Acute venous thrombosis is a common and dangerous disease. According to statistics, its frequency in the general population is about 160 per 100,000 population. Thrombosis in the inferior vena cava (IVC) system is the most frequent and dangerous type of this pathological process and is the main source of pulmonary embolism (84.5%). The superior vena cava system gives 0.4-0.7% pulmonary embolism (PE), the right heart - 10.4%. The share of venous thrombosis of the lower extremities accounts for up to 95% of all thrombosis cases in the IVC system. The diagnosis of acute venous thrombosis is diagnosed in vivo in 19.2% of patients. In the long term, deep vein thrombosis (DVT) leads to the formation of post-thrombophlebitic disease, manifested by chronic venous insufficiency up to the development of trophic ulcers, which significantly reduces the ability to work and the quality of life of patients.
The main mechanisms of intravascular thrombus formation, known since the time of R. Virchow, are a slowdown in blood flow (stasis), hypercoagulation, trauma to the vessel wall (damage to the endothelium). Acute venous thrombosis often develops against the background of various oncological diseases (malignant tumors of the gastrointestinal tract, female genital area, etc.) due to the fact that cancer intoxication causes the development of hypercoagulable changes and suppression of fibrinolysis, as well as due to mechanical compression of the veins by the tumor and germination her into the vascular wall. Obesity, pregnancy, oral hormonal contraceptives, hereditary thrombophilia (deficiency of antithrombin III, protein C and S, Leiden mutation, etc.), systemic connective tissue diseases, chronic purulent infections, allergic reactions are also considered predisposing factors for DVT. Patients of the elderly and senile age and persons suffering from chronic venous insufficiency of the lower extremities, as well as patients with myocardial infarction, decompensated heart failure, stroke, bedsores, gangrene of the lower extremities, are at the highest risk of developing DVT. Traumatological patients are of particular concern, since fractures of the femur are mainly found in elderly and senile people who are most burdened with somatic diseases. Thrombosis in trauma patients can occur with any injury to the lower extremities, since all etiological factors of thrombosis (vascular damage, venous congestion and changes in the blood coagulation properties) take place.
Reliable diagnosis of phlebothrombosis is one of the urgent clinical tasks. Physical examination methods make it possible to make a correct diagnosis only in typical cases of the disease, while the frequency of diagnostic errors reaches 50%. For example, thrombosis of the veins of the gastrocnemius muscles with preserved patency of the remaining veins is often asymptomatic. Because of the danger of missing an acute DVT of the lower legs, clinicians often make this diagnosis in every case of pain in the calf muscles. Particular attention should be paid to "trauma" patients in whom the presence of pain, edema and discoloration of the limb may be the result of the trauma itself, and not DVT. Sometimes the first and only manifestation of such a thrombosis is massive PE.
The tasks of instrumental examination include not only confirmation or refutation of the presence of a thrombus, but also determination of its length and degree of embolism. Isolation of embolism-prone thrombi into a separate group and the study of their morphological structure are of great practical importance, since without this it is impossible to develop effective prevention of pulmonary embolism and the choice of optimal treatment tactics. Thromboembolic complications are more often observed in the presence of a floating thrombus with a heterogeneous structure, an uneven hypo- or isoechoic contour, in contrast to thrombi with a hyperechoic contour and a homogeneous structure. An important criterion for the embolism of a thrombus is the degree of its mobility in the lumen of the vessel. Embolic complications are more often observed with pronounced and moderate mobility of thrombosis.
Venous thrombosis is a rather dynamic process. Over time, the processes of retraction, humoral and cell lysis contribute to a decrease in the size of the thrombus. At the same time, the processes of its organization and recanalization are going on. In most cases, the patency of the vessels is gradually restored, the valve apparatus of the veins is destroyed, and the remnants of blood clots in the form of parietal overlays deform the vascular wall. Difficulties in diagnosis can be in the occurrence of repeated acute thrombosis against the background of partially recanalized veins in patients with post-thrombophlebitic disease. In this case, a rather reliable criterion is the difference in veins in diameter: in patients with signs of recanalization of thrombosis, the vein in diameter decreases due to the subsidence of the acute process; with the development of retrombosis, a significant increase in the diameter of the vein again occurs with indistinct ("blurred") contours of the walls and surrounding tissues. The same criteria are used in the differential diagnosis of acute parietal thrombosis with post-thrombotic changes in the veins.
Of all the non-invasive methods used to diagnose thrombosis, ultrasound scanning of the venous system has been increasingly used recently. The method of triplex angioscanning, proposed by Barber in 1974, includes the study of blood vessels in the B-mode, the analysis of the Doppler frequency shift in the form of classical spectral analysis and flux (in velocity and energy modes). The use of spectral has made it possible to accurately measure the blood flow inside the lumen of the veins. The use of the method () made it possible to quickly distinguish occlusive thrombosis from non-occlusive thrombosis, to identify the initial stages of thrombus recanalization, and also to determine the location and size of venous collaterals. In dynamic studies, the ultrasound method provides a fairly accurate control over the effectiveness of thrombolytic therapy. In addition, with the help of ultrasound examination, it is possible to establish the causes of the appearance of clinical symptoms similar to those in the pathology of veins, for example, to identify a Baker cyst, intermuscular hematoma or a tumor. The introduction of expert class ultrasonic devices with transducers with a frequency of 2.5 to 14 MHz made it possible to achieve almost 99% diagnostic accuracy.
Material and methods
The examination included examination of patients with clinical signs of venous thrombosis and PE. Patients complained of edema and pain in the lower (upper) limb, pain in the gastrocnemius muscle (more often of a bursting character), "pulling" pain in the popliteal region, pain and induration along the saphenous veins. Examination revealed moderate cyanosis of the lower leg and foot, dense edema, pain on palpation of the lower leg muscles, in most patients positive symptoms of Homans and Moses.
All subjects underwent triplex scanning of the venous system using modern ultrasound devices with a linear transducer with a frequency of 7 MHz. At the same time, the condition of the thigh veins, popliteal vein, leg veins, as well as the great and small saphenous veins was assessed. A convex probe with a frequency of 3.5 MHz was used to visualize the iliac veins and IVC. When scanning the IVC, iliac veins, great saphenous vein, femoral veins and veins of the lower leg in the distal part of the lower extremities, the patient was in the supine position. The study of the popliteal veins, veins of the upper third of the leg and the lesser saphenous vein was carried out in the patient's prone position with a roller placed under the ankle joint area. Difficulties in diagnostics arose during visualization of the distal part of the superficial femoral vein in obese patients, visualization of leg veins with pronounced trophic and indural tissue changes. In these cases, a convex probe was also used. The scanning depth, echo amplification and other parameters of the study were selected individually for each patient and kept unchanged during the entire examination, including dynamic observations.
Scanning was started in cross-section to exclude the presence of a floating apex of the thrombus, as evidenced by full contact of the venous walls during light compression with the transducer. After making sure that there was no free floating apex of the thrombus, the compression test with the sensor was performed from segment to segment, from proximal to distal. The proposed technique is the most accurate not only for detecting thrombosis, but also for determining its length (excluding the iliac veins and IVC, where the patency of the veins was determined in the CDC mode). veins confirmed the presence and characteristics of venous thrombosis. In addition, a longitudinal section was used to locate the anatomical fusion of the veins. During the examination, the condition of the walls, the lumen of the veins, the localization of the thrombus, its length, and the degree of fixation to the vascular wall were assessed.
Ultrasound characterization of venous thrombi was carried out in relation to the lumen of the vessel: they were distinguished as parietal, occluding and floating thrombi. Signs of parietal thrombosis were visualization of a thrombus with the presence of free blood flow in the lumen of the vein, the absence of complete collapse of the walls during compression of the vein by the sensor, the presence of a filling defect in CDC, and the presence of spontaneous blood flow in spectral Doppler (Fig. 1).
Rice. 1. Non-occlusive popliteal vein thrombosis. Longitudinal vein scan. The envelope blood flow in the energy flow coding mode.
Ultrasonic criteria for floating thrombi were: visualization of a thrombus as an echogenic structure located in the lumen of a vein with the presence of free space, oscillatory movements of the apex of a thrombus, absence of contact of the vein walls during compression by a sensor, the presence of free space when performing respiratory tests, bending type of blood flow in CPC, the presence of spontaneous blood flow with spectral Doppler. When a floating thrombus was detected, the degree of its mobility was assessed: pronounced - in the presence of spontaneous thrombus movements with calm breathing and / or holding the breath; moderate - when oscillatory movements of a thrombus are detected during functional tests (cough test); insignificant - with minimal mobility of a thrombus in response to functional tests.
Research results
From 2003 to 2006, 236 patients aged 20 to 78 years were examined, of which 214 with acute thrombosis clinic and 22 with pulmonary embolism clinic.
In the first group, in 82 (38.3%) cases, the patency of deep and superficial veins was not disturbed and the clinical symptoms were due to other reasons (Table 1).
Table 1... Conditions with symptoms similar to DVT.
The diagnosis of thrombosis was confirmed in 132 (61.7%) patients, while in most cases (94%) thrombosis was detected in the IVC system. DVT was detected in 47% of cases, superficial veins - in 39%, damage to both the deep and superficial venous systems was observed in 14%, including in 5 patients with the involvement of perforating veins.
