Review

Current Approaches and Controversial Issues in the Diagnosis of Deep Vein Thrombosis via Duplex Doppler Ultrasound
Diana Gaitini, MD Unit of Ultrasound, Department of Medical Imaging, Rambam Medical Center, POB 9602, 31906, Haifa, Israel

Received 13 September 2005; accepted 28 February 2006

ABSTRACT: Duplex and color Doppler sonography (DUS) is currently the technique of choice for the diagnosis of deep venous thrombosis (DVT) in symptomatic patients, because it has proven safe and cost-effective, with a very high sensitivity and specicity (96% and 98%, respectively) for the diagnosis of proximal DVT. Several issues regarding its method and clinical indications remain controversial, however. Although isolated calf vein thrombosis does not seem to have a signicant adverse outcome in the short term, scanning the calf only in patients with localized symptoms or signs is cost-effective. Bilateral examination is indicated in high-risk patients or when screening asymptomatic patients. When negative, a complete DUS examination of the proximal and distal veins, at least down to the level of the popliteal trifurcation, allows withholding anticoagulant therapy without the risk of major complications. This examination may be repeated if signs or symptoms worsen. Some populations of asymptomatic patients at high risk of DVT may benet from DUS screening. Bilateral DUS examination of lower limb veins should be performed as the initial examination in the workow of pulmonary embolism only in patients with risk factors for DVT. Recurrent thrombosis is a challenging diagnosis for all imaging modalities. A diagnostic strategy combining clinical probability score and D-dimer test may rene the selection of patients. The pitfalls and limitations of venous DUS are related to vein anatomy, ow changes, technical issues, and operC 2006 Wiley Periodicals, Inc. J Clin ator expertise. V Ultrasound 34:289297, 2006; Published online in Wiley InterScience (www.interscience.wiley.com). DOI: 10.1002/jcu.20236 Keywords: duplex Doppler ultrasonography; color Doppler ultrasonography; veins; extremities; venous thrombosis; embolism; pulmonary

BACKGROUND

' 2006 Wiley Periodicals, Inc. VOL. 34, NO. 6, JULY/AUGUST 2006DOI 10.1002/jcu

eep venous thrombosis (DVT) of the lower limb is a common and life-threatening condition. In the United States, its incidence is calculated at 70100,000 cases, with as many as 200,000 hospitalizations/year. It carries the risk of pulmonary embolism (PE) and postthrombotic syndrome. The incidence of PE is calculated at 600,000 cases/year, 100,000 of them being fatal.13 Early and accurate diagnosis of DVT is therefore mandatory, yet clinical diagnosis is unreliable: only 2030% of symptomatic patients have proven DVT, and 90% of patients with fatal PE are asymptomatic for DVT.4 Therefore, objective methods of examination are required to reach an accurate and reliable diagnosis. There is agreement that, in the current state-of-the-art, duplex and color Doppler sonography (DUS) is the main diagnostic tool for DVT diagnosis, while ascending X ray venography is either abandoned or reserved for patients with negative or equivocal DUS results and a high clinical probability of DVT.2 Although venography is still the gold standard test, it relies on the variable and complex anatomy of the venous system, lacks physiologic information, is costly and invasive, and carries a risk for contrast media reaction and postvenographic phlebitis.5,6 Impedance plethysmography, a noninvasive and functional test, fails to detect nonocclusive proximal DVT, occlusive DVT in a duplicated vein, and isolated calf DVT.7 The only noninvasive technique that investigates both the anatomy and physiology of the veins is DUS.814 Among its advantages are its low cost, availability, portability, and accuracy. It is required as the primary instrumentation for peripheral 289

