1

[ Pulmonary and Cardiovascular How I Do It ] 56

2 57
3 58
4 59
5 60
6
7
How I Do It 61
62
8 Point-of-Care Ultrasound for Bedside Diagnosis of Lower Extremity DVT 63
9 64
10 65
Q15 Q1 Mary E. Barrosse-Antle, MD; Kamin H. Patel, RDMS, RVT; Jeffrey A. Kramer, MD; and Cameron M. Baston, MD, MSCE
11 66
12 67
13 68
The point-of-care ultrasound (POCUS) DVT examination can facilitate rapid bedside diagnosis
14 69
and treatment of lower extremity DVT. Awaiting radiology-performed Doppler ultrasonography
15 70
16 and interpretation by radiologists can lead to delays in lifesaving anticoagulation, and the
71
17 POCUS DVT examination can provide timely diagnostic information in the patient with lower 72
18 extremity symptoms. This article outlines accepted techniques for the POCUS DVT examination, 73
19 discusses the historical context from which the current recommendations have evolved, and 74
20 provides illustrations alongside ultrasound images of relevant venous anatomy to orient the 75
21 clinician. Finally, common pitfalls and methods to avoid them are described. 76
22 CHEST 2021; -(-):--- 77
23 78
24 KEY WORDS: critical care; DVT; pulmonary embolism; training (int. med.); ultrasound Q5
79
25 80
26 81
27 82
28 Case Example Background Q6
83
29 A 73-year-old woman in the ICU with Rapid diagnosis of lower extremity DVT 84
30 septic shock due to spontaneous bacterial can expedite treatment and reduce the risk 85
31 peritonitis develops left lower extremity of life-threatening complications. Although 86
32 redness, tenderness, and swelling. She has the gold standard for diagnosis of DVT 87
33 a history of cirrhosis complicated by remains contrast venography, in practice 88
34 89
portopulmonary hypertension and this invasive study has been replaced by
35 90
esophageal varices. She was admitted duplex ultrasonography from thigh to ankle
36 91
1 month ago for variceal hemorrhage. Her as the diagnostic modality of choice.1
37 92
38
lower extremity swelling is noted However, the limited availability of 93
39 overnight when there are no radiology professional ultrasonographers on nights 94
40 technologists in the hospital. How can and weekends in many clinical settings 95
41 point-of-care ultrasound (POCUS) be used places responsibility on the bedside 96
42 to facilitate diagnosis and appropriate provider to establish the diagnosis. Clinical 97
43 management of this patient, who is at decision tools, such as the Wells Criteria 98
44 high risk of decompensation from for DVT supplemented with the D-dimer 99
45 untreated VTE as well as from empiric when indicated, may risk stratify a patient’s 100
46 anticoagulation? likelihood of DVT.2 This information alone 101
47 102
48 103
49 104
50 105
51 B-mode = brightness-mode; DFA = deep femoral
ABBREVIATIONS: CORRESPONDENCE TO: Mary E. Barrosse-Antle, MD; email: Mary. Q4
106
artery; POCUS = point-of-care ultrasound; SEC = spontaneous echo [email protected]
52 contrast 107
Published by Elsevier Inc. under license from the American College of
53 Q2 Q3 AFFILIATIONS: From the Hospital of the University of Pennsylvania Chest Physicians. 108
54 (M. E. Barrosse-Antle, K. H. Patel, and C. M. Baston), Philadelphia, DOI: https://doi.org/10.1016/j.chest.2021.07.010 109
PA; and the Penn Presbyterian Medical Center (J. A. Kramer), Phila-
55 110
delphia, PA.

