2. INTRODUCCIÓN
60% de TVP no tratadas progresan a TEP
Dx de TVP en ptes con TEP agudo 20-50%
EF no es suficiente para el dx de TVP
30% de los pacientes enviados a urgencias para
evaluación de TVP tienen el diagnostico
Cook. Et al. Diagnostic Ultrasonography for peripheral vascular emergencies. Crit Care Clin. 2014
3. INTRODUCCIÓN
Cook. Et al. Diagnostic Ultrasonography for peripheral vascular emergencies. Crit Care Clin. 2014
• Solo 8% TVP ocurren en las extremidades superiores.
• Las venas de mayor riesgo para causar TEP son la femoral
común, superficial y poplítea.
• Puede haber duplicación de la vena poplítea y safena 25%.
• 20% de TVP distales se propagan a las venas proximales
durante la 1ª semana.
4. PROBABILIDAD PRE
TEST
Wells PS. Et al. Value of assessment of pretest probability of
deep vein thrombosis in clinical management. Lancet 1997
Característica Clínica Puntaje
Cáncer activo / tto hasta hace 6 meses 1
Parálisis, paresia, inmovilización reciente con
yeso en extremidad inferior
1
Postración en cama reciente por mas de 3 días
o cirugía mayor en las ultimas 4 semanas
1
Molestias a lo largo del trayecto del sistema
venoso profundo
1
Edema de toda lla pierna 1
Aumento del perímetro de la pantorrilla de mas
de 3 cm respecto a la pierna contralateral
1
Edema con fóvea mayor en la pierna
sintomática
1
Venas colaterales superficiales (no varicosas) 1
Otro dx alternativo tanto o mas probable que la
TVP
-2
Probabilidad
pre test para
TVP
Puntaje Riesgo TVP
(%)
Baja < 0 3-13%
Moderada 1-2 17 -38%
Alta > 2 60-75%
5. PACIENTE CRITICO
8-18%
20-25% Autopsias
23% en ptes vmi y profilaxis
• Inmovilización
• Qx mayor
• Malignidad
• Estados Pro inflamatorios
• Hiper-cogulabilidad
• Catéteres
No expresan sx
Edemas distales
Ibrahim et al. Crit care Med. 2002
14. ¿AHORRA TIEMPO?
Am J Emerg Med 2004
Estudio observacional prospectivo
EM vs Radiólogos
Ptes con sospecha tvp 156 (34 pacientes 22% tenían tvp)
Desde el triage al 2 CUS de EM ----95 min
Triage hasta radiología---------------- 220 min
Diferencia de 125 min (94 a 134 min) p <0.001
Concordancia entre EM y radiólogos Kappa de 0.9
15. ¿AHORRA TIEMPO?
Estudio observacional prospectivo
EM 2 CUS vs Esp Vascular CCUS
Ptes con sospecha tvp 112 (34 pacientes tenían tvp)
Tiempo medio del examen 3 min 28 seg
Kappa de 0.9
Academic Emergency Medicine 2000
16. US VS VENOGRAFIA
BMC Medical Imaging 2005
99 Estudios incluidos
US vs venografia en pacientes con sospecha de TVP
Compraron S y E
- TVP proximal y distal
- Uso de dupplex US
- Triplex US
- Compresión US
17. S= 90.35 General
S: 93.8% Proximal
S= 56.8% Distal
E: 97.8%
S= 94.2% Proximal
S= 63.8% Distal
E: 93.8%
CUS es
equiparable al
duplex o
triplex para
TVP proximal
22. 2-CUS Y RESIDENTES
The Journal of Emergency Medicine, Vol. 32, No. 2, pp. 197–200, 2007
S: 89%
E: 97%
90 min entrenamiento
R2 vs vascular
23. Emerg Med. 2016;17(2):201–208.
2 CUS por residentes
Gold standard: radiólogos CCUS
288 pacientes
Tiempo: 4 min
Errores:
• Confundir nódulos linfáticos con V. Femoral común
• No identificación adecuada de la V poplítea
• No compresión adecuada
24. S: 57.1%
E: 96.1%
VPP: 61.5%
VPN: 95.4%
2 Casos el trombo
no fue identificado
porque estaba en
la Safena
Error más frecuente:
identificación poplítea
26. Bernardi et al. JAMA 2008
Pacientes con Sospecha de tvp
Sin: anticoagulación o historia de TVP
Seguimiento 3 meses
Aleatorización en 2 grupos: 2 CUS o Estrategia de toda la pierna
US al inicio normal se tomaba un dimero d.