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venous testing according to the standards of the Intersocietal Commission for the Accreditation of Vascular Laboratories.15 The primary goal of DUS examination of the veins is to diagnose the presence or absence of a thrombus. Further information includes thrombus extent (mainly its upper limit) and characterization (fresh or organized, free-oating or attached, and partially or totally occlusive). Its ndings have some prognostic value as for the development of postthrombotic syndrome and the risk of PE. Patients with proximal DVT tend to present a slower and incomplete resolution of thrombus and to develop a more severe postthrombotic syndrome because of valve incompetence.16 A free-oating thrombus seems to carry an increased risk of PE, although it tends to attach to the vein wall or resolve and does not warrant any specic therapeutic procedure.17 When no thrombosis is found, DUS may put forward alternative diagnoses (also known as pseudothrombophlebitis) such as popliteal Bakers cyst, hematoma, popliteal aneurysm, pseudoaneurysm, lymphadenopathy, or other tumors. The incidence of these alternative diagnoses is 1118%.18 The sensitivity and specicity of DUS for the diagnosis of DVT in symptomatic patients are very high. Compressibility under probe pressure is the most accurate test. Compressibility under probe pressure had reached a 97100% sensitivity and a 9899% specicity for the diagnosis of proximal, femoral and popliteal DVT, but its sensitivity dropped to 5070% and its specicity to 60% for the diagnosis of isolated calf DVT. The visibility of the thrombus as a xed, echoic image within the vein lumen had a sensitivity of approximately 50% for both proximal and calf DVT. This poor sensitivity has been attributed to the low echogenicity of the fresh thrombus,1922 although there seems to be a continuum between blood stasis, which is clearly hyperechoic, and thrombosis, whose echogenicity changes with time. In a meta-analysis of 100 cohort studies that compared duplex Doppler sonography with contrast X ray venography in patients with suspected DVT, the sensitivity was 96.5% for proximal DVT and 71.2% for distal DVT, with a 94.3% specicity. Some earlier studies have reported a lower sensitivity, which may be explained by less advanced ultrasound technology, limitations in examination technique, and operator expertise.23
DIFFICULT AND CONTROVERSIAL ISSUES

troversial issues include the diagnosis of isolated calf vein thrombosis, bilateral versus unilateral examination, focused versus extensive examination, single versus serial scanning in patients with initially negative DUS results, screening of asymptomatic patients at high risk for DVT, suspected PE, suspected recurrent DVT, urgent offhour DUS, and the need for a diagnostic strategy to rene the selection of patients referred for venous sonography. Difcult issues include pitfalls and limitations of the method for DVT diagnosis. Isolated Calf Vein Thrombosis The deep calf venous network comprises 3 paired veinsposterior tibial, bular, and anterior tibialand 2 nonpaired muscular veinssoleal and gastrocnemialadjacent to the corresponding arteries, except for the soleal vein. Supercial veins such as the small saphenous vein (saphena parva) may also be a source of thrombophlebitis and pain. The prevalence of isolated calf vein thrombosis (CVT) is low (512%) in symptomatic patients25 but is higher in asymptomatic patients at high risk of DVT: 15% after knee or hip surgery and 45% after coronary artery bypass surgery.2628 DUS remains inconclusive in 3255% of cases of calf veins thrombosis, although power Doppler sonography may help identify the paired calf veins.29 Bucek et al30 tested sonographic contrast infusion for the examination of the calf veins and succeeded in reducing the rate of indeterminate scans from 55% to 20%. Nevertheless, the use of sonographic contrast media has not been approved by the US Food and Drug Administration. On the other hand, technologic progresses may overcome some limitations of DUS in the detection and examination of calf veins. A comprehensive lower extremity examination including all the paired and nonpaired veins has been recommended by some authors to increase DUS accuracy, and to avoid overlooking possible thrombophilic disorders.31,32 In a meta-analysis of the literature available before 1999, Gottlieb et al33 found a wide (9.382.7%) variation in the reported rate of indeterminate results of calf DUS examinations. In their own study, these authors observed no adverse outcome on a 3month follow-up of patients with DUS diagnosed CVT who did not receive anticoagulation.34 In a more recent prospective study, they were able to see all segments of all the paired calf veins in less than 40% of patients undergoing a protocol in which the deep calf veins were evaluated either systematically or only if local signs and sympJOURNAL OF CLINICAL ULTRASOUNDDOI 10.1002/jcu

There are several controversial or difcult issues regarding the diagnosis of DVT via DUS.24 Con290