chestjournal.org 1

REV 5.6.0 DTD
CHEST4429_proof
25 August 2021
8:06 am
EO: CHEST-21-0921

111 may be used to start empiric anticoagulation, but General Principles 166
112 point-of-care ultrasound (POCUS) offers the ability to 167
113 Transducer Selection 168
more accurately diagnose or rule out a proximal DVT
114 The transducer of choice for the DVT scan for most 169
in symptomatic patients3 when radiology technologists
115 patients is the high-frequency linear array transducer. 170
are unavailable. In addition, the presence of DVT may
116 This transducer provides superior resolution of 171
inform the likelihood of pulmonary embolism in a
117 172
patient with pulmonary symptoms,4 and a superficial structures.12 However, in patients who are
118 173
combination of the POCUS DVT examination and obese or have severe edema, the linear array transducer
119 174
lung ultrasound has been used to enhance the may not provide sufficient depth for examination of the
120 175
121 conventional Wells score for pulmonary embolism deep veins. In these cases, the curvilinear transducer on 176
122 with improved predictive performance.5 The POCUS the vascular or high-frequency setting can be used. This 177
123 DVT examination has been validated in the ED, transducer offers increased depth of scanning at the 178
124 wards, and critical care settings,6-10 and it is now expense of lower resolution. 179
125 commonly accepted as an important diagnostic tool 180
126 Machine Settings 181
for a trained clinician.
127 The ultrasound machine should be set to the “venous” 182
128 In the current paper, we first describe when to use the mode, if available. Depth should be chosen so that the 183
129 POCUS DVT examination. We next discuss the 184
vessel is visible in the middle third of the screen. Gain
130 accepted approaches to the POCUS DVT examination, 185
should be set based on the echogenicity of blood in the
131 starting with general principles of the diagnostic scan, 186
artery, ensuring that fluid remains anechoic but
132 then compare two-point, two-zone, and whole leg 187
133
maximizing visibility of other structures. If possible, 188
DVT examinations. Finally, we review common pitfalls focal depth should be set at the level of the vessel of
134 189
to avoid when performing the POCUS DVT interest.
135 190
examination.
136 191
137 Mode of Scanning 192
138 Brightness-mode (B-mode) ultrasonography presents 193
139
Selecting the Appropriate Patient for the 194
images in gray scale, as shown in Figure 1. In B-mode,
140 POCUS DVT Examination 195
fluid (including blood) appears black, or hypoechoic,
141 Understanding the appropriate patient on whom to 196
whereas the vessel wall and surrounding tissue appear
142 perform the POCUS DVT examination is as important 197
relatively brighter, or hyperechoic. In radiology-
143 as knowing the technique of the scan. In high-resource 198
performed lower extremity vascular ultrasonography,
144 hospital settings, the POCUS DVT examination is most 199
145
B-mode compression ultrasound identifies a DVT, and 200
commonly performed when a delay in diagnosis of even color Doppler scanning mode assesses flow through the
146 201
a few hours may affect outcomes, such as at rapid vessel to determine whether the thrombus is occlusive or
147 202
responses, in the ICU, in the ED, and at night. In the nonocclusive. Although color Doppler adds information
148 203
case example given earlier, we describe a patient who has to the scan, B-mode ultrasonography is sufficient for
149 204
150
high pretest probability of DVT and in whom identification of a DVT when the occlusive nature of the 205
151 anticoagulation carries high risk. Waiting for a thrombus will not change management, and it has been 206
152 radiology-performed ultrasound would result in hours shown to have a similar sensitivity for detection of lower 207
153 of delay. In one study of the intensivist-performed extremity DVT in acute scenarios.13 However, use of 208
154 POCUS DVT examination in the ICU, a diagnosis of 209
Doppler as an advanced POCUS scanning technique can
155 DVT was obtained a median of 13.8 h earlier with 210
help in detection of more proximal venous thrombosis
156 POCUS than with the radiology-performed vascular 211
such as iliac vein thrombosis, which is of particular
157 study.11 212
158
relevance in pregnant patients14 and is discussed in 213
159 In hospitals with less access to vascular radiologists, it more detail later. 214
160 may take days to obtain a radiology-performed study. In 215
161 this setting, the majority of patients suspected of having Venous Anatomy 216
162 a lower extremity DVT may benefit from the POCUS Figure 1 shows the relevant vascular anatomy of the 217
163 DVT examination. The risk of false-negative or false- lower extremity. At the inguinal crease, the common 218
164 positive findings from a POCUS DVT examination must femoral vein runs medial to the common femoral 219
165 220
be balanced against the risk of delayed diagnosis. artery. The great saphenous vein, a superficial vein,

2 How I Do It [ -#- CHEST - 2021 ]

REV 5.6.0 DTD
CHEST4429_proof
25 August 2021
8:06 am
EO: CHEST-21-0921
221 276
222 277
223 278
224 279
225 280
226 281
227 282
228 283
229 284
230 285
231 286
232 287
233 288
234 289
235 290
236 291
237 292
238 293
239 294
240 295
print & web 4C=FPO

241 296
242 297
243 298
244 299
Figure 1 – Vascular anatomy and veins captured by the two-point and two-zone approaches on Brightness-mode ultrasound, which displays images in Q11 Q12
245 300
gray scale. The area inside the blood vessels is anechoic, or black. Surrounding soft tissue is hyperechoic, or bright. The gray bars on the depiction of the
246 leg illustrate where the transducer is positioned for the two-point point-of-care ultrasound (POCUS) DVT examination. The two-point POCUS DVT 301
247 examination only captures the common femoral artery and vein in the femoral region, and it only captures the popliteal artery and vein in the popliteal 302
fossa. In contrast, the two-zone POCUS DVT examination captures the area demarcated by the brackets. A, In the femoral region, it requires scanning
248 303
from the CFA and vein below the junction of the deep femoral vein and the femoral vein. B, In the popliteal region, the PV down to the ultimate
249 confluence of the distal calf veins is scanned. CFA ¼ common femoral artery; CFV ¼ common femoral vein; PA ¼ popliteal artery; PV ¼ popliteal vein; 304
250 TPT ¼ tibioperoneal trunk. 305
251 306
252 307
joins the common femoral vein medially. Slightly Review of Literature: Techniques for the
253 308
254
distal to this, the common femoral vein is formed by POCUS DVT Examination 309
the confluence of the deep femoral vein (also known Multiple scanning protocols have been developed, but
255 310
256
as the profunda femoral vein) and the femoral vein, we recommend a two-zone POCUS DVT examination 311
257 both of which are deep veins. The femoral vein was for diagnosis of DVT in the ICU based on sensitivity and 312
258 previously known as the superficial femoral vein, but ease of application. Figure 1 presents the relevant 313
259 its name was updated to reflect that it is clinically a vascular anatomy and areas scanned by the various 314
260 deep vein. In the popliteal fossa, the popliteal vein POCUS DVT examinations. Historically, the two-point 315
261 runs superficial to the popliteal artery. The popliteal POCUS DVT examination, which assesses only the 316
262 vein is formed by the convergence of the anterior 317
common femoral vein and popliteal vein (but not the
263 tibial vein and the tibioperoneal trunk, which 318
femoral or great saphenous veins), was considered
264 comprises the peroneal vein and the posterior tibial 319
sufficiently sensitive for detection of DVT. This was
265 320
vein. Thrombus in the common femoral vein, deep based on several studies of symptomatic outpatients that
266 321
femoral vein, femoral vein, and popliteal vein are showed essentially no cases of isolated femoral vein
267 322
considered proximal DVTs. Thrombus in the anterior DVT. The most frequently cited of these early studies is
268 323
269
tibial vein, tibioperoneal trunk, peroneal vein, and the 1993 study by Cogo et al16 of 189 outpatients who 324
270 posterior tibial vein are considered distal DVTs. were diagnosed with symptomatic proximal DVT by 325
271 Thrombus isolated to the greater saphenous vein is venogram. This study found no patients with isolated 326
272 technically considered a superficial venous thrombosis, femoral vein DVT, so all femoral vein DVTs extended to 327
273 but if the thrombus is within 3 cm of the sapheno- a venous segment captured by the two-point 328
274 femoral junction it is treated as a DVT.15 examination. Another study of outpatients showed that 329
275 330