Probable causes (risk factors) for the development of venous thrombosis are presented in Table. 2.
table 2... Thrombosis risk factors.
| Risk factor | Number of patients | |
|---|---|---|
| abs. | % | |
| Trauma (including prolonged plaster immobilization) | 41 | 31,0 |
| Varicose veins | 26 | 19,7 |
| Malignant neoplasms | 23 | 17,4 |
| Operations | 16 | 12,1 |
| Taking hormonal drugs | 9 | 6,8 |
| Thrombophilia | 6 | 4,5 |
| Chronic limb ischemia | 6 | 4,5 |
| Iatrogenic causes | 5 | 4,0 |
In our observations, the most common form of thrombosis, as well as lesions of the veins at the level of the popliteal-tibial and femoral-popliteal segments, were most often detected (Table 3).
Table 3... Localization of DVT.
More often (63%) there were thrombosis, completely occluding the lumen of the vessel, in second place in frequency (30.2%) were parietal thrombi. Floating thrombi were diagnosed in 6.8% of cases: in 1 patient - in the saphenofemoral anastomosis with ascending thrombosis of the trunk of the great saphenous vein, in 1 - ileofemoral thrombosis with a floating apex in the common iliac vein, in 5 - in the common femoral vein with thrombosis of the femoropopliteal segment and in 2 - in the popliteal vein with DVT of the lower leg.
The length of the non-fixed (floating) part of the thrombus, according to ultrasound data, varied from 2 to 8 cm. Moderate mobility of thrombotic masses was more often detected (5 patients), in 3 cases the mobility of the thrombus was minimal. In 1 patient, with calm breathing, spontaneous movements of the thrombus in the lumen of the vessel were visualized (high degree of mobility). In our observations, floating thrombi with a heterogeneous echo structure (7 people) were more often detected, while the hyperechoic component prevailed in the distal section, and the hypoechoic component in the area of the thrombus head (Fig. 2).
Rice. 2. Floating thrombus in the common femoral vein. B-mode, longitudinal vein scan. Thrombus of a heteroechoic structure with a clear hyperechoic contour.
In dynamics, to assess the course of the thrombotic process, 82 patients were examined, of which 63 (76.8%) had partial recanalization of thrombotic masses. In this group, 28 (44.4%) patients had a central type of recanalization (with longitudinal and transverse scanning in CDC mode, the recanalization canal was visualized in the center of the vessel); in 23 (35%) patients, parietal recanalization of thrombotic masses was diagnosed (more often blood flow was determined along the vein wall, immediately adjacent to the artery of the same name); In 13 (20.6%) patients, incomplete recanalization with fragmentary asymmetric staining in the CDC mode was detected. Thrombotic occlusion of the vein lumen was observed in 5 (6.1%) patients, in 6 (7.3%) cases, the vein lumen was restored. Signs of retrombosis persisted in 8 (9.8%) patients.
conclusions
Complex ultrasound examination, including angioscanning using spectral, color and power Doppler modes and soft tissue echography, is a highly informative and safe method that allows the most reliable and quick solution to the issues of differential diagnosis and treatment tactics in outpatient phlebological practice. It is advisable to conduct this study at the outpatient stage for earlier identification of patients who are not indicated (and sometimes contraindicated) thrombolytic therapy, and their referral to specialized departments; when confirming the presence of venous thrombosis, it is necessary to identify persons with a high risk of thromboembolic complications; observe the dynamics of the course of the thrombotic process and thereby adjust the treatment tactics.
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1 GBUZ of the Republic of Mordovia "Republican Clinical Hospital No. 4"
2 FSBEI HE Saratov State Medical University named after IN AND. Razumovsky Ministry of Health of Russia "
The article discusses the results of sonographic diagnosis of phlebothrombosis of the lower extremities in 334 patients. The main factors in the development of thrombosis in men were polytrauma, combined surgical interventions and cardiovascular diseases; in women - cardiovascular diseases and tumors of the uterus and ovaries. Color duplex scanning of veins allows to reveal the presence and level of phlebothrombosis, flotation of thrombotic masses, to assess the effectiveness of anticoagulant therapy and surgical prevention of pulmonary embolism. Tactical issues in floating thrombosis of the inferior vena cava system should be resolved individually, taking into account both the localization and length of the proximal part of the thrombus, and the patient's age and the presence of phlebothrombosis factors. In the presence of embolism-prone thrombosis against the background of severe concomitant pathology and contraindications to open surgery, the installation of a cava filter is a measure of PE prevention. In young patients, open or endovascular installation of temporary cava filters is advisable. In 32.0% of patients on the cava filter after its implantation, massive thrombosis was revealed, and in 17.0% - thrombus flotation below the level of plication was found, which confirms the importance and effectiveness of urgent surgical prevention of pulmonary embolism.
sonography
dopplerography
venous thrombosis
kava filter
veins of the lower extremities
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DIAGNOSIS AND TREATMENT OF FLOATING THROMBOSIS IN THE SYSTEM OF THE VENA CAVA INFERIOR
Ipatenko T.V. 1 Davydkin V.I. 2 Shchapov V.V. 1 Savrasov T.V. 1, 2 Makhrov V.V. 1 Shirokov I.I. 21 State budgetary institution of health of the Republic of Mordovia "Republican clinical hospital No. 4"
2 Saratov State medical University. V. I. Razumovsky
Abstract:
The article contains the results of ultrasonic diagnosis of acute venous thrombosis of lower extremities in 334 patients. The main risk factors venous thrombosis in men include injury, combined surgery and severe cardiovascular diseases; in women - cardiovascular diseases and tumors of female genitals. Color duplex scanning of the veins allows to establish the presence and level of the thrombotic process, flotation of a blood clot, to evaluate the effectiveness of treatment and surgical prevention of pulmonary embolism. Tactical issues with floating thrombus in the inferior Vena cava should be decided individually, taking into account both the localization of the proximal part of the thrombus and its extent and age of the patient and factors of the phlebothrombosis. In the presence of this conclusion was thrombosis on the background of severe comorbidity, and contraindications for open surgery to install a Vena cava filter is a measure for the prevention of pulmonary embolism. In patients of young age appropriate to install a removable Vena cava filters, or perform open surgery with a temporary Vena cava filter. From 32.0?% Patients showed thrombosis of the Vena cava filter after implantation, 17.0?% Of patients found to have a floating thrombus below the level of plication, which confirms the importance and effectiveness of urgent surgical prevention of pulmonary embolism.
Keywords:
venous thrombosis
veins of the lower extremities
Phlebothrombosis of the lower extremities is one of the leading problems of practical phlebology in terms of clinical and scientific significance. They are widespread among the adult population, and drug treatment is not effective enough. At the same time, a high level of incapacity for work and disability remains. Phlebothrombosis is distinguished by the blurring of the clinical picture in the first hours and days of the disease, and the first symptom is pulmonary thromboembolism (PE), which is the leading cause of both general and surgical mortality. In this regard, timely and accurate diagnosis of embolic venous thrombosis using informative, accessible and non-invasive methods is extremely important. Doppler ultrasound scanning (USDS) has become the main method for diagnosing these phlebothrombosis, which is a potential source of pulmonary thromboembolism.
There are few publications in the literature that detail the ultrasound characteristics of venous thrombus embolism. The leading criteria for thrombus embologency are considered to be the degree of its mobility and the length and echogenicity of the floating part, the characteristics of the outer contour of the thrombus (even, uneven, indistinct), the presence of a circular blood flow around the thrombus in the mode of color duplex mapping, both in longitudinal and transverse scanning.
Prevention of PE is an integral component of the treatment of patients with acute venous thrombosis. Unfortunately, the use of indirect anticoagulants does not contribute to the prevention of separation and migration of formed blood clots into the pulmonary arteries. Therefore, when an extended floating and embolic thrombosis is detected, surgical intervention is indicated to prevent thromboembolic migration (thrombectomy, plication, or endovascular implantation of a cava filter).
The question of surgical tactics for floating deep vein thrombosis of the extremities should be resolved individually, taking into account the localization of the proximal part of the thrombus, its length, flotation, the presence of comorbid and intercurrent pathology.
In the presence of severe intercurrent pathology and contraindications to open surgery in patients with embolism-prone thrombosis of the main veins, the installation of a cava filter is indicated for absolute indications (contraindications to anticoagulant therapy, embolic thrombosis if surgical thrombectomy is impossible, recurrent PE). In this case, it is important to take into account the fact of fixing floating thrombi (thrombus length is not more than 2 cm) and the possibility of conservative treatment tactics.
The unpredictability of the course of venous thrombosis in the inferior vena cava system is proved by the diagnosis of floating thrombosis in patients without any clinical signs of venous pathology, the detection of embolic thrombosis in patients with chronic venous diseases, facts of pulmonary embolism in occlusive forms of deep vein thrombosis.
Purpose of the study: improvement of sonographic diagnostics and results of urgent interventions in patients with acute phlebothrombosis.
Materials and research methods
We have analyzed the results of physical and sonographic diagnostics of phlebothrombosis of the lower extremities in 334 patients who were hospitalized in the state budgetary healthcare institution of the Republic of Mordovia "Republican Clinical Hospital No. 4". The patients' age was 20-81 years; 52.4% were women, 47.6% were men; 57.0% of them were able-bodied, and 19.4% were young (Table 1).
Table 1
Gender and age of the examined patients
table 2
Distribution of floating blood clots in the deep vein system of the lower extremities
The largest was the group of patients aged 61 and older (143 people); among men, persons aged 46 to 60 years prevailed - 66 (52.3%) people, among women - aged 61 and older - 89 (62 , 3%) people.
Phlebothrombosis in men under the age of 45 was more common in persons who abuse intravenous psychoactive substances. At the age of 60 and more, the number of female patients begins to prevail over the male, which is explained by the predominance of other risk factors in women: gynecological diseases (large uterine fibroids, ovarian tumors), ischemic heart disease, obesity, trauma, varicose veins and others. The decrease in morbidity in the general population in men aged 60 years or more is explained by a decrease in their proportion in the corresponding age groups, high mortality from PE, the development of chronic venous insufficiency and post-thrombophlebitic syndrome.
