ULTRASOUND: Vascular
Case Author: Deborah Rubens, MD, University of Rochester
History
37-year-old woman with right leg swelling that has lasted for 1 week.
Imaging Findings
Sagittal ultrasound image with spectral tracing of the right common femoral vein (A) shows a patent vessel with a monophasic waveform. Sagittal ultrasound image with spectral tracing of the left common femoral vein (B) shows a tracing with normal phasicity. Transverse color Doppler image of the right common iliac vein (C) shows a decreased-caliber vessel with adjacent hypoechoic tissue (arrow). The spectral tracing of the common iliac vein is also monophasic.
Diagnosis
Extrinsic compression
Teaching Points
The waveforms in the common femoral veins should be evaluated bilaterally to assess for indirect signs of more proximal obstruction, which can be intrinsic or extrinsic.
A monophasic waveform is abnormal and must be assessed further with imaging of the iliac veins up to and including the inferior vena cava if possible with ultrasound. If ultrasound is not adequate, CT or MRI should be performed. A monophasic waveform indicates more central disease at least 60% of the time.
Acute deep venous thrombosis typically enlarges the vein, though it can also cause a monophasic waveform if there is a long nonocclusive thrombus that severely narrows the lumen.
Causes of a monophasic waveform include intrinsic thrombosis, extrinsic compression from adenopathy or other pelvic mass (including pregnancy), or chronic obstruction, including a small scarred vessel.
Heart failure typically distends the vein and causes an abnormally pulsatile biphasic waveform with increased and reversed blood flow toward the feet during each heartbeat because of the increased right-sided pressure.
Suggested Readings
Lin EP, Bhatt S, Rubens DJ, Dogra VS. The importance of monophasic Doppler waveforms in the common femoral vein: a retrospective study. J Ultrasound Med 2007; 26:885–891
Selis JE, Kadakia S. Venous Doppler sonography of the extremities: a window to pathology of the thorax, abdomen and pelvis. AJR 2009; 193:1446–1451
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