chestjournal.org 3

REV 5.6.0 DTD
CHEST4429_proof
25 August 2021
8:06 am
EO: CHEST-21-0921

331 the two-point POCUS DVT examination had a College of Chest Physicians recommends that the test of 386
332 sensitivity of 100% for detection of proximal DVT.17 In choice be based on the pretest probability of DVT. In 387
333 388
addition, a randomized controlled trial of the two-point patients with a low pretest probability of DVT, proximal
334 389
POCUS DVT examination vs whole-leg ultrasonography vein ultrasound is recommended; in patients with
335 390
(groin to ankle) found that the two methods were moderate or high pretest probability, either proximal
336 391
equivalent for detection of DVT in symptomatic compression or whole-leg ultrasound is recommended.23
337 392
338
outpatients.18 Reflecting this finding, the American However, guidelines do not give detailed 393
339 College of Critical Care Medicine in its 2015 Guidelines recommendations regarding the optimal bedside 394
340 for the Appropriate Use of Bedside General and Cardiac procedure to be performed by nonradiologists. For 395
341 Ultrasonography in the Evaluation of Critically Ill example, the American College of Emergency Physicians 396
342 Patients recommended the two-point POCUS DVT recommends a “multilevel compression [ultrasound] on 397
343 examination, citing that DVTs are rarely found in small, proximal veins.”24 398
344 isolated vein segments.13 399
345 Performing the Two-Zone POCUS DVT Examination 400
346 Evidence, however, suggests that outpatients may have a 401
Ultrasonographic diagnosis of a venous thrombus is
347 different distribution of thrombus than ED patients, 402
made through inspection of the vein and assessment of
348 inpatients, and critically ill patients, limiting the 403
349
venous compressibility. First, the transducer is placed in 404
sensitivity of the two-point examination in these groups.
350 transverse orientation perpendicular to the skin with the 405
A 2014 study of resident-performed two-point POCUS
351 indicator to the patient’s right. The vein should be 406
DVT examinations in an ICU concluded that the two-
352 centered under the transducer in the middle of the 407
point examination has inadequate sensitivity in medical
353 screen and should be inspected for echoes that would 408
critical care patients due to a high incidence of isolated
354 suggest a thrombus. Then, using the transducer, 409
femoral vein DVTs not detected by this method.1
355 pressure is applied until the vein completely collapses. If 410
Another study in the ED revealed a significant
356 the angle of the ultrasound image is different from the 411
357
percentage of DVTs isolated to proximal veins not 412
angle of force, venous collapse may not be visible, as
358 included in the standard two-point compression 413
shown in Figure 2. In our experience, this is one of the
Q8
359 approach.19 Based on these findings, we recommend the 414
more common causes of false-positive scans by trainees.
360 two-zone POCUS DVT examination, which captures 415
To correct this, the ultrasound probe should be
361 those DVTs isolated to the femoral and deep femoral 416
362
completely perpendicular to the skin (and therefore to 417
veins. Of note, there is variability in how far the femoral
363 vein is followed in the two-zone approach. We advocate 418
364 for compressing the femoral vein to its most inferior 419
365 visible point as shown in Figure 1, which maximizes the 420
366 421
sensitivity of the study for proximal DVTs without
367 422
adding significant time.
368 423
369 The terminology of the various types of POCUS DVT 424
370 examinations can be misleading, as some practitioners 425
371 refer to the true two-zone examination as a “two-point 426
372 427
examination.” We recommend using precise language
373 Plane of image Plane of force 428
when describing the technique of the examination being
374 429
used. It is generally safest to avoid the two-point
375 430
376
examination, both as a term and as a technique. 431
print & web 4C=FPO

377 432
378 433
379
Review of Guidelines 434
380 Guidelines largely endorse extended compression 435
381 ultrasound from the common femoral vein to distal calf Figure 2 – Compression off axis. This figure shows that compression off 436
axis can lead to a false-positive point-of-care ultrasound DVT exami-
382 veins as the test of choice to diagnose lower extremity 437
nation. If force is applied straight downward, perpendicular to the skin,
383 DVT (American Society of Hematology,20 American but the ultrasound beam is directed at an oblique angle, the image seen 438
384 on ultrasound will not show the area of vein that is being compressed. 439
Institute of Ultrasound in Medicine,21 Society of Instead, the ultrasound will show vein that is not compressed, which
385 440
Radiologists in Ultrasound22). In contrast, the American may be mistaken for a DVT.