Si el dimero D era normal y US negativo: No anticoagulación
Si dimero D anormal y US negativa, se programaban para una segunda US en 7 días , segunda US normal : no
anticogulacion
Estrategia de 2 puntos: V. femoral común y poplítea: compresión (único criterio dx)
Toda la pierna: CCUS, podría usarse Doppler color o flujo si había dudas.
33. TECNICA
• Trendelemburg reverso
• Rotación externa de la
cadera y flexión de la rodilla
30 grados
Cook. Et al. Diagnostic Ultrasonography for peripheral vascular emergencies. Crit Care Clin. 2014
Up to 60% of untreated DVTs progress to PE, which results in over 50,000 deaths each year
Physical examination findings alone are not accurate in the diagnosis of DVT [5]. US traditionally is the diagnostic method of choice, but US performed by the radiologist or US technologist is not always available to the emergency physician (EP). The overall time to perform a complete US by an on-call technologist can be hours when travel time, transport, and interpretation are included. Further, when on-call services are not available, patients needlessly might be admitted and possibly anticoagulated. Even with the advent of low-molecular-weight heparin, this process is costly, potentially risky, and cumbersome.
Only 30% of patients sent to the ED to be evaluated for DVT have that diagnosis [6–8]. Because most PE deaths occur within the first 1 to 24 hours, rapid, accurate diagnosis in the ED is critical [7,9]. Because the evaluation of lower extremity DVT in the symptomatic outpatient incorporates more than just a US, a discussion of the different diagnostic modalities follows. The authors pay particular attention to the combined use of pretest probability (how likely the patient is to have a DVT), D-dimer testing, and ED US.
Up to 60% of untreated DVTs progress to PE, which results in over 50,000 deaths each year
Physical examination findings alone are not accurate in the diagnosis of DVT [5]. US traditionally is the diagnostic method of choice, but US performed by the radiologist or US technologist is not always available to the emergency physician (EP). The overall time to perform a complete US by an on-call technologist can be hours when travel time, transport, and interpretation are included. Further, when on-call services are not available, patients needlessly might be admitted and possibly anticoagulated. Even with the advent of low-molecular-weight heparin, this process is costly, potentially risky, and cumbersome.
Only 30% of patients sent to the ED to be evaluated for DVT have that diagnosis [6–8]. Because most PE deaths occur within the first 1 to 24 hours, rapid, accurate diagnosis in the ED is critical [7,9]. Because the evaluation of lower extremity DVT in the symptomatic outpatient incorporates more than just a US, a discussion of the different diagnostic modalities follows. The authors pay particular attention to the combined use of pretest probability (how likely the patient is to have a DVT), D-dimer testing, and ED US.
Neoplasia activa:
Parálisis, paresia o reciente inmovilización con yeso de Extremidad Inferior
:Estancia en cama reciente por más de 3 días reciente o cirugía mayor en las últimas 4 semanas:Molestias a lo largo del trayecto del sistema venoso profundo:Edema de toda la pierna:Aumento del perímetro de la pantorrilla de más de 3 cm respecto a la pierna contralateral:Edema con fóvea mayor en la pierna sintomática:Venas colaterales superficiales (no varicosas):Otro diagnóstico alternativo tanto o más probable que la TVP:
Las venas de mayor riesgo para causar embolismo pulmonar son la femoral común, superficial y poplítea.
La poplítea esta formada por la vena tibial anterior, posterior y peroneal
Pasa por el canal aductory se vuele la vena safena . Se une la la femor profundapara formal la vena femoral común
La vena femorl profunda no es considerada fuente de embolismo pulmonar y por eso no se incluye en la evaluación.
La vena femoral común y la safena están medial a la arteria femoral, por los primeros 5 cm distales al ligamento inguinal, luego pasan por la parte posterior de la arteia cuando entran en el canal aductor.