Ultrasonographic diagnostics and echoscopic monitoring were carried out on ultrasound devices Vivid 7 (General Electric, USA), Toshiba Aplio, Toshiba Xario (Japan), operating in real time using convex transducers 2-5, 4-6 MHz and linear transducers with a frequency of 5 -12 MHz. The study began with a projection of the femoral artery (in the groin area) with an assessment of blood flow in the transverse and longitudinal sections in relation to the longitudinal axis of the vein. In this case, the blood flow of the femoral artery was assessed. During scanning, the diameter of the vein, its compressibility (by compressing the vein with a sensor until the blood flow stops while maintaining blood flow in the artery), the state of the lumen, the safety of the valve apparatus, the presence of changes on the walls, the state of the paravasal tissues were assessed. The state of the hemodynamics of the veins was assessed using functional tests: a respiratory and cough test or a straining test. At the same time, the condition of the thigh veins, popliteal vein, leg veins, as well as the great and small saphenous veins was assessed. The hemodynamics of the inferior vena cava, as well as the iliac, great saphenous, femoral and leg veins in the distal part, were assessed in the supine position of the patient. The study of the popliteal veins, veins of the upper third of the leg and the lesser saphenous vein was carried out in the patient's prone position with a roller placed under the ankle joint area. To study the great veins and in case of difficulties in the study, a convex one was used, otherwise - linear sensors.
Cross-sectional scanning was performed to reveal the mobility of the thrombus head, as evidenced by the complete contact of the venous walls with slight compression by the transducer. During the examination, the nature of phlebothrombosis was established: parietal, occlusive or floating.
The list of laboratory diagnostic methods included the determination of the D-dimer level, coagulogram, and the study of thrombophilia markers. If pulmonary embolism was suspected, the complex of examination also included computed tomography in the mode of angiopulmonography and examination of the abdominal cavity and small pelvis.
For the purpose of surgical prevention of pulmonary embolism in acute phlebothrombosis, 3 methods of surgery were used: implantation of a cava filter, plication of a vein segment, and crossectomy and / or phlebectomy. In the postoperative period, ultrasound diagnostics aimed to assess the state of venous hemodynamics, the degree of recanalization or intensification of the thrombotic process in the venous system, the presence or absence of thrombus fragmentation, the presence of flotation, thrombosis of the contralateral limb veins, thrombosis of the plication zone or cava filter, and the linear and volumetric blood flow velocities were determined. and collateral blood flow.
Statistical analysis was performed using the Statistica software. Evaluation of differences in results between groups was carried out according to Pearson's criteria (carried out according to Pearson's criteria) and Student's (t). Differences were considered statistically significant, the level of significance of which was more than 95% (p< 0,05).
Research results and their discussion
The leading sign of phlebothrombosis was the presence of echo-positive thrombotic masses in the lumen of the vessel, the density of which increased with increasing age of the thrombus. At the same time, the valves of the valves ceased to differentiate, the transmission pulsation from the artery was not determined, the diameter of the thrombosed vein increased by 2-2.5 times compared to the contralateral vessel, when compressed by the sensor, it is not compressed. At the onset of the disease, when blood clots are visually indistinguishable from the normal lumen of the vein, we consider it especially important to perform compression ultrasonography. On the 3-4th day of the disease, there was a thickening and thickening of the venous wall due to phlebitis, and perivasal tissues became "blurred".
Parietal thrombosis was performed in the presence of a thrombus, free blood flow in the absence of complete contact of the walls during a compression test, the presence of a filling defect in duplex scanning and spontaneous blood flow in spectral Doppler ultrasonography.
Criteria for floating thrombosis were visualization of a thrombus in the lumen of a vein with the presence of free space and blood flow around the head, movement of the thrombus head in time with cardiac activity, during a test by straining or compression with a vein sensor, no contact of the venous walls during a compression test, bending around the type of blood flow, the presence of spontaneous blood flow with spectral doppler. For the final elucidation of the nature of the thrombus, the Valsalva test was used, which, however, poses a danger due to additional flotation of the thrombus.
Thus, according to the data of color duplex scanning, floating thrombi were found in 118 (35.3%) cases. Most often they were detected in the deep vein system of the pelvis and thigh (in 45.3% - in the deep veins of the thigh, in 66.2% - in the iliac veins), less often in the system of deep veins of the leg and great saphenous vein of the thigh. There was no difference in the frequency of thrombus flotation in men and women.
The frequency of floating phlebothrombosis has increased in recent years, which is associated with color duplex scanning in all patients before surgery, who are in prolonged immobilization, as well as, without fail, in patients with limb injuries and after operations on the osteoarticular system. We believe that, despite the obvious clinical picture of the presence of superficial varicothrombophlebitis, there is always a need for CDS to exclude subclinical floating thrombosis in both superficial and deep veins.
As you know, coagulation processes are accompanied by activation of the fibrinolytic system, and these processes run in parallel. For clinical practice, it is very important to establish both the flotation of the thrombus, the nature of the spread of the thrombus in the vein, and the likelihood of its fragmentation in the process of recanalization.
In CDS of the lower extremities, it is important: non-floating thrombi were found in 216 (64.7%) patients, of which occlusive thrombosis was found in 181 (83.8%) patients, non-occlusive parietal thrombosis - in 35 (16.2%) patients.
Parietal thrombi were detected as masses fixed to the vein walls over a considerable extent. At the same time, the lumen of the vein between the thrombotic masses and the wall itself was preserved. In the process of anticoagulant therapy, parietal thrombi are able to fragment, cause an embolism hazardous state and recurrent embolism of small branches of the pulmonary artery. With mobile and floating thrombi, soldered to the venous wall only in its distal part, a real and high risk of thrombus rupture and pulmonary embolism is created.
Among the non-occlusive forms of thrombosis, a dome-shaped thrombus can be distinguished, the sonographic signs of which are a wide base equal to the diameter of the vein, the absence of oscillatory movements in the blood flow, and the length of the thrombus up to 4 cm.The risk of pulmonary embolism in this variant of thrombosis is low.
Repeated color duplex scans were performed in all patients until the moment of fixation of the floating tail of the thrombus to the vein wall, then within 4 to 7 days of treatment, and always before the patient was discharged.
Patients with floating blood clots underwent ultrasound angioscanning of the veins of the lower extremities on the day of surgery, as well as 48 hours after implantation of the cava filter or vein plication (figure). In normal longitudinal scanning of the inferior vena cava, the cava filter is visualized as a hyperechoic structure, the shape of which depends on the filter model. The position of the cava filter in the vein at the level or slightly distal to the orifices of the renal veins or at the level of 1-2 lumbar vertebrae was considered typical. With CDS at the site of the filter, an expansion of the lumen of the vein is usually noted.
According to the data of color duplex scanning after implantation of cava filters, in 8 (32.0%) of 25 patients, massive thrombi were fixed on the filter. The vein segment in the area of plication was passable in 29 (82.9%) of 35 patients, in 4 (11.4%) continued thrombosis below the plication site was detected, in 2 (5.7%) blood flow in the plication area was not at all possible to determine, and the blood flow was carried out only along the collateral pathways.
The inferior vena cava with the installed sensor. Colored blood flow is visible (blue - flowing to the sensor, red - flowing from the sensor). On the border between them, a normally functioning cava filter
It was found that the implantation of the cava filter promotes the progression of the thrombotic process and increases the rate of recurrence of thrombosis, which can be explained, among other things, not only by the progression of the process, but also by the presence of a foreign body in the lumen of the vein and a slowdown in the main blood flow in this segment. The incidence of progression of thrombosis in patients who underwent plication and were treated only with medication is almost the same, but it is significantly lower in comparison with the same indicator after endovascular interventions.
conclusions
1. The main risk factors for phlebothrombosis in men include concomitant trauma, combined surgical interventions and the presence of severe cardiovascular diseases; in women - severe diseases of the cardiovascular system and genitals.
2. The advantages of color duplex scanning include the ability to objectively monitor the presence and level of thrombotic process, thrombus flotation, assess the effectiveness of drug therapy, monitor the course of phlebothrombosis after surgical prevention of pulmonary embolism. Ultrasonography allows you to solve tactical issues with floating thrombi individually, taking into account both the localization of the proximal part of the thrombus, its length, the nature of the thrombotic process and phlebothrombosis factors.
3. In the presence of embolic thrombosis against the background of severe concomitant pathology and contraindications to open surgery, the installation of a cava filter is a measure of PE prevention. In young patients, it is advisable to install removable cava filters or perform open operations with the installation of a temporary cava filter.
4. Massive thrombi on the cava filter after its endovascular implantation were found in 32.0% of patients; floating thrombi were found below the vein plication site in 17.0% of cases. These data indicate the effectiveness of PE prevention by surgical treatment of floating embologenous thrombosis in the inferior vena cava system.
Bibliographic reference
Ipatenko V.T., Davydkin V.I., Shchapov V.V., Savrasova T.V., Makhrov V.V., Shirokov I.I. DIAGNOSTICS AND TREATMENT OF FLOTING THROMBOSES IN THE LOWER CAVITY SYSTEM // Scientific Review. Medical sciences. - 2017. - No. 6. - P. 34-39;URL: https://science-medicine.ru/ru/article/view?id=1045 (date of access: 27.01. We bring to your attention the journals published by the "Academy of Natural Sciences"
M. I. PARKINA, V. V. Makhrov, V. V. Shchapov, O.S. Vedyashkina
ULTRASONIC DIAGNOSTICS OF ACUTE VENOUS THROMBOSES
LOWER LIMBS Abstract. The article discusses the results of ultrasound diagnostics of acute venous thrombosis of the lower extremities in 334 patients. In 32% of patients massive thrombi on the cava filter after its implantation were revealed, in 17% of patients floating thrombi were found below the site of vein plication, which confirms the need for urgent surgical prophylaxis of pulmonary embolism and its high efficiency.
