 1973; 1 (5845) 108-109
• 12 Froggatt DL, Tibbutt DA. Hazard of ultrasonic detection of deep vein thrombosis. BMJ 1973; 1 (5853) 614
• 13 Thorpe L, Hogan J, Klemp K. Can pulmonary embolism be diagnosed by duplex ultrasound? a case study. SPVN 1989; 7 (4) 10-11
• 14 Yedlicka JW, Hunter DW, Letourneau JG. Pulmonary embolism after femoral vein compression during sonography: case report. Semin Intervent Radiol 1990; 7 (1) 24-26
• 15 Ferral H, Yedlicka Jr JW, Hunter DW, Letourneau JG. Pulmonary embolism during compression US of the lower extremity. Radiology 1992; 185 (2) 614
• 16 Perlin SJ. Pulmonary embolism during compression US of the lower extremity. Radiology 1992; 184 (1) 165-166
• 17 Schroder WB, Bealer JF. Venous duplex ultrasonography causing acute pulmonary embolism: a brief report. J Vasc Surg 1992; 15 (6) 1082-1083
• 18 Feld R. Pulmonary embolism caused by venous compression ultrasound examination. J Vasc Surg 1993; 17 (2) 450
• 19 Maune J. Two case reports in the literature concerning duplex scanning and pulmonary embolism. J Vasc Nurs 1994; 12 (1) 26
• 20 Bahcivan M, Elmali M, Karamustafa H, Aslan S, Diren HB. A rare cause of pulmonary emboli in a patient with deep vein thrombosis: Doppler ultrasonographic compressibility maneuver. Cardiovasc Intervent Radiol 2007; 30 (4) 803-805
• 21 Nunn KP, Thompson PK. Towards evidence based emergency medicine: best BETs from the Manchester Royal Infirmary. Using the ultrasound compression test for deep vein thrombosis will not precipitate a thromboembolic event. Emerg Med J 2007; 24 (7) 494-495
• 22 Sufian S, Arnez A, Lakhanpal S. Case of the disappearing heat-induced thrombus causing pulmonary embolism during ultrasound evaluation. J Vasc Surg 2012; 55 (2) 529-531
• 23 Bikdeli B, Sharif-Kashani B, Chitsaz E , et al. Dexter versus sinister deep vein thrombosis: which is the more sinister? Findings from the NRITLD DVT registry. Semin Thromb Hemost 2011; 37 (3) 298-304
• 24 Horii Y, Yoshimura N, Hori Y , et al. Correlation between the site of pulmonary embolism and the extent of deep vein thrombosis: evaluation by computed tomography pulmonary angiography and computed tomography venography. Jpn J Radiol 2011; 29 (3) 171-176
• 25 Aper T, Simanowski J. Diagnostic and surgical treatment of the thrombophlebitis in the saphenofemoral junction. Ultraschall Med 2009; 30 (2) 180-184
• 26 Casian D, Gutsu E, Culiuc V. Extraluminal venous interruption for free-floating thrombus in the deep veins of lower limbs. Chirurgia (Bucur) 2010; 105 (3) 361-364
• 27 Pacouret G, Alison D, Pottier JM, Bertrand P, Charbonnier B. Free-floating thrombus and embolic risk in patients with angiographically confirmed proximal deep venous thrombosis. A prospective study. Arch Intern Med 1997; 157 (3) 305-308
• 28 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 (3) 520-527
• 29 Bertoïa A, Barrellier MT, Nguyen-Van V, Berger L, Le Hello C. [Incidence and distribution of 1026 lower limb venous thrombi diagnosed by ultrasonography in 3263 patients with cancer]. J Mal Vasc 2013; 38 (4) 243-251
• 30 Kucher N, Tapson VF, Goldhaber SZ ; DVT FREE Steering Committee. Risk factors associated with symptomatic pulmonary embolism in a large cohort of deep vein thrombosis patients. Thromb Haemost 2005; 93 (3) 494-498
• 31 Tzoran I, Saharov G, Brenner B , et al; RIETE Investigators. Silent pulmonary embolism in patients with proximal deep vein thrombosis in the lower limbs. J Thromb Haemost 2012; 10 (4) 564-571