4 How I Do It [ -#- CHEST - 2021 ]

REV 5.6.0 DTD
CHEST4429_proof
25 August 2021
8:06 am
EO: CHEST-21-0921
441 the vein as well) before pressure is applied along the centimeter as the transducer slides from the level of the 496
442 plane of the probe. A second common error in technique common femoral vein to the most distal point at which 497
443 498
is to apply too much resting pressure on the ultrasound the femoral vein is visible. Compression of the deep
444 499
such that the vein collapses and is no longer visible. femoral vein more distally may require more pressure as
445 500
With sufficient ultrasound gel, the transducer can rest it travels deeper in the leg. Special attention should be
446 501
gently on the patient’s skin and provide a clear image paid to venous junctions because thrombus is more
447 502
448
without the need for pressure. likely to form at points of confluence. Figure 3 shows the 503
449 appearance of normal femoral vasculature at multiple 504
Remaining oriented to the vascular anatomy is one of levels on compression ultrasound. Video 1 includes
450 505
451
the biggest challenges of performing the POCUS DVT compression ultrasound of the femoral region. 506
452 examination. A common error in the novice scanner is 507
to start too distal on the thigh, especially in patients with To scan the popliteal region, compression is applied at
453 508
454 obesity. To visualize the common femoral artery and 1-cm intervals starting at the level of the popliteal vein 509
455 vein, the transducer should be positioned at the inguinal and artery in the popliteal fossa to below the junction of 510
456 crease, just distal to the inguinal ligament and proximal the popliteal vein with the anterior tibial vein and the 511
457 to the junction of the greater saphenous vein with the tibioperoneal trunk and subsequent formation of the 512
458 common femoral vein. The bifurcation of the common tibioperoneal trunk from the peroneal and the posterior 513
459 tibial veins. Shown in Figure 4 is the appearance of 514
femoral artery into the deep femoral artery and
460 normal popliteal vasculature with and without 515
superficial femoral artery should occur slightly more
461 compression. Video 1 includes compression ultrasound 516
proximally than the junction of the lateral perforator
462 of the popliteal region. 517
with the common femoral vein, which is followed by the
463 518
464
formation of the common femoral vein from the femoral To rule out DVT at the site of inspection, a vein should 519
465 vein and the deep femoral vein. Starting at Point A in compress easily, and the walls of the vein should touch 520
466 Figure 3, compression is applied approximately every when compressed. However, in patients with increased 521
467 522
468 523
Anterior Representation Axial Representation View on Ultrasound
469 524
Without Compression With Compression Without Compression With Compression
470 525
471
A 526
472 CFA CFA 527
473 528
CFV
474 529
475 Collapsed CFV 530
476 531
B
477 532
A
478 SFA SFA 533
GSV
479 B DFA DFA 534
CFV
480 C 535
481 Collapsed CFV + GSV 536
482 537
C
483 538
484 SFA SFA 539
485 540
print & web 4C=FPO

FV
486 DFA DFV DFA 541
487 Collapsed DFV + FV 542
488 543
489 Figure 3 – Normal femoral vasculature on ultrasound. This figure shows the vascular anatomy at three major junctions in the femoral region with 544
490 and without compression. With the ultrasound placed at point “A” on the interior view, the CFV can be appreciated medial and slightly deep to the 545
491 CFA in cross-section. With compression, the CFA distorts slightly, and the CFV completely collapses. With the ultrasound at point “B” at the level of 546
the junction of the GSV with the CFV, the SFA and DFA are also joining anterior and lateral to the veins. With compression, the DFA and SFA
492 547
remain patent, and the CFV and GSV collapse completely until the walls of the vein are touching. Finally, with the ultrasound on point “C” on the Q13
493 anterior view, the DFV and the FV are starting to join. Once again, with compression, the DFV and the FV collapse completely to indicate absence of Q16 548
494 thrombus. CFA ¼ common femoral artery; CFV ¼ common femoral vein; DFA ¼ deep femoral artery; DFV ¼ deep femoral vein; FV ¼ femoral 549
vein; GSV ¼ great saphenous vein; PA ¼ popliteal artery; PV ¼ popliteal vein; SFA ¼ superficial femoral artery; TPT ¼ tibioperoneal trunk.
495 550

chestjournal.org 5

REV 5.6.0 DTD
CHEST4429_proof
25 August 2021
8:06 am
EO: CHEST-21-0921

551 Posterior Representation Axial Representation View on Ultrasound 606
552 Without Compression With Compression Without Compression With Compression 607
553 A 608
554 609
555
Collapsed PV 610
556 PV 611
557 612
558 613
559 PA PA 614
560 615
561 616
562 B 617
563 Collapsed 618
564 PeV + PTV + AT 619
565 PeV PTV 620
566 AT 621
567 622
print & web 4C=FPO

