Case of the Month July 2014, Page 4

For a larger image, please click on Lung Cancer 6

ANSWER:  Vascular Doppler ultrasound of the lower extremities

This image demonstrates a non-compressive left popliteal vein in the left lower leg.  The non-compressibility of the vessel indicates there is a thrombus within the vessel.

Other important details:
• A lower leg vascular ultrasound  has  low sensitivity but high specificity when evaluating for DVT
• 50% of patients with pulmonary embolus do not have DVT
• Ventilation/perfusion scans (V/Q scans) are indirect indicators of pulmonary artery thrombus and may be helpful in patient who cannot undergo a CT scan.  
• V/Q scan
 A V/Q scan does not directly visualize the clot, only the disruption of vascular perfusion
 High sensitivity (~ 100%) but poor specificity
 Limitation: High percentage of non-diagnostic intermediate probability scans (> 60%)

CT angiogram of the chest for pulmonary embolism:  The preferred diagnostic test for evaluating for pulmonary embolism.  It is a rapid test, non-invasive, and readily available.


• Anticoagulation and fibrinolysis
 Hemorrhage complications in 2-15%
• IVC filter if contraindications to drug therapy or for recurrent emboli
• pulmonary thromboendarterectomy (surgical removal of the thrombus)
 Much less frequent
 Indicated in patient with significant hemodynamic compromise

This patient was seen by a cardiothoracic surgeon, who deemed the patient not a surgical candidate.  The patient was treated with intravenous heparin (anticoagulation).

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