Key words: sonography, Doppler sonography, vein thrombosis, thrombus, cava filter, veins of the lower extremities.
PARKIN M. I., MAKHROV V. V., SHCHAPOV V. V., VEDYASHKINA O. S.
ULTRASOUND DIAGNOSIS OF ACUTE VENOUS THROMBOSIS OF THE LOWER EXTREMITIES
Abstract. The article considers the results of ultrasonic diagnosis of acute venous thrombosis of the lower extremities in 334 patients. 32% of patients showed massive blood clots on the cava filter after implantation. 17% of patients showed floating clots below the vein plication. The ultrasound diagnosis confirms the need for an urgent surgical prophylaxis of pulmonary embolism, and its high efficiency.
Keywords: ultrasound, Doppler, blood clot, venous thrombosis, cava-filter, veins of the lower extremities.
Introduction. Acute venous thrombosis of the lower extremities is one of the most important problems of clinical phlebology in terms of practical and scientific significance. Phlebothrombosis is extremely common among the population, conservative treatment is not effective enough, the level of temporary and permanent disability is high. Often the clinic is erased, and the first symptom of venous thrombosis is pulmonary embolism (PE), which is one of the leading causes of postoperative mortality. In this regard, timely diagnosis of embologenous conditions using accessible and non-invasive methods is very important. These criteria are met by the CDS of the lower extremities, although there are not many works devoted to the study of the echosemiotics of floating thrombi. Until now, there is no unified point of view in determining the ultrasound criteria for embologenous thrombi. Insufficient information about the embologenic properties of floating thrombi explains the absence of these
The aim of the study is to improve the diagnosis and treatment results in patients with acute venous thrombosis of the lower extremities.
Material and research methods. Analyzed the results of clinical and ultrasound diagnostics of acute venous thrombosis of the lower extremities in 334 patients in 2011-2012 who were hospitalized in the department of vascular surgery of the state budgetary institution of health care of the Republic of Mordovia "Republican Clinical Hospital No. 4".
The age of the patients ranged from 20 to 81 years; 52.4% were women, 47.6% were men; 57% of them were able-bodied, and 19.5% were young. Basic information on the distribution of patients by sex and age is presented in Table 1.
Table 1
Distribution of patients by sex and age_
Up to 45 years old 45-60 years old 60 years old and older
Abs. number% Abs. number% Abs. number% Abs. number %
Men 39 60.0 66 52.3 54 37.7 159 47.6
Women 26 40.0 60 47.6 89 62.3 175 52.4
Total 65 19.4 126 37.7 143 42.8 334 100
The most numerous cohort of patients was the group of 60 years and older (143 people), among men, persons aged 45 to 60 years prevailed - 66 people (52.3%), among women - those aged 60 and older - 89 (62 , 3%) people.
Acute venous thrombosis occurs before the age of 45 more often in men, which is associated with the abuse of intravenous administration of psychoactive substances, and at the age of 60 or more, the number of female patients begins to prevail over the male. This can be explained by the fact that women are beginning to dominate other risk factors: gynecological diseases, coronary artery disease, obesity, trauma, varicose veins, etc. A decrease in the incidence in the general population of men aged 60 years and more is explained by a decrease in their share in the corresponding age groups , short life expectancy, high mortality from PE, development of chronic venous insufficiency and post-trophlebitis syndrome.
Ultrasonographic diagnostics and dynamic echoscopy were performed on
ultrasonic devices SonoAce Pico (Korea), Vivid 7 (General Electric, USA), Toshiba
Xario SSA-660A (Toshiba, Japan) operating in real time using 7 and 3.5 MHz sensors. The study began with the groin in the transverse and longitudinal sections in relation to the vascular bundle. The blood flow of the adjacent artery was assessed. When obtaining an image of the veins, the following parameters were assessed: diameter, compressibility (compression by the sensor until the blood flow in the vein was stopped while maintaining blood flow in the artery), features of the course, the state of the internal lumen, the safety of the valve apparatus, changes in the walls, the state of the surrounding tissues, and the blood flow of the adjacent artery was assessed. The state of venous hemodynamics was also assessed using functional tests: respiratory and cough test or a straining test. At the same time, the condition of the thigh veins, popliteal vein, leg veins, as well as the great and small saphenous veins was assessed. When scanning the IVC, iliac veins, great saphenous vein, femoral veins and veins of the lower leg in the distal part of the lower extremities, the patient was in the supine position. The study of the popliteal veins, veins of the upper third of the leg and the lesser saphenous vein was carried out in the patient's prone position with a roller placed under the ankle joint area. For the study of the great veins and in case of difficulties in the study, convex, otherwise linear, transducers were used.
Scanning was started in cross-section to exclude the presence of a floating apex of the thrombus, as evidenced by full contact of the venous walls during light compression with the transducer. During the examination, the nature of the venous thrombus was established: parietal, occlusive and floating thrombi.
For the purpose of surgical prevention of pulmonary embolism in acute phlebothrombosis, 3 methods of surgery were used: installation of a cava filter, plication of a vein segment, and crossectomy and / or phlebectomy. In the postoperative period, ultrasound diagnostics aimed to assess the state of venous hemodynamics, the degree of recanalization or intensification of the thrombotic process in the venous system, the presence or absence of thrombus fragmentation, the presence of flotation, thrombosis of the contralateral limb veins, thrombosis of the plication zone or cava filter, and the linear and volumetric blood flow velocities were determined. and collateral blood flow. Statistical processing of the obtained digital data was carried out using the Microsoft Office 2007 software package.
Research results. The main signs of thrombosis included the presence of echo-positive thrombotic masses in the lumen of the vessel, the echo density of which increased as the duration of the thrombus increased. At the same time, the valve leaflets ceased to differentiate, the transmitting arterial pulsation disappeared, and the diameter increased.
a thrombosed vein is 2-2.5 times as compared to the contralateral vessel; when compressed by a sensor, it is not compressed. In the early days of the disease, we consider it especially important to compress ultrasonography, when the thrombus is visually indistinguishable from the normal lumen of the vein. On the 3-4th day of the disease, there was a thickening and thickening of the walls of the veins due to phlebitis, the perivasal structures became "blurred".
Signs of parietal thrombosis were the presence of a thrombus with free blood flow in the absence of complete collapse of the walls during compression ultrasonography, the presence of a filling defect in duplex scanning, and spontaneous blood flow in spectral Doppler ultrasonography.
Criteria for a floating thrombus were visualization of a thrombus in the lumen of a vein with free space, oscillatory movements of the thrombus head, no contact of the vein walls during compression with a sensor, the presence of free space when performing respiratory tests, bending around the type of blood flow, the presence of spontaneous blood flow in spectral Doppler ultrasonography. For the final elucidation of the nature of the thrombus, the Valsalva test was used, which is dangerous due to additional flotation of the thrombus.
Thus, according to the data of ultrasound diagnostics, floating thrombi were found in 118 (35.3%) patients (Fig. 1).
60 -50 -40 -30 -20 -10 -0 -
Fig 1. Frequency of floating blood clots in the system of superficial and deep veins of the extremities
It was found that according to color duplex scanning, floating thrombi are most often detected in the deep vein system (especially in the ileofemoral segment - 42.0%), less often in the deep vein system of the leg and
ileofemoral segment
deep veins of the thigh
popliteal vein and leg veins
saphenous vein of the thigh
saphenous vein of the thigh. There was no difference in the frequency of floating blood clots in the deep system in men and women.
In 2011, the frequency of floating thrombosis was 29.1% of all examined patients, which is 1.5 times less than in 2012 (Table 2). This is due to the ultrasound diagnostics in all patients admitted to the clinic, as well as if there is a suspicion of acute pathology of the venous system. This fact is confirmed by the fact that in 2012 there was a significant increase in the proportion of patients in whom floating blood clots in the superficial system were detected only according to CDS data. In this regard, the presence of superficial varicothrombophlebitis, despite a clear clinical picture, dictates the need for CDS to detect subclinical floating thrombosis of both superficial and deep veins.
Table 2
Distribution of floating blood clots in the deep vein system of the lower extremities
Localization 2011 2012 Total
If I float, I float, I float,
thrombi thrombi thrombi thrombi
Ileofemoral 39 23 (59.0%) 35 27 (55.2%) 74 50 (67.6%)
Deep veins of the thigh 31 12 (38.7%) 33 15 (45.5%) 64 27 (42.2%)
Popliteal vein and 36 6 (16.7%) 31 10 (32.3%) 67 16 (23.9%)
leg veins
Subcutaneous veins of the thigh 69 10 (14.5%) 60 15 (25.0%) 129 25 (19.4%)
Total 175 51 (29.2%) 159 67 (42.2%) 334 118 (35.3%)
As you know, the coagulation processes are accompanied by the activation of the fibrinolytic system, these processes run in parallel. For clinical practice, it is very important to establish not only the flotation of the thrombus, but also the nature of the spread of the thrombus in the vein, the possibility of its fragmentation in the process of recanalization.
With CDS of the lower extremities, non-floating thrombi were found in 216 patients (64.7%): occlusive thrombosis was found in 183 patients (54.8%), non-occlusive parietal thrombosis - in 33 (9.9%).