568 PA PA 623
569 624
570 625
571 626
572 Figure 4 – Normal popliteal vasculature on ultrasound. This figure shows the vascular anatomy at two major junctions in the popliteal region with 627
and without compression. With the ultrasound at level “A,” the PV is superficial (and, in this patient, somewhat lateral) to the PA. The anchoring
573 628
anatomy of the tibial plateau is clearly visible. With compression, the PV completely collapses. With the ultrasound positioned at level “B,” the three
574 major calf vessels are joining to create the PV: the PeV, the PTV, and the AT. All three collapse completely with compression. AT ¼ anterior tibial 629
575 vein; PA ¼ popliteal artery; PeV ¼ peroneal vein; PTV ¼ posterior tibial vein; PV ¼ popliteal vein; TPT ¼ tibioperoneal trunk. 630
576 631
577 632
578 popliteal vein. In these cases, having the patient swing 633
579 central venous pressure, the deep veins may be more 634
their leg over the side of the bed will further engorge the
580 difficult to compress. Insufficient pressure is a common 635
popliteal vein to improve visualization. In patients in the
581 cause of false-positive studies. Pressure should be 636
prone position for treatment of ARDS, the popliteal
582 applied until either the vein completely collapses or the 637
region can be scanned, but the femoral region is not
583 adjacent artery deforms to rule out DVT. 638
584
easily accessible. 639
585 Patient positioning can impede or facilitate a successful 640
Advanced techniques in the POCUS DVT examination
586 scan. Placing the patient in a slight amount of reverse 641
can include the use of pulsed-wave or spectral
587 Trendelenburg makes the veins easier to visualize, but it 642
Doppler to assess for augmentation and phasicity. In
588 may take more pressure to compress the vein due to 643
these techniques, the specific patterns of flow with
589 increased venous pressure. In the supine patient, we 644
distal compression of the leg and with respiration,
590 place the patient in the “frog leg” position, with the hip 645
591 respectively, are used to identify patterns that suggest 646
rotated externally and the knee bent at slightly less than
592 proximal thrombus. The specifics of these techniques 647
90 degrees. From this position, the femoral and popliteal
593 are beyond the scope of a typical POCUS 648
vasculature is easily accessed. Because extending the leg
594 examination, but they may be considered in patients 649
fully at the knee reduces the diameter of the popliteal
595 with elevated risk of iliac DVT. 650
vein, we recommend that there always be a slight bend at
596 651
597
the knee when scanning the popliteal region. Other Special note should be made of the approach with 652
598 options for scanning the popliteal region are to place the pregnant patients, who are at increased risk of DVT, 653
599 patient in the lateral decubitus position or in the prone especially proximal DVT.25 The POCUS DVT 654
600 position. In the prone position, a roll of towels should be examination has been shown to be a safe and effective 655
601 placed under the ankle to create a bend at the knee. strategy in pregnant patients,26 but practitioners should 656
602 When compressing the popliteal region, we recommend have a particularly high index of suspicion for pelvic 657
603 using the nonscanning hand to provide counter-pressure DVT (in particular, DVT in the common iliac vein, 658
604 on the anterior knee. In patients with obesity or external iliac vein, or internal iliac vein). Clues to the 659
605 660
lymphedema, it may be very difficult to visualize the presence of pelvic DVT that can be seen in the leg veins

6 How I Do It [ -#- CHEST - 2021 ]

REV 5.6.0 DTD
CHEST4429_proof
25 August 2021
8:06 am
EO: CHEST-21-0921
661 by an advanced clinician include the Doppler techniques 716
662 described earlier and increased venous diameter in one 717
663 718
leg relative to the other.15 Whenever there is doubt, a
664 719
radiology-performed diagnostic study should be
665 720
requested.
666 721
667 722
668
Thrombus on Ultrasound 723
669 The defining feature of a venous thrombus on 724
670 ultrasound is venous noncompressibility. Acute DVT 725
671 may be completely anechoic on ultrasound or may 726
672 727
contain echoes.27 If echogenic material is visualized in
673 728
the vein, then an acute thrombus may be present, and it
674 729
should not be vigorously compressed due to the
675 730
theoretical risk of causing embolization, although this
676 731
has not been shown in the literature.28 Acute DVT may

print & web 4C=FPO

677 732
678 also cause associated dilation of the vein. Figure 5 shows 733
679 a common femoral vein DVT. Video 1 depicts DVTs at 734
680 the femoral and popliteal levels. 735
681
Figure 6 – Nerve. Shown in the red circle is a nerve, which is a 736
hyperechoic, cylindrical structure that may be confused with a DVT.
682 However, a nerve will not be compressible at any point, and vascular 737
683 Common Pitfalls anatomy should be identifiable nearby. 738
684 739
We have discussed several common mistakes in
685 740
technique when performing the POCUS DVT scan; the Nerves and Lymph Nodes
686 741
following sections address structures that may cause Nerves and lymph nodes are two structures that may
687 742
confusion when visualized on ultrasound. Whenever resemble a DVT on ultrasound. As seen in Figure 6 and
688 743
689
there is confusion when scanning the leg in the short Video 2, nerves are cylindrical, hyperechoic structures 744
690 axis, we recommend rotating the transducer to capture that have an appearance of honeycombing throughout 745
691 the image in the long axis. This approach often provides their length. They often travel alongside the vascular 746
692 a better understanding of the structure of interest. bundle. However, in contrast to veins, they are not 747
693 748
694 749
695 750
696 751
697 752
698 753
699 754
700 755
701 756
702 757
703 758
704 759
705 760
706 761
707 762
708 763
print & web 4C=FPO

print & web 4C=FPO

709 764
710 765
711 766
712 767
713 Figure 5 – Common femoral vein DVT. This is an image of a common Figure 7 – Lymph node. This figure shows a lymph node, which is a 768
714 femoral vein DVT in the right leg. An isoechoic thrombus is present at hyperechoic structure that may be confused with a DVT. However, 769
the junction of the greater saphenous vein with the common femoral unlike a thrombus, the lymph node is a discrete, elliptical structure in-
715 770
vein, circled in red. dependent of blood vessels.

chestjournal.org 7

REV 5.6.0 DTD
CHEST4429_proof
25 August 2021
8:06 am
EO: CHEST-21-0921

771 826
772 827
773 828
774 829
775 830
776 831
777 832
778 833
779 834
780 835
781 836
782 837
783 838
784 839
785 840
786 841
787 842
788 843
789 Figure 8 – A-B, Popliteal cyst. A, The hypoechoic pocket of fluid that comprises a popliteal cyst. B, The narrow neck of fluid that connects the larger 844
790 pocket to the joint space. 845
791 846
792 847
anechoic or compressible at any point. They will also translate and see a discrete beginning and end of the
793 848
794
exhibit anisotropy, which is a change in echogenicity lymph node, whereas a vein is a continuous structure. 849
795 with change in the angle of insonation. 850
796 Popliteal Cyst 851
As seen in Figure 7 and Video 3, lymph nodes are
797 A popliteal cyst, or a Baker’s cyst, is a fluid-filled 852
discrete, elliptical, noncompressible structures that are
798 outpouching of the gastrocnemius-semimembranosus 853
often echogenic and can be found in the femoral and
799 854
popliteal regions. However, it is possible to fan or membrane. In adults, it is often related to degenerative
800 855
801 856
802 857
803 858
804 859
805 860
806 861
807 862
808 863
809 864
810 865
811 866
812 867
813 868
814 869
815 870
816 871
817 872
818 873
print & web 4C=FPO