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toms were present. The rate of adverse outcomes (ie, thrombus extension to the thigh or pulmonary embolism) was not signicantly different between these 2 groups.35 For calf vein evaluation, special attention must be paid to the painful areas. Proximal extension of isolated CVT may occur in up to 20% of cases. Because many calf thrombi do not progress to proximal veins or give rise to PE, an aggressive, invasive approach via X ray venography to diagnosing and treating CVT may not be warranted,8 but a policy of DUS scanning the calf in patients with localized symptoms or physical ndings is cost-effective. There are also controversies regarding the need for anticoagulant treatment in the presence of isolated CVT. According to the American Society of Chest Surgeons, anticoagulation is recommended in symptomatic patients, at least for 612 weeks.36 Other authors recommend anticoagulation only in cases of proximal propagation diagnosed on follow-up examination.34 When not justied by clinical ndings, repeated DUS examination is questionable, because it yields positive results in only 1.3% of cases.23 Bilateral versus Unilateral DUS In symptomatic patients, the incidence of contralateral, asymptomatic DVT is low (57%).37 A bilateral examination is indicated when screening asymptomatic patients at high risk of DVT, such as after coronary bypass surgery, major neurosurgery, spinal cord injury, total hip arthroplasty, and suspicion of PE.3739 The asymptomatic contralateral leg of a patient with a history of DVT can be examined to help distinguish recurrent DVT from postthrombotic syndrome.40 In the clinical routine, although diagnosing asymptomatic contralateral thrombosis has implications in preventing postthrombotic disorders, unilateral DUS examination of the symptomatic leg is considered the standard procedure39,41 in some countries, whereas bilateral examination is the rule in others. Focused Compression versus Continuous, Full Lower Limb Examination Some authors have proposed a limited, 2-point examination technique using compression testing on the common femoral and the popliteal veins, claiming that it is able to detect approximately 99% of thrombi that extend above the knee. This protocol is based on the fact that most symptomatic patients have a continuous clot involving more than 1 single venous segment.4244 With this technique, an isolated thrombus in the femoVOL. 34, NO. 6, JULY/AUGUST 2006DOI 10.1002/jcu

ral (wrongly but universally named the supercial femoral) vein or in calf veins will remain unidentied. In a multicenter study performed on symptomatic ambulatory patients, a complete examination of proximal and distal veins was performed, and the patients were followed up for 3 months after a negative sonographic examination. Neither proximal DVT nor pulmonary embolism occurred, and distal DVT occurred in only 0.5% of these patients. Although this approach may prove cost-effective in ambulatory symptomatic patients, a complete examination of the entire proximal venous system, including the popliteal trifurcation in the proximal calf, remains necessary in most patients and should be the usual procedure when performing venous DUS examinations.40 Single versus Serial Scanning in Patients with Negative DUS How dangerous is it to denitely rule out venous thrombosis in a symptomatic patient with negative DUS examination? The incidence of PE at 3 months follow-up of patients with a negative initial DUS examination was1.6% (1.3 % in outpatients, and 10% in inpatients). The incidence of PE in untreated CVT was 0.71.1%, similar to PE in patients with normal X ray contrast venography.35,45,46 Repeated sonography performed after 1 week in patients with intermediate or high clinical probability for DVT and a negative rst sonographic examination increased the percentage of patients with diagnosed DVT from 32.5% to 33.5%. This diagnostic improvement was clearly too small to justify repeated scanning as a routine procedure.47 In their meta-analysis, Goodacre et al23 identied no study that compared repeated sonography with X ray venography in all patients. Repeated sonography appears to have a positive yield of 1.3%, 89% of these being conrmed via X ray venography and the rest via clinical followup.23 In a multicenter study, no proximal DVT or PE developed at 3 months follow-up after a negative complete and bilateral DUS examination of the lower limb veins. The authors concluded that it is safe to withhold anticoagulant therapy in patients with clinically suspected DVT after a single, negative sonographic examination.48 Nevertheless, a repeated examination is warranted if the clinical situation worsens. Screening Asymptomatic Patients with High Prevalence of DVT Several studies have evaluated DUS as a screening test in asymptomatic patients after coronary 291

