A 60 year old woman with a past medical history of HTN, HLD, and recent TIA now on Aspirin and Eliquis presents to the ED with one month of crampy, intermittent abdominal pain. She describes feeling sharp cramps in the epigastric region which typically last a couple of minutes and then resolve on their own. She cannot recall any exacerbating or relieving factors. She does not have any associated nausea, vomiting, diarrhea, or dysuria. She is currently without pain. On exam, her abdomen is non-tender without any rebound or guarding. POCUS findings are as below. What’s the diagnosis?

Answer: Abdominal Aortic Aneurysm with impending rupture

• The aorta can be visualized with the curvilinear probe and is found lying just anterior to the spine. AAA is defined as an aorta >3cm in diameter; repair is considered with diameter >5cm or in symptomatic patients. Smoking is the greatest risk factor, increasing chances 4x compared to lifetime non-smokers. Other risk factors include family member with AAA, male sex, and age >60¹.
• Physical exam is only 29% sensitive for aortic diameter 3.0 – 3.9cm, 50% for 4.0 – 4.9cm, and 76% for greater than 5.0cm². This patient did have a palpable abdominal pulsation with deep pressure. Tenderness is associated with unstable AAA, though lack of pain does not rule this out.
• Bedside US dramatically increases sensitivity to >90% for diagnosing and measuring AAAs of all sizes³. Measurements should be taken from the outside wall to outside wall in transverse and longitudinal views. This patient’s aorta was measured to be >5cm and had concerning signs of thickened walls.
• CTA is the gold standard for diagnosis and measurement in stable patients. This patient had findings of extension of luminal contrast beyond the expected aortic wall and calcifications, which was concerning for impending rupture⁴. The patient was evaluated by vascular surgery and taken Level 1 to the OR for emergent open aortic repair.

References:

1. Tintinalli’s Emergency Medicine: A Comprehensive Study Guide, 9th Edition. Prince, L. Johnson, G. Chapter 60. Page 416. McGraw Hill Professional, 15 Nov. 2023.
2. Lederle FA, Simel DL: The rational clinical examination. Does this patient have abdominal aortic aneurysm? JAMA 281: 77, 1999. [PMID: 9892455]
3. American College of Emergency Physicians: Emergency ultrasound imaging criteria compendium. Ann Emerg Med 48: 487, 2006. [PMID: 16997700]
4. Vu KN, Kaitoukov Y, Morin-Roy F, Kauffmann C, Giroux MF, Thérasse E, Soulez G, Tang A. Rupture signs on computed tomography, treatment, and outcome of abdominal aortic aneurysms. Insights Imaging. 2014 Jun;5(3):281-93. doi: 10.1007/s13244-014-0327-3. Epub 2014 May 1. PMID: 24789068; PMCID: PMC4035490.

A 19 year old female with a past medical history of autism and anxiety presents with right lower extremity swelling and pain. Two weeks ago, she developed right lower back pain with radiation into her right hip and leg which she describes as sore. She is sexually active and was started on hormonal contraception 2-3 months ago. Vital signs include BP 117/75, HR 108, RR 18, SpO2 99% RA, T 97.5F. The patient’s right lower extremity is neurovascularly intact with tenderness to palpation and swelling without color change. A right lower extremity ultrasound is shown below. What’s the diagnosis? How is this ultrasound performed?

Answer: Right Common Femoral and Popliteal DVT

DVT Ultrasound Evaluation: must evaluate at least 2 regions, typically femoral and popliteal veins

Femoral Vein

1. Most often performed using the linear probe (curvilinear probe may provide greater penetration for larger body habitus)
2. Start just distal to the groin where the iliac vein becomes the common femoral vein
3. Follow common femoral vein down to where the common femoral splits off into greater saphenous, femoral, and the deep femoral vein (approximately mid-thigh) and continue to follow the femoral vein until at least the mid-thigh, compressing in 1 cm increments to ensure compressibility of veins throughout

Popliteal Vein

1. Place probe on posterior aspect of the knee and look for popliteal vein (superficial to popliteal artery)
2. Follow popliteal vein and compress in 1 cm increments to ensure compressibility until the vein divides into the fibular, posterior tibial and anterior tibial veins

DVT Ultrasound Pearls:

• A vein is compressible if the walls touch with compression – if you are pushing hard enough to compress the artery but not the vein, there is likely a DVT!
• Evaluation of femoral and popliteal regions is crucial because a DVT within either of these veins is considered “proximal” and requires medical management with anticoagulants and further evaluation for iliac/IVC involvement or pulmonary embolism.
• Clinical diagnosis of DVT is typically unreliable due to the infrequency of classic findings (edema, warmth, erythema, pain, and tenderness) which are only present in 23 to 50 percent of patients
• Venogram remains the “gold standard” for the diagnosis of deep venous thrombosis. However, ultrasound is the most accurate non-invasive test to diagnose deep venous thrombosis.

This patient received prompt anticoagulation in the ED and after being admitted, received a CT venogram revealing acute deep vein thrombosis in the infrahepatic inferior vena cava, bilateral common iliac, bilateral external iliac, bilateral internal iliac and bilateral common femoral veins requiring percutaneous mechanical thrombectomy!

References:

Baker M, Anjum F, dela Cruz J. Deep Venous Thrombosis Ultrasound Evaluation. [Updated 2023 Aug 8]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2023 Jan-.

https://sso.uptodate.com/contents/overview-of-the-treatment-of-proximal-and-distal-lower-extremity-deep-vein-thrombosis-dvt?search=dvt%20management&source=search_result&selectedTitle=1~150&usage_type=default&display_rank=1#H5

https://coreultrasound.com/dvt/