Parietal thrombi were most often fixed to the vein walls throughout and were characterized by the preservation of the gap between the thrombotic masses and the venous wall. However, they can fragment and migrate into the pulmonary circulation. With floating thrombi, adhered to the vascular wall only in the distal part of the affected vein, a real high risk of pulmonary embolism is created.
Among the non-occlusive forms of thrombosis, a dome-shaped form can be distinguished
thrombus, the morphological features of which are a wide base equal to
the diameter of the vein, the absence of oscillatory movements in the blood flow and the length up to 4 cm.
Control color duplex scanning was performed in all patients until the moment of fixation of the floating tail of the thrombus to the vein wall and then within 4 to 7 days of treatment and before the patient was discharged.
In patients with floating thrombi, ultrasound angioscanning of the veins of the lower extremities was performed without fail before the operation, as well as 48 hours after implantation of the cava filter or vein plication (Fig. 2). Normally, with longitudinal scanning, the cava filter is visualized in the lumen of the inferior vena cava as a hyperechoic structure, the shape of which depends on the filter modification. The most typical position of the cava filter in a vein is at the level or immediately distal to the orifices of the renal veins or at the level of 1-2 lumbar vertebrae. Expansion of the lumen of the vein in the area of the filter is usually noted.
Fig 2. Inferior vena cava with the installed sensor. Colored blood flow is visible (blue flowing to the sensor, red - flowing from the sensor). There is a normally functioning cava filter on the border between them.
According to the data of color duplex scanning, after the installation of cava filters, in 8 (32%) of 25 patients, massive thrombi fixation on the filter was observed. The vein segment after plication was passable in 29 (82.9%) of 35 patients, in 4 (11.4%) - ascending thrombosis below the plication site was detected, in 2 (5.7%) - blood flow in the plication area was not at all possible visualize.
It should be noted that the rate of progression of the thrombotic process and recurrence of thrombosis is highest in patients who underwent KAV implantation.
filter, which can be explained by the presence of a foreign body in the IVC lumen, which changes the nature of blood flow in the segment. The frequency of recurrent thrombosis in patients who underwent plication or who were treated only conservatively is practically the same and, at the same time, is significantly lower in comparison with the same indicator after endovascular interventions.
Conclusions. The leading risk factors for thrombus formation in men include trauma and combined surgical interventions, severe cardiovascular diseases; in women - cardiovascular diseases and diseases of the female genital organs. Color duplex scanning allows to establish the presence and level of thrombotic process in a vein, thrombus flotation, to evaluate the effectiveness of drug therapy, to monitor the course of phlebothrombosis after surgical prophylaxis of PE. After endovascular implantation, massive thrombi on the cava filter were found in 32% of patients; after vein plication, floating thrombi below the site of surgery were found in 17% of patients, which confirms the feasibility and high efficiency of urgent surgical prevention of fatal pulmonary embolism.
LITERATURE
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2. Kulikov VP Ultrasound diagnostics of vascular diseases / Ed. V.P. Kulikov. - 1st ed. - M .: OOO STROM, 2007 .-- 512 p.
4. Saveliev V. S., Gologorsky V. A., Kirienko A. I. et al. Phlebology. Guide for Physicians / Ed. V.S.Savelyeva. - M: Medicine, 2001 .-- 664 p.
5. Saveliev VS, Kirieko AI, Zolotukhin IA, Andriyashkin AI Prevention of postoperative venous thromboembolic complications in Russian hospitals (preliminary results of the project "Security Territory") // Phlebology. - 2010. - No. 3. - S. 3-8.
6. Saveliev VS, Kirienko AI Clinical surgery: national leadership: in 3 volumes - T 3. - M: GEOTAR-Media. - 2010 .-- 1008 p.
7. Shulgina L. E., Karpenko A. A., Kulikov V. P., Subbotin Yu. G. Ultrasonic criteria of venous thrombosis embolism // Angiol and vascular surgery. -2005. - No. 1. - S. 43-51.
8. Linkin L. A., Weitz J. L. New anticoagulants // Semin. Thromb. Hemost. - 2003. - Vol. 6. - pp. 619-623.
9. Michiels C. et al. Role of endothelium and blood stasis in the appearance of varicose veins // Int. Angiol. - 2006. - Vol. 21. - pp. l-8.
10. Snow V., Qaseem A., Barry P. et al. Management of venous thromboembolism: a clinical practice guideline from the American College of Physicians and the American Academy of Family Physicians // Ann. Fam. Med. - 2007. - pp. 74-80.
Ultrasound diagnostics of acute venous thrombosis
Acute venous thrombosis of the inferior vena cava system is divided into embologenous (floating or non-occlusive) and occlusive. Non-occlusive thrombosis is a source of pulmonary embolism. The superior vena cava system gives only 0.4% of pulmonary embolism, the right heart - 10.4%, while the inferior vena cava is the main source of this formidable complication (84.5%).
A lifetime diagnosis of acute venous thrombosis can be established only in 19.2% of patients who died from pulmonary embolism. The data of other authors indicate that the frequency of correct diagnosis of venous thrombosis before the development of fatal pulmonary embolism is low and ranges from 12.2 to 25%.
Postoperative venous thrombosis is a very serious problem. According to B.C. Saveliev, postoperative venous thrombosis develops after general surgical interventions in an average of 29% of patients, in 19% of cases after gynecological interventions and in 38% of cases of transvesical adenomectomy. In traumatology and orthopedics, this percentage is even higher and reaches 53-59%. A special role is given to the early postoperative diagnosis of acute venous thrombosis. Therefore, all patients who pose a certain risk in terms of postoperative venous thrombosis should undergo a complete examination of the inferior vena cava system at least twice: before and after surgery.
It is considered of fundamental importance to identify violations of the patency of the great veins in patients with arterial insufficiency of the lower extremities. This is especially necessary for a patient in whom surgery is expected to restore arterial circulation in the limb, the effectiveness of such a surgical intervention decreases in the presence of various forms of obstruction of the great veins. Therefore, all patients with limb ischemia should be examined for both arterial and venous vessels.
Despite the significant advances made in recent years in the diagnosis and treatment of acute venous thrombosis of the inferior vena cava and peripheral veins of the lower extremities, interest in this problem has not only not diminished in recent years, but is constantly growing. A special role is still assigned to the issues of early diagnosis of acute venous thrombosis.
According to their localization, acute venous thrombosis is subdivided into thrombosis of the ilicaval segment, femoral-popliteal segment and thrombosis of the leg veins. In addition, the large and small saphenous veins can be affected by thrombotic lesions.
The proximal border of acute venous thrombosis can be located in the infrarenal part of the inferior vena cava, suprarenal, reach the right atrium and be in its cavity (echocardiography is shown). Therefore, the examination of the inferior vena cava is recommended to begin with the right atrium and then gradually descend down to its infrarenal section and the place where it flows into the inferior vena cava of the iliac veins. It should be noted that the closest attention should be paid not only to the examination of the trunk of the inferior vena cava, but also to the veins flowing into it. First of all, they include the renal veins. Usually, thrombotic lesion of the renal veins is due to the volumetric formation of the kidney. It should not be forgotten that the cause of thrombosis of the inferior vena cava can be the ovarian veins or testicular veins. Theoretically, it is believed that these veins, due to their small diameter, cannot lead to pulmonary thromboembolism, especially since the prevalence of a thrombus to the left renal vein and the inferior vena cava along the left ovarian or testicular vein, due to the tortuosity of the latter, looks casuistic. However, you should always strive to inspect these veins, at least their mouths. In the presence of thrombotic occlusion, these veins slightly increase in size, the lumen becomes heterogeneous and they are well located in their anatomical areas.
With ultrasound triplex scanning, venous thrombosis is subdivided in relation to the lumen of the vessel into parietal, occlusive and floating thrombi.
Ultrasound signs of parietal thrombosis are considered to be visualization of a thrombus with free blood flow in this area of the changed lumen of the vein, the absence of complete collapse of the walls when the vein is compressed by the sensor, the presence of a filling defect in the CDC, the presence of spontaneous blood flow in spectral Doppler ultrasonography.
Thrombosis is considered occlusive, the signs of which are the absence of wall collapse during compression of the vein with a sensor, as well as visualization of inclusions of various echogenicity in the lumen of the vein, the absence of blood flow and vein staining in spectral Doppler and CDC modes. Ultrasonic criteria for floating thrombi are: visualization of a thrombus as an echogenic structure located in the lumen of a vein with the presence of free space, oscillatory movements of the apex of the thrombus, no contact of the vein walls during compression with a sensor, the presence of free space when performing respiratory tests, bending around the type of blood flow when color coding the flow , the presence of spontaneous blood flow in spectral Doppler ultrasonography.
The possibilities of ultrasound technologies in the diagnosis of the age of thrombotic masses are of constant interest. Identification of signs of floating thrombi at all stages of thrombosis organization can improve the efficiency of diagnosis. Particularly valuable is the earliest diagnosis of fresh thrombosis, which makes it possible to take measures for early prevention of pulmonary embolism.
After comparing the ultrasound data of floating thrombi with the results of morphological studies, we came to the following conclusions.
Ultrasonic signs of a red thrombus are hypoechoic fuzzy contour, anechoic thrombus in the apex and hypoechoic distal part with separate echogenic inclusions. Signs of a mixed thrombus are a heterogeneous structure of a thrombus with a hyperechoic clear outline. In the structure of the thrombus in the distal parts, heteroechoic inclusions predominate, in the proximal parts, predominantly hypoechoic inclusions. Signs of a white thrombus are a floating thrombus with clear contours, a mixed structure with a predominance of hyperechoic inclusions, and with CDC, fragmented flows through thrombotic masses are recorded.