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artery bypass grafts,27 after admission in an internal medicine unit,37 after long-haul ights,49 and in patients with suspected pulmonary embolism.38 We conducted a screening study using bilateral DUS to detect asymptomatic DVT in 62 ambulatory cancer patients undergoing chemotherapy. Despite the known hypercoagulable state of these patients, we found no DVT and concluded that systematic DUS screening is not justied in this specic cancer population.50 In 1995, Wells et al28 concluded from a meta-analysis of studies with minimized bias that venous sonographic imaging had a high specicity (97%) but a low sensitivity (5470%), limiting the usefulness of DUS as a screening test. Quite logically, the sensitivity of DUS is greater in populations with a greater prevalence of DVT.23 From a recent meta-analysis of studies comparing DUS with X ray venography in asymptomatic patients, it was concluded that DUS is accurate for the diagnosis of DVT in asymptomatic postoperative orthopedic patients, whereas more research is needed in other clinical settings.51 Although the specicity of DUS for the diagnosis of DVT in asymptomatic patients is high (86 100%), its overall sensitivity is only approximately 50%, probably because of the smaller size and the nonocclusive character of the thrombus, as well as a higher prevalence of isolated CVT.28,52 Therefore, venous DUS should be complete (including calf veins) and bilateral when performed in asymptomatic patients.53 Suspected PE Bilateral lower extremities DUS is accepted as an initial examination for patients with clinically suspected PE.38 However, Fard et al54 reported that even bilateral X ray contrast venography revealed no DVT in approximately one third of patients with proven PE. In this study, DUS was positive in only 20% of patients who had proven PE but were asymptomatic for DVT. DUS was positive in 90% of patients with proven PE who were symptomatic for DVT, and there was a thrombus in the asymptomatic lower limb in 14% of them.54 According to Sheiman and McArdle, facing the low prevalence of DVT in patients that are just suspected for PE but asymptomatic for DVT (810%), bilateral lower extremities venous US should be performed as the initial examination in the workow of PE only in patients with risk factors for DVT. This policy would reduce the number of examinations performed without a decline in DVT detection.38 An US examination limited to the popliteal and femoral veins is com292

monly performed to detect DVT in patients with clinically suspected PE.55 According to Elias et al,56 a complete lower limb sonographic examination of both proximal and distal veins has a higher sensitivity but a slightly lower specicity. Of course, a negative DUS examination should not be used to rule out the diagnosis of PE.54,56 Suspected Recurrent DVT Venum venorum develop in thrombi over time, the acute event being followed by clot retraction, lumen recanalization and valve damage. After 69 months, complete vein recanalization occurs in only 45% of patients, and valve immobility and/or destruction remain in most cases. Reux from deep to supercial vein systems develops with subsequent enlargement of the saphenous and perforating veins, development of varicose veins in the subcutaneous fat, and clinical manifestations of the postthrombotic syndrome.5761 During the year following acute thrombosis, 1 out of 3 patients will exhibit symptoms of DVT, and recurrent DVT occurs in 1 out of 3 of these symptomatic patients. The annual likelihood of recurrence is 515%, with a cumulative recurrence rate of approximately 25% after 4 years.62 Differentiating acute on chronic thrombosis from postthrombotic syndrome is a clinical and imaging challenge. Some DUS features may help. A fresh thrombus (<710 days old) is mostly hypoechoic, homogeneous, partially compressible, and sometimes oating, and the vein diameter is enlarged. Thrombolysis is successful in 90% of these cases. On the contrary, an older, organized thrombus is hyperechoic, heterogeneous, uncompressible, and rmly adherent to the vein walls, and moderate or no vein enlargement is visible. Thrombolytic therapy may succeed in only 12% of these cases.58 Acute on chronic DVT is a difcult diagnosis for all diagnostic modalities, enhancing the value of a baseline study for distinguishing old residual thrombus from superimposed acute or chronic DVT. Urgent, Off-Hours DUS Is it justied to perform urgent DUS during off hours? This is a concern for every resident and sonographist, and places a high demand on vascular labs. Langan et al63 tested a program in which patients suspected of having DVT were either sent home with a single prophylactic dose (1 mg/kg) of low-molecular weight heparin, or kept in observation when heparin was contraindicated, then undergone DUS at 8 A.M. the next day. There was no death, PE, or immediate comJOURNAL OF CLINICAL ULTRASOUNDDOI 10.1002/jcu

CONTROVERSIES IN US DIAGNOSIS OF DVT

FIGURE 1. Algorithm for the diagnosis of DVT in symptomatic patients. Venous DUS examination should be performed in patients with a high clinical probability score and/or a positive D-dimer test. The appropriate examination is compression DUS of the complete venous system (including the distal veins when focal symptoms or signs are present) and bilateral examination in high-risk patients. Modied from Mantoni.65 DVT, deep venous thrombosis; US, sonographic examination.