Para diferenciar la vena de la arteria se utiliza la comresion
Es la tecnica mas comun
Como las venas son complacientes, una ligera presion puede comprimirlas
El doppler color
Ayuda a determinar si una estructura es o no vascular
La direccion del flujo
Y la presencia de pulsacion arterial
Doppler pulsado:
El flujo arterial es pulsatil, el venoso continuo
Aumento distal: sirve para identificar la vena y el sitio de obstruccion.
Se utuliza el doppler
Se realiza compresion en la parte distal del vaso y el transductor se ubica donde se requiera visualizar el vaso
La compresio distal resultara en un aumento del flujo en el sitio donde esta el tansductor.
La presencia de material hipoecoico intraluminal con ausencia de flujo al examen doppler color y de potencia (A y B) que impiden el colapso venoso con la presión del traductor (C y D) sumado a la ausencia de señal al examen espectral (E) son signos evidentes de TVP aguda
Trombo
-Agudo:Hipoecogénico
-Crónico: Mayor ecogenicidad
Homogenicidad del trombo Agudo: Homogéneo Crónico: heterogéneo
3. Alteración del calibre de la vena
Agudo: Aumento del calibre Crónico: Reducción de calibre
4. Ausencia de flujo o flujo mínimo en las TVP parciales o en resolución 5. Ausencia de compresividad de la vena
In 220 consecutive outpatients with clinically suspected deep-vein thrombosis of the leg, we compared contrast venography with real-time B-mode ultrasonography, using the single criterion of vein compressibility with the ultrasound transducer probe. The common femoral and popliteal veins were evaluated for full compressibility (no thrombosis) and noncompressibility (thrombosis). Both veins were fully compressible in 142 of the 143 patients with normal venograms (specificity, 99 percent; 95 percent confidence interval, 97 to 100). All 66 patients with proximal-vein thrombosis had noncompressible femoral veins, popliteal veins, or both (sensitivity, 100 percent; 95 percent confidence interval, 95 to 100). For all patients (including 11 with calf-vein thrombi), sensitivity and specificity were 91 (95 percent confidence interval, 82 to 96) and 99 percent, respectively. The sensitivity for isolated calf-vein thrombosis was only 36 percent. The compression ultrasound test was repeated in a subset of 45 consecutive patients by a second examiner, unaware of the results of the first test, whose results agreed in all patients with those of the first examiner (kappa = 1). We conclude that ultrasonography with the single criterion of vein compressibility is a highly accurate, simple, objective, and reproducible noninvasive method for detecting proximal-vein thrombosis in outpatients with clinically suspected deep-venous thrombosis.
Academic Emergency Medicine 2000
Optimal sensitivity is achieved by using duplex (proximal sensitivity 96%, distal sensitivity 71%, specificity 94%) or triplex US (proximal sensitivity 96%, distal sensitivity 75%, specificity 94%). Optimal specificity is achieved by using compression US alone (proximal sensitivity 94%, distal sensitivity 57%, specifi- city 98%). These findings suggest that compression US alone is probably the appropriate technique for most patients, if scanning is aimed simply at identifying proximal DVT. Most patients have a low probability of DVT, so optimal specificity is required to avoid generating excessive false positive results. However, when evaluating patients at high risk of DVT, or if scanning aims to identify distal DVT, then duplex or triplex US will probably be the appropriate technique.
Summary receiver-operating-characteristic (SROC) curve analysis (n = 6) for emergency physician–performed ultra- sound (EPPU) to detect deep venous thrombosis (DVT) using radiologist performed US as the reference standard. Individual studies are depicted as circles. The unweighted SROC curve is limited to the range where data are available
Summary receiver-operating-characteristic (SROC) curve analysis (n = 6) for emergency physician–performed ultra- sound (EPPU) to detect deep venous thrombosis (DVT) using radiologist performed US as the reference standard. Individual studies are depicted as circles. The unweighted SROC curve is limited to the range where data are available
Sixteen of the 28 were correctly identi ed by the residents with two-point compression as true positive DVTs. Among the 260 cases deemed to be negative for DVT by radiology ultrasound, 10 were falsely thought to be positive by the residents using two-point compression. Overall, the EM residents had a sensitivity of 57.1% (95% [CI 38.8-75.5]) and a speci city of 96.1% (95% CI [93.8-98.5]) for identi cation of proximal lower extremity DVT. This led to a test accuracy
of 92.4% with a positive predictive value of 61.5% (95% CI [42.8-80.2]) and a negative predictive value of 95.4% (95% CI [92.9-98.0]). The positive likelihood ratio is 14.9 (95% CI [7.5-29.5]) and the negative likelihood ratio was 0.45 (95% CI [0.29-0.68]).