E.A. MARUSHCHAK, Ph.D., A.R. ZUBAREV, MD, DSc, Professor, A.K. DEMIDOVA
Russian Scientific Research Medical University. N.I. Pirogov, Moscow
Methodology of ultrasound examination of venous thrombosis
The article presents a four-year experience in performing ultrasound studies of venous blood flow (12 394 outpatients and inpatients with acute venous pathology of the Central Clinical Hospital of the Russian Academy of Sciences). The methodology of performing primary and dynamic ultrasound examinations in patients with conservative treatment of venous thrombosis and when performing various methods of surgical prevention of pulmonary embolism is described on the basis of a large clinical material. Particular attention is paid to the interpretation of the results of ultrasound studies in terms of the likelihood of pulmonary embolism. The results of the application of the proposed methodology of ultrasound examination in the practice of a multidisciplinary ambulance hospital and a diagnostic and treatment center are analyzed.
Key words: ultrasound angioscanning, vein, acute venous thrombosis, deep vein thrombosis, pulmonary embolism, surgical prevention of pulmonary embolism
About Introduction
The epidemiology of acute venous thrombosis (AVT) is characterized by disappointing data: the incidence of this pathology in the world reaches 160 people per 100 thousand people annually, and in the Russian Federation - at least 250 thousand people. According to M.T. Severinsen (2010) and L.M. Lapie1 (2012), the incidence of phlebothrombosis (FT) in Europe is 1: 1000 annually and reaches 5: 1000 in patients with skeletal trauma. A large-scale analysis of the incidence of deep vein thrombosis (DVT) carried out in the United States in 2012 showed that 300-600 thousand Americans are diagnosed with this pathology annually, and 60-100 thousand of them die from pulmonary embolism (PE). These indicators are due to the fact that OBTs occur in patients with a wide variety of pathologies and are often secondary, complicating any diseases or surgical interventions.
For example, the incidence of venous thromboembolic complications (VTEC) in inpatient (including surgical) patients reaches 10-40%. V.E. Barinov et al. cite data on the frequency of PE among air travelers, equal to 0.5-4.8 cases per 1 million passengers, and fatal PE is the cause of 18% of deaths in airplanes and airports. PE is the cause of death in 5-10% of hospital patients, and this figure is steadily increasing. Massive and, as a consequence, lethal PE in some patients is the only, first and last manifestation of OBT. In a study by L.A. Laberco et al., Devoted to the study of PE in surgical patients, provides data on mortality from VTEC in Europe: their number exceeds the total mortality from breast cancer, acquired immunodeficiency syndrome and car accidents and is more than 25 times higher than mortality from infections caused by Staphylococcus aureus ...
Interestingly, 27 to 68% of all deaths from PE are potentially preventable. The high value of the ultrasound method (US) in the diagnosis of OBT is due to its non-invasiveness and approaching 100% sensitivity and specificity. Physical methods of examination of patients with suspected OBT make it possible to make a correct diagnosis only in typical cases of the disease, while the frequency of diagnostic errors reaches 50%. Thus, the ultrasound diagnostician has a 50/50 chance of verifying or excluding OVT.
Instrumental diagnostics of OBT is one of the urgent tasks in terms of visual assessment of the disease substrate, since the definition of angiosurgical tactics depends on the data obtained, and, if necessary, surgical prophylaxis of pulmonary embolism, the choice of its method. Execution of dynamic
Ultrasound is necessary both when conducting conservative treatment of OVT in order to assess the emerging changes in the affected venous bed, and in the postoperative period.
Ultrasound doctors are at the forefront of visual assessment of OBT. It is ultrasound that is the method of choice for this category of patients, which dictates the need not only to detect OBT, but also to correctly describe and interpret all possible characteristics of this pathological condition. The aim of this work was to standardize the methodology for performing ultrasound examination in OVT, aimed at minimizing probable diagnostic errors and maximizing adaptation to the needs of clinicians who determine treatment tactics.
About Materials
In the period from October 2011 to October 2015 at the Central Clinical Hospital of the Russian Academy of Sciences (Central Clinical Hospital of the Russian Academy of Sciences, Moscow), 12,068 primary ultrasound examinations of the blood flow of the inferior vena cava system and 326 of the superior vena cava system were performed (12,394 ultrasound examinations in total). It is important to emphasize that the Central Clinical Hospital of the Russian Academy of Sciences deliberately does not accept acute venous pathology through the ambulance channel. Out of 12,394 studies, 3,181 were performed on an outpatient basis for patients of the medical diagnostic center, 9,213 - for inpatients with suspected acute venous pathology or for prophylactic purposes in patients at risk for venous thromboembolic complications, as well as for indications as preoperative preparation. OBT were diagnosed in 652 inpatients (7%) and in 86 outpatients (2.7%)
(738 people in total, or 6%). Of these, the OVT localization in the inferior vena cava bed was detected in 706 (95%), in the superior vena cava bed - in 32 patients (5%). Vascular ultrasound was performed on the following devices: Voluson E8 Expert (GE HC, USA) using multifrequency convex (2.0-5.5 MHz) and linear (5-13 MHz) transducers in the following modes: B-mode, color Doppler mapping, energy Doppler mapping, pulse-wave mode and non-Doppler blood flow imaging (B-flow) mode; Logiq E9 Expert (GE HC, USA) with a similar set of transducers and programs plus high-quality ultrasound elastography.
About Methodology
The first task during ultrasound is to detect the substrate of the disease - venous thrombosis itself. OVT are characterized by individual and often mosaic anatomical localization in the cavity of the vena cava. That is why it is necessary to study in detail and polypositionally not only the superficial and deep bed of both lower (or upper) extremities, but also the ileocaval segment, including those with renal veins. Before conducting an ultrasound scan, it is necessary to familiarize oneself with the available data of the patient's medical history, which in some cases will help to refine the search and suggest atypical sources of OBT formation. One should always remember about the existing likelihood of a bilateral and / or multifocal thrombotic process along the venous bed. The informativeness and value of ultrasound for angiosurgeons is associated not so much with the fact of the verification of OBT as with the interpretation of the results obtained and with their de-
talization. So, on the basis of the ultrasound conclusion, presented as "non-occlusive thrombosis of the common femoral vein," angiosurgeon, besides confirming the fact of OBT, does not receive any other information and, accordingly, cannot determine in detail further tactics. Therefore, in the ultrasound protocol, the identified OBT must be accompanied by all its characteristics (border, nature, source, length, flotation length, attitude to anatomical landmarks, etc.). In the conclusion of the ultrasound, there should be an interpretation of the results aimed at further determining the tactics by the clinician. The terms iliocaval, iliofemoral are also clinical and not ultrasound.
About Primary ultrasound
The main technique for verifying OBT during ultrasound is the compression of the zone of interest (a fragment of the visualized vessel) by the sensor. It should be noted that the force of compression should be sufficient, especially when examining a deep bed, in order to avoid receiving false positive information about the presence of thrombotic masses where they are absent. A clean vessel that does not have pathological intravenous inclusions, containing only liquid blood, undergoes complete compression when squeezed, its lumen “disappears”. In the presence of thrombotic masses in the lumen (the latter can be of different structure and density), it will not be possible to completely compress the lumen, which can be confirmed by compression of the unchanged contralateral vein at a similar level. The thrombosed vessel has a larger diameter compared to the free contralateral one, and its staining in the color mode
Doppler imaging (CDM) will be at least uneven or absent altogether.
The study of the ileocaval segment is carried out with a convex transducer with a low frequency, however, in some cases, high-frequency linear transducers can be used in patients with low body weight. In obese patients with severe flatulence, as well as in the presence of adhesive disease after surgery, visualization of the ileocaval segment will be sharply difficult. The use of drugs that suppress and reduce the manifestations of gas formation, as well as cleansing enemas, improves imaging conditions only slightly, and in addition, it requires additional time or may even be contraindicated in patients with suspected non-occlusive OBT. The use of auxiliary modes, such as CDC, in these cases does not reduce the risk of diagnostic errors. For example, in case of non-occlusive local thrombosis of the external iliac vein in an obese patient, the vessel lumen in the CDC mode can completely stain, and it is not possible to compress the vein. To study the pelvic veins and some fragments of the iliac veins in case of poor visualization from the transabdominal approach, it is possible to use intracavitary sensors (transvaginal or transrectal ultrasound). When examining the deep venous bed of the lower extremities in obese patients, as well as in the presence of lymphostasis, when the depth of penetration of the ultrasound beam from the linear high-frequency transducer is insufficient, it is necessary to use the low-frequency convex one. In this case, you can define
thrombosis border, but the quality of visualization of the actual apex of the thrombus in B-mode will be unimportant. With poor visualization of the upper border and the nature of thrombosis or the venous segment as such, it is not necessary to give these characteristics in conclusion, remembering the main rule of the ultrasound diagnostic doctor: do not describe what you have not seen or seen badly. In this case, it is worth making a note that obtaining this information by the ultrasound method at the time of the examination is not possible for technical reasons. It should be understood that ultrasound as a technique has its limitations and the lack of clear visualization of the upper limit and the nature of thrombosis is a reason to use other research methods.