plication of anticoagulation, whereas an 89% reduction in after-hours DUS for DVT was achieved. To reduce unnecessary hospitalization, the clinical probability of DVT should be evaluated and/or a D-dimer test should be used to identify low-risk patients in which DUS may be delayed.40 Diagnostic Strategy for Symptomatic Patients The large number of patients referred for DUS examination for clinically suspected DVT contrasts with the low prevalence of proven DVT and led to a search for alternative strategies that would offer the possibility of rening the selection of patients for imaging. The proposed diagnostic strategies combine the clinical probability score with D-dimer test and compression sonography.6472 The clinical risk assessment score is based on patient history, symptoms and physical examination. A history of malignancy, previous DVT, recent immobilization, recent surgery, and difference in calf diameter were the most useful criteria for assessing the clinical probability of DVT.73 Wells et als clinical score stratied patients into groups with high, intermediate, and low probability of DVT and was proven effective in decreasing the number of unnecessary DUS examinations.74 The D-dimer test is the biochemical assay of a brin degradation product. It has a high negative predictive value for the diagnosis of DVT.6971 A
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D-dimer test at a cutoff level of 1 g/ml had a sensitivity of 9598% and a negative predictive value of 9698%, whereas its specicity and positive predictive value were only 55% and 48%, respectively.67,72 Because concentrations rise in inammatory states, recent surgery, or cancer, the usefulness of the D-dimer test is limited by the high rate of false positive results in these populations, particularly in hospitalized patients. Michiels et al75 found a sensitivity and negative predictive value of 98.6% and 99.5%, respectively, for the rapid ELISA VIDAS D-dimer assay. In patients suspected of DVT with a normal D-dimer test and a low clinical probability score, the prevalence of DVT was less than 0.5%, and the need for compression sonographic testing was reduced by 40 50%. A randomized multicenter trial demonstrated that the use of D-dimer testing can reduce the need for repeated sonography in outpatients with normal results on initial sonographic examination of the proximal veins.66 Based on clinical and biochemical parameters, the use of DUS may be restricted to patients with a high clinical probability score and/or a positive D-dimer test. This strategy proved to be safe and feasible in an emergency department setting.76 Facing a normal DUS examination in patients with a high clinical probability score and a positive D-dimer test, an additional procedure such as X ray venography or repeated DUS should be performed (Figure 1). This combination appears safe 293

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and seems to be the most cost-effective diagnostic workup for suspected DVT. Nevertheless, X ray contrast venography is no longer performed in many centers. The optimal strategy in a given institution depends on local equipment, expertise, and cost.77 Therefore, potential approaches to limiting the use of sonography by adding D-dimer tests in the evaluation of possible DVT are still organization-specic.78

Limitations and Pitfalls of DUS for the Diagnosis of DVT Anatomic limitations are associated with difculty in imaging the iliac veins (which are deep in the pelvis), the femoral vein at the level of the Hunter canal (an aponeurotic adductor hiatus, which is poorly compressible), and the calf veins (which are numerous, small, and variable). DUS with ow augmentation maneuvers may be useful for these sites. A possible pitfall is vein duplication, which occurs in up to 20% of the femoral and 35% of the popliteal veins, because one vein may be normal while the other contains a thrombus.77 Other issues are related to technical limitations, such as: a poorly compressible vein due to obesity or edema; an echogenic lumen due to low velocity blood ow as in low cardiac output; and vein distention due to congestive heart failure. Blood ow echogenicity resulting from blood stasis and erythrocyte aggregation may be a signicant source of false positive results. In these situations, dynamic tests (ow augmentation produced by passive limb raising or upstream muscle compression) may ensure a correct diagnosis. Furthermore, there are limitations due to lack of standard in the performance of vein DUS among vascular laboratories, varying from unilateral to bilateral, limited to complete, compression only to DUS examination.79 Better training and improved experience of sonographers, as well as technologic progresses, have led to a higher sensitivity of DUS in recent studies.23

risk of DVT. Several issues regarding the methodas well as clinical indicationsremain difcult or controversial. The presence or absence of isolated CVT should be determined in patients with localized symptoms and, bilaterally, in asymptomatic patients with a high risk of DVT. When the results are negative, complete compression and DUS examination of the proximal and distal veins at least down to the level of the popliteal trifurcationincluding the more distal veins when focal symptoms or signs are presentallows withholding anticoagulant therapy. Repeat examination is warranted if clinical deterioration occurs. Applying a diagnostic strategy that combines clinical probability score and a Ddimer test may signicantly reduce the number of required DUS examinations and additional investigations in a minority of cases. Operator expertise, technologic developments, improved selection of patients, and optimization of protocols will ensure better diagnostic accuracy.