819 874
820 875
821 876
822 877
823 Figure 9 – A-B, Superficial and deep veins. A, There is a superficial vein (circled in red) in the popliteal region that appears very prominent. However, it 878
824 is not running with an artery, and the tibial plateau is not visible. B, If the depth is increased, the anchoring anatomy of the tibial plateau is now visible, 879
and the true PA and PV can now be appreciated running side by side. The original superficial artery is now visible at the top of the screen, again circled
825 880
in red. PA ¼ popliteal artery; PV ¼ popliteal vein.

8 How I Do It [ -#- CHEST - 2021 ]

REV 5.6.0 DTD
CHEST4429_proof
25 August 2021
8:06 am
EO: CHEST-21-0921
881 RBCs or other cellular components. A blood vessel that 936
882 contains only SEC without DVT should be fully 937
883 938
compressible. An example of SEC is shown in Figure 10
884 939
and Video 6.
885 940
886 941
887 Training and Competency 942
888 The POCUS DVT examination is easy to learn and 943
889 perform. Studies have shown that, with as few as 2 h of 944
890 945
supervised, hands-on experience, a trainee can acquire
891 946
the skill to generate images of acceptable quality.29,30
892 947
Along these lines, the American College of Emergency
893 948
894
Physicians stipulates that 25 to 50 quality-reviewed 949
895 scans be performed in a modality to be considered 950
896 proficient in that scan.24 The certificate of completion 951
897 offered by the Society of Hospital Medicine and the 952
898 American College of Chest Physicians requires five DVT 953
899 studies.31 Competency thresholds for trainees have not 954
900 been well defined in the literature. Although the 955
901 Emergency Medicine Accreditation Council for 956
902 Graduate Medical Education requires a total of 150 957
903 958
bedside ultrasound examinations be performed prior to
904 959
graduation from residency, it does not specify how many
905 960
should be DVT studies.32 Similarly, specific benchmarks
906 961
907
have not been established in internal medicine or critical 962
908 care training programs. With the advent of increased 963
909 Figure 10 – Spontaneous echo contrast. Spontaneous echo contrast in levels of professionalization and board certification in 964
910 the lumen of the common femoral vein. A vein containing spontaneous critical care echocardiography, however, this is likely to 965
echo contrast will be compressible.
911 be an area of development in the future.33 966
912 967
913 joint disease and tends to communicate with the knee 968
Archiving and Reporting POCUS DVT Studies
914 joint space. A popliteal cyst may cause pain and 969
915 One of the most important aspects of performing the 970
erythema similar to a DVT. On ultrasound, a popliteal
916 POCUS DVT examination is maintaining an accurate 971
cyst is a well-defined, anechoic pocket of fluid that may
917 and accessible record for the reference of other 972
have a narrow neck connecting it to the joint space (Fig
918 providers. At our institution, there is currently a digital 973
8, Video 4).
919 archive in which POCUS studies are archived that links 974
920 to the patients’ electronic chart and can be viewed by 975
Superficial Veins
921 any practitioner with access to the chart. A note is also 976
922 In obese patients, the deep veins may be deeper than 977
entered into the chart documenting the findings of the
923 expected. As such, superficial veins may be confused for 978
examination. The American Institute of Ultrasound in
924 deep veins. One rule of thumb is that a deep vein is 979
Medicine has published practice parameters with
925 always associated with an artery, whereas a superficial 980
recommendations for documentation and quality
926 981
vein is not. Figure 9 (and Video 5) illustrates the assurance in the performance of the POCUS DVT
927 982
importance of knowing the vascular anatomy and using examination.34 If a direct connection to the patient’s
928 983
anchoring structures to identify the correct deep veins. chart is not possible, still images can be printed and
929 984
930 attached to the interpretation as described in that 985
931
Spontaneous Echo Contrast document, or a secure file drive can be used to digitally 986
932 Spontaneous echo contrast (SEC), also known as smoke, archive images from the ultrasound machine. 987
933 is a hyperechoic material that is detected by many Maintaining the security of patient information must be 988
934 modern ultrasound machines but is not believed to be assured at all times when handling personal health 989
935 990
pathogenic. SEC is caused by rouleaux formation of information.