In a number of cases, visualization of the upper border and the nature of thrombosis is helped by the Val-salvi test (straining the patient to create retrograde blood flow in the studied vessel, in which the diameter of the vein will increase and, possibly, thrombus flotation will be visible) and a distal compression test (clamping of the lumen of the vein above the level of thrombosis, at which the diameter of the vessel will also increase, which will improve visual assessment). Figure 1 demonstrates the moment of retrograde blood flow in the OBV during the Valsalvi test, as a result of which the floating thrombus, being washed from all sides by the blood flow, took a central position relative to the vessel axis. The Valsalvi test, like the test with distal compression, must be used with caution, since in case of embolic thrombosis, they can provoke PE. With regard to OVT, it is the B-mode that has the greatest diagnostic value. With good visualization, one se-
for a detailed description of all OVT characteristics. The rest of the modes (CDM, energy mapping (EC), B-A ^, elastography) are auxiliary. In addition, additional modes have some inherent artifacts that can mislead the doctor. These artifacts include the phenomenon of "flooding" of the lumen in the CDC mode with non-occlusive thrombosis or, conversely, the complete absence of staining of the lumen of a known passable vessel. There is little chance of diagnosing a thrombosis that is not recognized in the B-mode using only auxiliary ones. Also, when drawing up an ultrasound conclusion, you should not completely rely on data obtained only by additional modes.
It was mentioned above that for a competent construction of an ultrasound conclusion, one fact of detecting thrombotic masses in the lumen of a vein is not enough. The conclusion should contain information about the nature of thrombosis, its source, boundary in relation to ultrasound and anatomical landmarks and, in the case of floating thrombosis, an individual characteristic of its potential embologeness. A detailed assessment of the above parameters makes it possible to determine the indications for conservative treatment or for surgical prophylaxis of PE, including with the choice of its type.
Occlusive OBT and non-occlusive OBT of a parietal nature, being fixed to the vessel walls completely or on one side, respectively, have a low degree of embolism and, as a rule, are treated conservatively. A floating thrombus is a thrombus that has a single fixation point and is streamlined by blood flow from all sides. it
FIGURE 1. Application of the Valsalvi test to improve visualization of the floating thrombus head in B-mode (common femoral vein in the projection of the saphenofemoral junction)
1 - retrograde blood flow in the common femoral vein during straining with the effect of "spontaneous contrast"; 2 - the lumen of the common femoral vein; 3 - floating thrombus; 4 - sapheno-femoral anastomosis
FIGURE 2. Floating thrombi with varying degrees of embolism (top - thrombus with low threat of PE, bottom - thrombus with high threat of PE)
classical definition of FT. However, in different patients with floating thrombosis, even with an equal flotation length, the degree of embolism will be different, and therefore should be determined individually in real time. So, in a floating thrombus with a short body length and localization in the superficial femoral vein, the embolism will be rather low. In a long floating thrombus, which looks like a "worm" and is located in the lumen of the common femoral vein and above, the embolism is greater (Fig. 2). Below we will consider in more detail the characteristics of the floating head of a thrombus from the standpoint of determining its embolism.
The need to measure the flotation length, as a rule, is not in doubt, as well as the fact that the higher the value obtained, the worse the prognosis in terms of possible fragmentation of the thrombus. The thickness of the thrombus neck and its ratio to the length of the floating head, as well as the amplitude and type of vibrational (actually floating) movements of the head in the lumen of the vein characterize the elastic deformation forces acting on the thrombus, leading to separation. Echo-
the genicity and structure of a thrombus also provide information on the probability of fragmentation: the lower the echogenicity and the less homogeneous the structure of the thrombus, the higher the probability of its fragmentation. In addition to the characteristics of the tip of a floating thrombus, the upper border of the thrombus (the zone where the vessel begins to be completely compressed and no longer contains thrombotic masses) and its source are important to determine the degree of potential embolism. The higher the thrombosis border, the higher the blood flow velocity there. The more the venous segment has an anastomosis, the more there are “washing away” turbulent flows. The closer the localization of the thrombus head to the natural bends of the limb (groin, knee), the higher the likelihood of permanent compression of the lumen containing the thrombus. When characterizing the source of thrombosis, it should be remembered that a typical OBT “originates” in small muscle branches giving rise to the medial group of sural veins, and progresses from the bottom up, spreading to the popliteal (PT), then to the superficial femoral (PBV), common femoral vein (OBV ) and higher. Typical
thrombophlebitis forms in the dilated great saphenous (GSV) and small saphenous (SSV) veins.
Defining and describing a typical OBT in ultrasound is straightforward. A thrombus with an atypical source in a number of cases remains not diagnosed at all, namely, atypical thrombosis is the most embolous. Sources of atypical OBT can be: deep femoral veins (HDV), pelvic veins, injection sites of narcotic drugs (the so-called cutaneous-vascular fistula), venous catheter insertion area and the catheter itself, renal veins, tumor invasion, gonadal veins, hepatic veins , as well as the transition of thrombosis to deep veins through the fistulas and communicants of the affected saphenous veins (Fig. 3). Most often, atypical thrombosis is of a floating nature with weak fixation in the neck and is located in the femoral and iliocaval segments. Interventional OBT (post-injection and post-catheter) are formed at the point of damage (alteration) of the vessel, it is also the only point of fixation of the thrombus. Interventional thrombosis is often localized
nye, or segmental, that is, they are determined only in one venous segment (usually OBV), while deep veins above and below the thrombus are passable. Another group of atypical OBTs are combined deep and superficial vein thrombosis. Among them, according to the ultrasound picture, 3 options can be distinguished: 1. Ascending thrombophlebitis in the GSV pool and thrombosis of the medial group (most often) of the sural veins (occurs through the passage of a thrombus from the superficial veins through thrombosed perforating veins).
2 Ascending thrombophlebitis in the GSV and / or SSV basin with a transition to the deep vein system at the site of the anastomosis of the trunks (sapheno-femoral, sapheno-popliteal phlebothrombosis).
3 Various combinations of the above options, up to thrombosis of OBV with several floating heads. For example, ascending thrombophlebitis in the GSV basin with a transition to OBV at the site of the saphenofemoral anastomosis (SPS) plus OBV thrombosis in the progression of thrombosis from the deep veins of the leg through the passage of a thrombus from the superficial veins through thrombosed perforators (Fig. 4). The likelihood of developing a combined
thrombosis of the superficial and deep vein systems and bilateral PT once again confirms the need to perform a complete ultrasound of the venous blood flow of the inferior vena cava system along the entire length of both primary and dynamic studies.
Atypical thrombosis also includes OVT complicating the course of oncological diseases (thrombosis of the renal veins with transition to the inferior vena cava is not uncommon). Another atypical source is the deep femoral veins, which are most often affected during operations on the hip joint, as well as the pelvic veins, in which thrombosis occurs with a number of diseases of the organs of this region. The most insidious variant of atypical thrombosis is in situ thrombosis. This is a variant of local segmental thrombosis with no apparent source. As a rule, the place of thrombus formation in these cases is the valve sinuses with a low blood flow velocity in this area. Often in situ thrombi occur in the iliac veins or OBV, and in most cases they are diagnosed after PE, using second-order imaging techniques (computed tomography).
phlebography, angiography) or are not diagnosed at all, thus being the source of "PE without a source", completely detaching from the vessel wall, leaving no substrate in the lumen of the vein.
The description of mosaic or bilateral OBT should contain detailed information on both lower extremities and on all segments of the lesion separately. Assessment of the potential embolism hazard of a floating thrombus is carried out by means of a cumulative analysis of its characteristics. To facilitate this process, each of the criteria for a floating thrombus head is assigned 1 or 0 conditional points according to the scheme described below (Table 1). The resulting total score gives a more accurate picture of the potential PE. Working according to this scheme allows you to avoid a gap in the assessment of one or a number of criteria and, thus, not only to standardize the ultrasound technique, but also to improve its effectiveness. When diagnosing an OBT with a high threat of PE, it is necessary to understand that, probably, he will be shown to perform one or another type of surgical prophylaxis of this complication. The main operation for OBT on
FIGURE 3. Various sources of atypical thrombosis (projection of the sapheno-femoral anastomosis of the common femoral vein)
1 - source - femoral catheter; 2 - source - skin-vascular fistula (drug addicts); 3 - source - great saphenous vein; 4 - source - deep femoral vein; 5 - source - superficial femoral vein
TABLE 1. Determination of the potential degree of embolism of floating phlebothrombosis
Ultrasound criteria Interpretation of ultrasound criteria Points
Phlebohemodynamics in the area of localization of the floating head Active 1
Thrombus “outflow” zone Atypical thrombosis 1
Typical thrombosis 0
Neck width to flotation length ratio (mm, factor) Less than 1.0 1
Greater than or equal to 1.0 0
Breathing calm flotation Yes 1
Spring effect with Valsalva test Yes 1
Flotation length More than 30 mm 1
Less than 30 mm 0
Floating head structure Heterogeneous, reduced echogenicity, with contour defects or torn apex 1
Homogeneous, increased echogenicity 0
Dynamics of thrombosis growth Negative 1
Absent or minimal 0
Note. Assessment of the received data. 0-1 point - a low degree of potential embolism. 2 points - the average degree of potential embolism. 3-4 points - a high degree of potential embolism. More than 4 points - an extremely high degree of potential embolism.
the level of the lower extremities proper is the ligation of the PMB. A prerequisite for this intervention is the statement of the fact of patency of GBV, as well as the upper limit of thrombosis. So, if the floating head leaves the PBV into the OBV, then it will be necessary to perform thromboectomy from the OBV. In this case, information about the length of flotation and the anatomical landmark of the location of the thrombus apex (for example, relative to the inguinal fold, SPS, anastomosis of the PBV with distal GBV) will be very important. In the case of the transition of thrombosis significantly above the level of the inguinal fold, ligation of the external iliac vein (NarPV) is likely to be performed, for which it is also necessary to obtain information about the anatomical landmark of the upper border
thrombosis (for example, its relation to the anastomosis with the internal iliac vein (SVV) or its distance from the inguinal fold) and about the patency of the SVC. All this information should be contained in the descriptive part of the ultrasound protocol.