Thirty-two unique ultrasound operators contributed tothis study. There was a large range in the number of studies performed by each resident. Three residents performed only one ultrasound, and one resident performed 51 ultrasounds. Eleven residents performed at least 10 ultrasounds. The results of the ultrasounds for each operator can be seen in the appendix.
In two of the 22 discrepancies, the resident did not achieve adequate images of the common femoral vein. In one of these two, this appeared to be because the resident confused a lymph node with the common femoral vein.
In eight of the 22 cases, the resident’s incorrect interpretation could be attributed to inadequate visualization of the popliteal vein. In the majority of those videos, the popliteal vein was not visible and it is not clear what structure the resident thought was the popliteal vein.
In three of the 22 analyzed videos, the residents made other types of mistakes. In two, the residents obtained adequate visualization of the common femoral vein, but did not press hard enough to appropriately test for compressibility. In the third, the resident obtained adequate visualization ofthe common femoral vein, and upon review of the video,it appeared that part of the vein was not compressible. The resident, however, incorrectly interpreted the images and determined that there was no thrombus.
Sospecha de tvp
Sin: anticoagulación o historia de TVP
Seguimiento 3 meses
Aleatorización en 2 grupos: 2 CUS o Estrategia de toda la pierna
US al inicio normal se tomaba un dimero d.
Si el dimero D era normal y US negativo: No anticoagulación
Si dimero D anormal y US negativa, se programaban para una segunda US en 7 días , segunda US normal : no anticogulacion
Estrategia de 2 puntos: V. femoral común y poplítea: compresión (único criterio dx)
Toda la pierna: CCUS, podría usarse Doppler color o flujo si había dudas.
Se confirma TVP con la compresión o venografia
Resultados
2098 pacientes
2- CUS: 1045
CCUS: 1053
2 CUS:
TVP sintomática ocurrio en 7 de 801 pacientes
Incidencia de 0.9%
Estrategia de toda la pierna
TVP sintomática en 9 de 763 pacientes
Incidencia 1.2%
Diferencia de 0.3%
Resultados
2098 pacientes
2- CUS: 1045
CCUS: 1053
2 CUS:
TVP sintomática ocurrió en 7 de 801 pacientes
Incidencia de 0.9%
Estrategia de toda la pierna
TVP sintomática en 9 de 763 pacientes
Incidencia 1.2%
Diferencia de 0.3%
Riesgo de Enfermedad Tromboembólica a 3m
0.9% vs 1.2% No significativo
23% pacientes con TV distal recibieron anticoagulación SIN disminuir riesgos de TEP
CUS prox Seriado:
Positivo = tratamiento
Negativo = Dímero D
Negativo = salida
Positivo = CUS en 1 semana
RIESGO BAJO
En pacientes con baja probabilidad pre test, iniciar el proceso diagnostico con un Dímero D o CUS del sistema venoso proximal, sobre no iniciar proceso dx (1B), Venografia (1B), CCUS (2B)
Si el Dímero D es negativo, no mas tests (1B)
Si el CUS es negativo, no mas tests (1B)
Si el dímero D es positivo, continuar con CUS (2C)
Si el CUS es positivo para TVP iniciar tratamiento, no realizar venografia confirmatoria (2C)
RIESGO MODERADO
En pacientes con probabilidad moderada, iniciar con Dímero D, US compresión sistema venosos proximal o de toda la extremidad , frente al no test dx (1B) o venogradia (1B)
Si el Dímero D es negativo, no más test (1B)
Si el Dímero D es positivo, realizar CUS proximal, o CCUS (1B) frente a no realizar más exámenes o venografia (1B)
Si se inicia CUS proximal como examen inicial y es negativo, se recomienda repetir el CUS en 1 semana o realizar Dímero D (1C) frente a no realizar más exámenes o venografia.