chestjournal.org 9

REV 5.6.0 DTD
CHEST4429_proof
25 August 2021
8:06 am
EO: CHEST-21-0921

991 In addition to appropriately archiving studies for clinical 4. Kearon C. Natural history of venous thromboembolism. Circulation. 1046
992 2003;107(23 suppl 1):I22-I30. 1047
reference, practitioners of POCUS should familiarize
993 5. Nazerian P, Volpicelli G, Gigli C, et al. Diagnostic performance of 1048
themselves with the documentation needed to be Wells score combined with point-of-care lung and venous
994 1049
reimbursed for their services.35,36 Documentation ultrasound in suspected pulmonary embolism. Acad Emerg Med.
995 2017;24(3):270-280. 1050
should include study indications, images from the study,
996 6. Mayo PH, Beaulieu Y, Doelken P, et al. American College of Chest 1051
and interpretation of the images. There are specific Physicians/La Société de Réanimation de Langue Française
997 1052
Current Procedural Terminology codes for POCUS statement on competence in critical care ultrasonography. Chest.
998 2009;135(4):1050-1060. 1053
999 scans that can be used for reimbursement. 7. Burnside PR, Brown MD, Kline JA. Systematic review of emergency 1054
1000 physician-performed ultrasonography for lower-extremity deep vein 1055
thrombosis. Acad Emerg Med. 2008;15(6):493-498.
1001 Conclusions 1056
8. Roberts L, Rozen T, Murphy D, et al. A preliminary study of
1002 Competency in performing the POCUS DVT intensivist-performed DVT ultrasound screening in trauma ICU 1057
1003 examination is attainable with an understanding of the patients (APSIT Study). Ann Intensive Care. 2020;10(1):122. 1058
1004 9. Fischer EA, Kinnear B, Sall D, et al. Hospitalist-Operated 1059
vascular anatomy and practice. The two-zone POCUS Compression Ultrasonography: a Point-of-Care Ultrasound Study
1005 1060
DVT examination has a high sensitivity and specificity (HOCUS-POCUS). J Gen Intern Med. 2019;34(10):2062-2067.
1006 1061
for proximal lower extremity DVTs, and it is the 10. Pomero F, Dentali F, Borretta V, et al. Accuracy of emergency
1007 physician-performed ultrasonography in the diagnosis of deep-vein 1062
scanning technique we use most commonly in the ICU. thrombosis: a systematic review and meta-analysis. Thromb
1008 1063
1009
If clinical suspicion is high, however, most societies Haemost. 2013;109(1):137-145.
1064
recommend extending the zone of compression as far as 11. Kory PD, Pellecchia CM, Shiloh AL, Mayo PH, DiBello C, Koenig S.
1010 Accuracy of ultrasonography performed by critical care physicians 1065
1011 the vessels can be visualized. Although POCUS in the for the diagnosis of DVT. Chest. 2011;139(3):538-542. 1066
1012 hands of skilled practitioners can lead to early diagnosis 12. Szabo TL, Lewin PA. Ultrasound transducer selection in clinical 1067
1013 and appropriate treatment of VTE, decisions regarding imaging practice. J Ultrasound Med. 2013;32(4):573-582. 1068
1014 initiation of treatment should be undertaken only with 13. Frankel HL, Kirkpatrick AW, Elbarbary M, et al. Guidelines for the 1069
appropriate use of bedside general and cardiac ultrasonography in
1015 the support of providers experienced in POCUS. We the evaluation of critically ill patients-part I: general 1070
1016 recommend consideration of a follow-up study by ultrasonography. Crit Care Med. 2015;43(11):2479-2502. 1071
1017 14. Avula R, Niemann M, Dorinzi N, Robinson K, Sharon M, Minardi J. 1072
radiology based on the guidelines described here. Occult iliac deep vein thrombosis in second trimester pregnancy:
1018 1073
Specific recommendations for training and certification clues on bedside ultrasound. Clin Pract Cases Emerg Med. 2017;1(3):
1019 183-186. 1074
are still pending.
1020 15. Tait C, Baglin T, Watson H, et al. Guidelines on the investigation 1075
1021 and management of venous thrombosis at unusual sites. Br J 1076
1022
Case Follow-Up Haematol. 2012;159(1):28-38.
1077
16. Cogo A, Lensing AW, Prandoni P, Hirsh J. Distribution of
1023 The patient was found to have a noncompressible left thrombosis in patients with symptomatic deep vein thrombosis. 1078
1024 common femoral vein on a two-zone POCUS DVT Implications for simplifying the diagnostic process with compression 1079
ultrasound. Arch Intern Med. 1993;153(24):2777-2780.
1025 examination and was started on a therapeutic heparin 1080
1026 17. Lensing AW, Prandoni P, Brandjes D, et al. Detection of deep-vein 1081
drip for DVT. She did not develop a pulmonary thrombosis by real-time B-mode ultrasonography. N Engl J Med.
1027 embolus, and she had slow improvement in her lower 1989;320(6):342-345. 1082
1028 18. Bernardi E, Camporese G, Büller HR, et al. Serial 2-point 1083
extremity redness and edema.
1029 ultrasonography plus D-dimer vs whole-leg color-coded Doppler 1084
ultrasonography for diagnosing suspected symptomatic deep vein
1030 1085
Acknowledgments thrombosis: a randomized controlled trial. JAMA. 2008;300(14):
1031
Q9 1653-1659. 1086
Financial/nonfinancial disclosures: The authors have reported to
1032
Q14 CHEST the following: C. M. B. receives royalties on a POCUS textbook 19. Adhikari S, Zeger W, Thom C, Fields JM. Isolated deep venous 1087
1033 from McGraw Hill. None declared (M. E. B.-A., K. H. P., J. A. K.). thrombosis: implications for 2-point compression ultrasonography 1088
of the lower extremity. Ann Emerg Med. 2015;66(3):262-266.
1034 Additional information: The Videos can be found in the Multimedia 1089
20. Lim W, Le Gal G, Bates SM, et al. American Society of Hematology
1035 section of the online article. 2018 guidelines for management of venous thromboembolism: 1090
1036 diagnosis of venous thromboembolism. Blood Adv. 2018;2(22):3226- 1091
Q10
1037
References 3256.
1092
1. Caronia J, Sarzynski A, Tofighi B, et al. Resident performed two- 21. AIUM Practice Parameter for the Performance of a Peripheral
1038 Venous Ultrasound Examination. J Ultrasound Med. 2020;39(5): 1093
point compression ultrasound is inadequate for diagnosis of deep
1039 vein thrombosis in the critically III. J Thromb Thrombolysis. E49-E56. 1094
1040 2014;37(3):298-302. 22. Needleman L, Cronan JJ, Lilly MP, et al. Ultrasound for lower 1095
1041 2. Wells PS, Anderson DR, Rodger M, et al. Evaluation of D-dimer in extremity deep venous thrombosis: multidisciplinary 1096
the diagnosis of suspected deep-vein thrombosis. N Engl J Med. recommendations from the Society of Radiologists in ultrasound
1042 2003;349(13):1227-1235. consensus conference. Circulation. 2018;137(14):1505-1515. 1097
1043 3. Sud S, Mittmann N, Cook DJ, et al. Screening and prevention of 23. Bates SM, Jaeschke R, Stevens SM, et al. Diagnosis of DVT: 1098
1044 venous thromboembolism in critically ill patients: a decision analysis antithrombotic therapy and prevention of thrombosis, 9th ed: 1099
and economic evaluation. Am J Respir Crit Care Med. 2011;184(11): American College of Chest Physicians Evidence-Based Clinical
1045 1100
1289-1298. Practice Guidelines. Chest. 2012;141(suppl 2):e351S-e418S.