In case of localization of an embolic OBT in the iliocaval segment, the implantation of a cava filter or plication of the inferior vena cava (IVC) is most often performed. The kava filter or plication zone should be located under the renal orifices
FIGURE 5. The upper limit of the ascending thrombophlebitis of the great saphenous vein
1 - lumen of the common femoral
2 - thrombus in the lumen of the great saphenous vein; arrow - distance to safe-no-femoral anastomosis
veins to exclude disturbances of venous outflow through the renal veins in case of closure of the lumen of the IVC distal to this site. In addition, it is necessary to assess the patency of the actual renal veins, as well as the deep bed of the contralateral side and the veins of the superior vena cava system, since through these veins, if they are patented, access for intervention will be provided. It is also necessary to indicate the distance from the apex of the thrombus to the renal vein closest to it, since cava filters are of different types and differ from one another at least in their size. For the same purposes, it is necessary to indicate the diameter of the IVC during inhalation and exhalation. When the floating head of a thrombus is located above the mouth of the renal veins, it is necessary to indicate where exactly in relation to the mouths of the renal veins the thrombosis changes its character from occlusive or parietal to actually floating, and to measure the length of flotation. If flotation begins below the orifices of the renal veins, it is possible to perform an endovascular thrombectomy from an IVC. In ascending thrombophlebitis, it is necessary to indicate the upper limit of thrombosis in relation to anatomical landmarks (for example, the distance to the SPS, Fig. 5), as well as the presence and diameter of the upper tributaries of the GSV (in some cases, with pronounced varicose transformation of the upper tributaries, their diameter is greater than the diameter of the trunk GSV, which can lead to ligation of the wrong vessel). It is also important to state the fact of intactness of the lumen of the deep bed vessels (OBV, HBV, PBV), excluding the variant of combined thrombosis. As a rule, indications for surgical intervention are presented when thrombosis passes to the thigh. It should be remembered that with ascending thrombophlebitis, the true border of thrombosis is practically
always above the clinical zone of hyperemia! In case of GSV thrombophlebitis with the transition of a thrombus into the OBV lumen (combined sapheno-femoral phlebothrombosis), one should remember the need for venotomy and thrombectomy from the OBV, which will require information on the length of the floating thrombus head in the OBV lumen and the anatomical landmark of the localization of its apex in the deep bed ... In some cases, in the presence of concomitant thrombosis, it will be necessary to perform simultaneous ligation of the PBV and ligation of the GSV, possibly in combination with thrombectomy. In these cases, information must be given in detail on the deep and superficial bed separately: on thrombophlebitis (thrombosis of superficial veins with or without transition to a deep bed and in relation to anatomical landmarks) and phlebothrombosis (deep vein thrombosis, also in relation to anatomical landmarks) according to the algorithms described above.
About Repeated ultrasounds
The ultrasound dynamics of OBT in conservative treatment is interpreted as positive with a decrease in the length of flotation and / or the level of thrombosis, as well as with the appearance of signs of recanalization. Also, a positive point is an increase in the echogenicity and homogeneity of thrombotic masses, the absence of floating movements. Registration of reverse processes is a negative trend. The ultrasound dynamics of OBT in the postoperative period is interpreted as positive in the absence of the presence of thrombotic masses above the level of deep vein ligation and in the presence of signs of recanalization of thrombotic masses below the ligation site; with intact blood
flow through the veins above the level of the dressing. Ultrasound dynamics is interpreted as negative in the presence of thrombotic masses above the deep vein ligation site, in case of HBV damage or the appearance of bilateral phlebo-thrombosis.
According to dynamic ultrasound, including the degree of recanalization of thrombotic masses in the postoperative period (as well as in conservative treatment), the effectiveness of anticoagulant therapy is assessed, and drug doses are adjusted. When performing an ultrasound scan after surgery, one should remember about the possibility of progression of thrombosis. The greatest risk of this complication arises in a situation where, in addition to the ligation of the PMV, thrombectomy from the OBV was performed. With the progression of thrombosis, "fresh" thrombotic masses are located above the vein ligation site. The source may be GBV, the actual dressing site, or the site of thrombectomy. The reason for the progression of thrombosis may be inadequate anticoagulant therapy and / or technical errors of surgical intervention (for example, when ligating a vein above the anastomosis with GBV - this situation is interpreted not as a ligation of the PBV, but as a ligation of the OBV).
In case of ascending thrombophlebitis of the GSV, ligation of the GSV at the anastomosis with OBV or peri-ostium resection of the GSV can be performed. A possible finding in case of technical errors in the operation may be a residual GSV stump, often with upper tributaries opening into it or the presence of stump thrombosis. In the presence of a residual stump, the so-called. "Mickey Mouse's second ear", that is, during transverse scanning in the groin projection, 3 lumens are determined
TABLE 2. Reduction of mortality from pulmonary embolism
2009 2010 2011 2012 2013 2014 2015
Treated 13 153 1 4229 14 728 15 932 14 949 14 749 10 626
Died 119 132 110 128 143 105 61
Died from PE b 12 11 0 4 3 3
vessels: common femoral artery, OBV and the GSV stump opening into it. The GSV stump, especially if the upper tributaries flowing into it, can serve as a source of the progression of thrombosis with the transition to OBV. Another finding may be the statement of the actual failure to perform the operation. This is possible in the case of ligation or resection not of the GSV trunk itself, but of one of its large varicosely transformed tributaries. This ultrasound picture should be differentiated from the upper tributary flowing separately into the OBV or from the doubling of the BPV trunk. With the simultaneous performance of peri-osteal resection of the GSV and ligation of the PMV (with or without thrombectomy from the OBV) for concomitant thrombosis during postoperative ultrasound, the blood flow through the OBV originating only from the GBV is localized. The presence of additional flows in this case may indicate technical errors in the operation.
The kava filter is located in the form of clear hyperechoic signals, different in shape, depending on the type of filter: like an umbrella or a spiral. The presence of a clear blood flow in the projection of the cava filter, which occupies the entire lumen of the vein in the CDC, indicates its complete patency. In the B-mode, the full permeability of the filter is characterized by the absence of thrombotic masses in it, which look like echo-positive fragments.
There are 3 types of thrombotic lesions of the cava filter. 1. Embolism of the filter due to the separation of the floating head of the thrombus (depending on the size of the head occluding it, it can be complete or incomplete, with complete overlap of the lumen or with the presence of parietal blood flow).
2. Germination of the filter due to the progression of iliofemoral thrombosis. In this case, it is also necessary to assess the safety or absence of blood flow in the inferior vena cava.
3. Filter thrombosis as a new source of thrombus formation (the cava filter is a foreign body and itself can serve as an intravenous matrix for thrombus formation).
Extremely rare, isolated observations are cases of migration of the cava filter above the established position and the progression of thrombosis above the level of the renal veins through the filter (the latter prevents blood flow from the renal veins). In the latter case, it is necessary to establish the anatomical landmarks of the upper limit of thrombosis already above the level of the filter, establish its nature, the presence or absence of flotation and measure its length, i.e., describe all those characteristics that are described during the initial study.
In patients with an implanted cava filter or IVC plication, attention should be paid to the presence or absence of retroperitoneal hematoma and free fluid in the abdominal cavity.
If a patient has been implanted with a removable cava filter, then a necessary condition for its removal will be a combination of two factors determined by ultrasound: the absence of fragments of thrombotic masses in the filter and the absence of embolic-dangerous thrombi in the inferior vena cava bed. May have me-
one hundred variant of the course of floating FT, when embolism does not occur in the filter: the head does not come off, but for several days continues to remain at its level, maintaining the threat of separation; at the same time, over time, under the influence of anticoagulant therapy, its lysis occurs "in place". This is the very case when the kava filter is removed without fulfilling its intended purpose.
0 Ultrasound for OBT of the superior vena cava system
In most cases of upper limb OBTs are of an occlusive nature and are not embolistic. The authors did not find the floating character of FT of the superior vena cava bed in any patient. The bed of the superior vena cava is well accessible for ultrasound; difficulties may arise only when visualizing some fragments of the subclavian veins. Here, as in the study of the ileocaval segment, it is possible to use a convex low-frequency sensor, as well as the use of auxiliary modes. The main information that is required from the ultrasound diagnostics doctor is to verify the OBT of the superficial or deep bed, or their combined lesion, as well as to describe the occlusive or parietal nature of thrombosis, since thrombosis of the superficial and deep bed has different conservative treatment. Ultrasound is becoming especially important
in case of suspicion of OBT of the superior vena cava bed in patients with intravenous catheters (cubital, subclavian). In case of occlusive thrombosis of the venous segment carrying the catheter, its removal is indicated, and in case of atypical non-occlusive catheter thrombosis, when thrombotic masses, localized on the catheter, float in the lumen, venotomy with thrombectomy and catheter removal is likely. The very fact of diagnosing catheter thrombosis as a probable source of angiosepsis can provide additional information in relation to
carrying the severity of the patient's condition and further tactics of its management.
About Conclusion
Ultrasound of venous blood flow is a mandatory study both for the primary diagnosis of OBT and throughout the hospital stage of patient treatment. A wider implementation of ultrasound with a preventive purpose, taking into account the risks of venous thrombo-embolic complications in the corresponding categories of patients, minimizes the onset of both self-
my TELA, and, accordingly, death from her. The methodology presented in the article for performing ultrasound of venous blood flow in combination with a high frequency of prescribing the study itself, as well as with the active introduction of endovascular methods of surgical prevention of PE (used at the Central Clinical Hospital of the Russian Academy of Sciences since 2012) led to a significant decrease in mortality from PE, which is reflected in Table 2. (2015 - data at the time of submission of the article to the editors as of the beginning of October).
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