Si el CUS es negativo , pero Dímero D positivo, repetir el CUS en 1 semana (1B)
Si el CUS seriado es negativo o CUS inicial es negativo, o Dímero D negativo, no mas exámenes.
Si el CCUS es negativo, no más exámenes frente a US seriado o dímero D o venografia 1B)
Si el CUS proximal es positivo , iniciar manejo frente a realizar venografia (1B)
Si se detecta TVP distal en el CCUS , realizar US seriada para descartar extensión al sistema proximal frente a iniciar tratamiento. (2C)
RIESGO ALTO
En pacientes con alta probabilidad pre test, Compresión de sistema venosos proximal o US de toda la pierna frente al no test dx (1B), o venografia (1B)
Si el CUS proximal o CCUS positivo, iniciar tratamiento frente a realizar venografia(1B)
CUS proximal negativo, realizar Dímero D o CCUS, o repetir CUS proximal en 1 semana frente a no realizar más exámenes o venografia
Paciente con CUS proximal negativo, y Dímero D positivo, realizar CCUS o repetir CUS en una semana
Si CUS Seriado es negativo, CCUS negativo, Dímero D negativo, no más exámenes
No usar Dímero D como examen único para descartar TVP
VP RECURRENTE
Iniciar la evaluación con CUS proximal o Dímero D
Si dímero D es positivo realizar CUS proximal
CUS proximal negativo, repetir en 7 días, o realizar Dímero D y repetir CUS en 7 días
CUS proximal positivo iniciar tto
US no dx realizar venografia, o CUS seriada
TVP previa ipsilateral US anormal sin estudios previos para comparar, realizar venografia, o dímero D, o CUS seiado
US no dx y dímero D positivo realizar venografia
Recommendations for evaluation of suspected lower extremity recurrent DVT: proximal US as initial test. Where there are preferred strategies, these are indicated by boldface print; less preferred strategies are indicated by italicizing/shading. §See Kearon et al.11 £“Negative” refers to a normal US or an area of prior noncompressibility with a stable or decreased residual diameter or an interval increase in residual diameter of , 2 mm. #“Nondiagnostic” refers to a technically limited US, an area of prior noncompressibility with increase in residual venous diameter of , 4 mm but 2 mm, or an area of prior noncompressibility without prior measurement of residual diameter for comparison. &“Positive” refers to a new noncom- pressible segment or an area of prior noncompressibility with an interval increase in residual diameter of 4 mm. @Consider additional serial proximal US. aGrade 1B vs venography, CTV, or MR venography. bGrade 1B for treating DVT vs venography if new noncompressible segment in the common femoral or popliteal vein; Grade 2B for treating DVT vs venography for a 4-mm increase in venous diameter during compression compared with that in the same venous segment on a previous result. cGrade 2B vs no further testing and vs venography. dGrade 1B vs further testing with venography. eGrade 2B for at least one additional proximal US or moderate or highly sensitive D-dimer over venography. fGrade 2B for at least one additional proximal US or mod- erate or highly sensitive D-dimer over no further testing. gGrade 2B for at least one additional proximal US over venography. hGrade 2B for at least one additional proximal US over no further testing. iGrade 1B for treating DVT over venography for new noncompressible segment compared to previous CUS result; Grade 2B for treating DVT over venography for a 4-mm increase in venous diameter during compression compared with that in the same venous segment on a previous result. jGrade 1B for proximal US (or highly sensitive D-dimer; see Figure 7) over venog- raphy, CTV, or MRI. CTV 5 CT scan venography; MR 5 magnetic resonance.
To perform the ultrasound examination, position the patient on a flat stretcher in the reverse Trendelenburg position so that the lower extremity is in a dependent position. Externally rotate the hip and flex the knee about 30 to allow access to the CFC, SFV, and PV
Imágenes: www.ecografiaclinica.es
Corte transversal a nivel femoral medio (AFS: arteria femoral superficial; AFP: arteria femoral profunda; VFC: vena femoral común)
Corte transversal a nivel femoral distal (AFS: arteria femoral superficial VFS: vena femoral superficial
orte transversal a nivel poplíteo (VP: vena poplítea AP: arteria poplítea)