10 How I Do It [ -#- CHEST - 2021 ]

REV 5.6.0 DTD
CHEST4429_proof
25 August 2021
8:06 am
EO: CHEST-21-0921
1101 24. Ultrasound guidelines: emergency, point-of-care and clinical accurately detect deep venous thrombosis in the emergency 1156
1102 ultrasound guidelines in medicine. Ann Emerg Med. 2017;69(5):e27- department. Ann Emerg Med. 2010;56(6):601-610. 1157
e54.
1103 31. American College of Chest Physicians. Point-of-care ultrasound 1158
25. Chan WS, Ginsberg JS. Diagnosis of deep vein thrombosis and certificate of completion. https://www.chestnet.org/Education/
1104 pulmonary embolism in pregnancy. Thromb Res. 2002;107(3-4):85- Advanced-Clinical-Training/Certificate-of-Completion-Program/ 1159
1105 91. SHM-COC. Accessed March 8, 2021. 1160
1106 26. Chan WS, Spencer FA, Lee AY, et al. Safety of withholding 32. American Council for Graduate Medical Education. Emergency 1161
anticoagulation in pregnant women with suspected deep vein Medicine Defined Key Index Procedure Minimums Review
1107 thrombosis following negative serial compression ultrasound and 1162
Committee for Emergency Medicine. In: https://www.acgme.org/
1108 iliac vein imaging. CMAJ. 2013;185(4):E194-E200. Portals/0/PFAssets/ProgramResources/Emergency_Medical_Services_ 1163
1109 27. Tapson VF, Carroll BA, Davidson BL, et al. The diagnostic approach Defined_Key_Index_Procedure_Minimums.pdf?ver¼2020-01-16-11 1164
to acute venous thromboembolism. Clinical practice guideline. 0823-213. Accessed January 9, 2021.
1110 1165
American Thoracic Society. Am J Respir Crit Care Med. 1999;160(3): 33. Brown SM, Sekiguchi H, Pinsky MR. A new era in critical care
1111 1043-1066. 1166
ultrasound: professionalization. Ann Am Thorac Soc. 2017;14(12):
1112 28. Nunn KP, Thompson PK. Towards evidence based emergency 1747-1749. 1167
1113 medicine: best BETs from the Manchester Royal Infirmary. Using
34. AIUM Practice Parameter for the Performance of Point-of-Care 1168
the ultrasound compression test for deep vein thrombosis will not
1114 precipitate a thromboembolic event. Emerg Med J. 2007;24(7):494-
Ultrasound Examinations. J Ultrasound Med. 2019;38(4):833- 1169
849.
1115 495. 1170
35. Grider D. Ultrasonography in Critical Care. Society of Critical Care
1116 29. Farahmand S, Farnia M, Shahriaran S, Khashayar P. The accuracy of 1171
limited B-mode compression technique in diagnosing deep venous Medicine: Critical Connections. https://www.sccm.org/
1117 Communications/Critical-Connections/Archives/2018/ 1172
thrombosis in lower extremities. Am J Emerg Med. 2011;29(6):687-
1118 690. Ultrasonography-in-Critical-Care. Accessed June 30, 2021. 1173
1119 30. Crisp JG, Lovato LM, Jang TB. Compression ultrasonography of the 36. Koenig SJ, Lou BX, Moskowitz Y, Narasimhan M, Mayo PH. 1174
lower extremity with portable vascular ultrasonography can Ultrasound billing for intensivists. Chest. 2019;156(4):792-801.
1120 1175
1121 1176
1122 1177
1123 1178
1124 1179
1125 1180
1126 1181
1127 1182
1128 1183
1129 1184
1130 1185
1131 1186
1132 1187
1133 1188
1134 1189
1135 1190
1136 1191
1137 1192
1138 1193
1139 1194
1140 1195
1141 1196
1142 1197
1143 1198
1144 1199
1145 1200
1146 1201
1147 1202
1148 1203
1149 1204
1150 1205
1151 1206
1152 1207
1153 1208
1154 1209
1155 1210

chestjournal.org 11

REV 5.6.0 DTD
CHEST4429_proof
25 August 2021
8:06 am
EO: CHEST-21-0921