REFERENCES 1. Anderson FA, Wheeler HB, Goldberg RT, et al. A population-based perspective of the hospital incidence and case facility rates of deep vein thrombosis and pulmonary embolism. The Worcester DVT Study. Arch Intern Med 1991;151:933. 2. Weinmann EE, Salzman EW. Deep vein thrombosis. N Engl J Med 1994;331:1630. 3. Kyrle PA, Eichinger S. Deep vein thrombosis. Lancet 2005;365:1163. 4. Wells PS, Hirsh J, Anderson DR, et al. Accuracy of clinical assessment of deep vein thrombosis. Lancet 1995;345:1326. 5. Hull R, Hirsh J, Sackett DL, et al. Cost-effectiveness of clinical diagnosis, venography and noninvasive testing in patients with symptomatic deepvein thrombosis. N Engl J Med 1981;304:1561. 6. Flanigan DP, Goodreau JJ, Burnham S, et al. Vascular-laboratory diagnosis of clinically suspected acute deep vein thrombosis. Lancet 1978;2:331. 7. Hull TD, van Aken WG, Hirsh J, et al. Impedance plethysmography using the occlusive cuff technique in the diagnosis of venous thrombosis. Circulation 1976;53:696. 8. Kearon C, Julian JA, Math M, et al. Noninvasive diagnosis of deep vein thrombosis. Mc Master Diagnostic Imaging Practice Guidelines Initiative. Ann Intern Med 1998;128:663. 9. Birdwell BG, Raskob GE, Whitsett TL, et al. The clinical validity of normal compression ultrasonography in outpatients suspected of having deep vein thrombosis. Ann Intern Med 1998;128:1. 10. Wells PS, Hirsh J, Anderson DR, et al. Comparison of the accuracy of impedance plethysmography and compression ultrasonography in outpatients
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CONCLUSION

DUS is currently the technique of choice for the diagnosis of DVT in symptomatic patients. It is a highly accurate, widely available, and noninvasive technique that does not entail ionizing radiation and contrast media injection. Furthermore, it is safe and cost-effective. When results are negative for DVT, it may help provide an alternative diagnosis. DUS should be performed as a screening method for asymptomatic patients at high 294

CONTROVERSIES IN US DIAGNOSIS OF DVT with clinically suspected deep vein thrombosis. A two centre paired-design prospective trial. Thromb Haemost 1995;74:1423. Lensing AWA, Prandoni P, Brandjes D, et al. Detection of deep vein thrombosis by real time B-mode ultrasonograpy. N Engl J Med 1989;320: 342. White RH, McGahan JP, Daschbach MM, et al. Diagnosis of deep vein thrombosis using duplex ultrasound. Ann Intern Med 1989;111:297. Polak JF, Cutler SS, OLeary DH. Deep veins of the calf: assessment with color Doppler ow imaging. Radiology 1989;171:481. Gaitini D, Kaftori JK, Pery M, et al. High resolution real-time ultrasonography in the diagnosis of deep vein thrombosis. Rofo 1988;149:26. ICAVL standards for accreditation in noninvasive vascular testing. Part II. Vascular laboratory operationsperipheral venous testing. 200:18. Available at: http://www.intersocietal.org/icavl/pdfs/ venous2005.pdf. Asbeutah AM, Riha AZ, Cameron JD, et al. Fiveyear outcome study of deep vein thrombosis in the lower limbs. J Vasc Surg 2004;40:1184. Voet D, Afschrift M. Floating thrombi: diagnosis and follow-up by duplex ultrasound. Br J Radiol 1991; 64:1010. Langsfeld M, Matteson B, Johnson W, et al. Bakers cysts mimicking the symptoms of deep vein thrombosis: diagnosis with venous duplex scanning. J Vasc Surg 1997;25:658. Theodorou SJ, Theodorou DJ, Kakitsubata Y. Sonography and venography of the lower extremities for diagnosing deep vein thrombosis in symptomatic patients. Clin Imaging 2003;27:180. Baxter GM. The role of ultrasound in deep venous thrombosis. Clin Radiol 1997;52:1. Mussurakis S, Papaioannou S, Voros D, et al. Compression ultrasonography as a reliable imaging monitor in deep venous thrombosis. Surg Gynecol Obstet 1990;171:233. Cogo A, Lensing AW, Koopman MM, et al. Compression ultrasonography for diagnostic management of patients with clinically suspected deep vein thrombosis: prospective cohort study. BMJ 1998; 316:17. Goodacre S, Sampson F, Thomas S, et al. Systematic review and meta-analysis of the diagnostic accuracy of ultrasonography for deep vein thrombosis. BMC Med Imaging 2005;5:6. Dauzat M, Laroche JP, Deklunder G, et al. Diagnosis of acute lower limb deep venous thrombosis with ultrasound: trends and controversies. J Clin Ultrasound 1997;25:343. Gottlieb RH, Widjaja J, Tian L, et al. Calf sonography for detecting deep venous thrombosis in symptomatic patients: experience and review of the literature. J Clin Ultrasound 1999;27:415. Oishi CS, Grady-Benson JC, Otis SM, et al. The clinical course of distal deep venous thrombosis after total hip and total knee arthroplasty, as determined with duplex ultrasonography. J Bone Joint Surg Am 1994;76:1658. Reis SE, Polak JF, Hirsch DR, et al. Frequency of deep venous thrombosis in asymptomatic patients with coronary artery bypass grafts. Am Heart J 1991; 122:478. Wells PS, Lensing AW, Davidson BL, et al. Accuracy of ultrasound for the diagnosis of deep venous thrombosis in asymptomatic patients after orthopedic surgery: a meta-analysis. Ann Intern Med 1995; 122:47. Forbes K, Stevenson AJ. The use of power Doppler ultrasound in the diagnosis of isolated deep venous thrombosis of the calf. Clin Radiol 1998;53:752. Bucek RA, Kos T, Schober E, et al. Ultrasound with Levovist in the diagnosis of suspected calf vein thrombosis. Ultrasound Med Biol 2001;27: 455. Labropoulos N, Webb KM, Kang SS, et al. Patterns and distribution of isolated calf deep vein thrombosis. J Vasc Surg 1999;30:787. Badgett DK, Comerota MC, Khan MN, et al. Duplex venous imaging: role for a comprehensive lower extremity examination. Ann Vasc Surg 2000; 14:73. Gottlieb RH, Widjaja J, Mehra S, et al. Clinically important pulmonary emboli: does calf vein US alter outcomes? Radiology 1999;211:25. Gottlieb RH, Widjaja J. Clinical outcomes of untreated symptomatic patients with negative ndings on sonography of the thigh for deep vein thrombosis: our experience and a review of the literature Am J Roentgenol 1999;172:1601. Gottlieb RH, Voci SL, Syed L, et al. Randomized prospective study comparing routine versus selective use of sonography of the complete calf in patients with suspected deep venous thrombosis. Am J Roentgenol 2003;180:241. Geerts WH, Heit JA, Clagett GP, et al. Prevention of venous thromboembolism Chest 2004;126:338S. Bressollette L, Nonent M, Oger E, et al. Diagnostic accuracy of compression ultrasonography for the detection of asymptomatic deep venous thrombosis in medical patients. The TADEUS project. Thromb Haemost 2001;86:529. Sheiman RG, McArdle CR. Clinicaly suspected pulmonary embolism: use of bilateral lower extremity US as the initial examinationa prospective study. Radiology 1999;212:75. Cronan JJ. Deep venous thrombosis: one leg or both legs? Radiology 1996;200:323. 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GAITINI 43. Cogo A, Lensing AWA, Koopman MM, et al. Compression ultrasonography for diagnostic management of patients with clinically suspected deep vein thrombosis: prospective cohort study. BMJ 1998; 316:17. 44. Elias E, Mallard L, Elias M, et al. A single complete ultrasound investigation of the venous network for the diagnostic management of patients with a clinically suspected rst episode of deep venous thrombosis of the lower limbs. Thromb Haemost 2003;89:221. 45. Sluzewski M, Koopman MM, Schuur KH, et al. Inuence of negative ultrasound ndings on the management of in and outpatients with suspected deep vein thrombosis. Eur J Radiol 1991;13:174. 46. Wolf B, Nichols DM, Duncan JL. Safety of a single duplex scan to exclude deep venous thrombosis. Br J Surg 2000;87:1525. 47. Friera A, Gimenez NR, Caballer P, et al. Deep vein thrombosis: can a second sonographic examination be avoided? AJR Am J Roentgenol 2002;178:1001. 48. Elias A, Mallard L, Elias M, et al. 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