Ultrasonic diagnosis of sharp venous thrombosis. Ultrasound diagnostics of venous thrombosis in outpatient conditions

The date: 23.07.2020

Acute venous thrombosis is a common and dangerous disease. According to statistical data, its frequency in the overall population is about 160 per 100,000 population. Thrombosis in the system of the lower vein (NPB) is the most frequent and dangerous variety of this pathological process and is the main source of pulmonary vessel embolism (84.5%). The system of the upper floor of the vein gives 0.4-0.7% of pulmonary artery thromboembolism (TEL), the right heart departments are 10.4%. The share of thrombosis veins of the lower extremities accounts for up to 95% of cases of all thrombosis in the NPV system. The diagnosis of acute venous thrombosis is long diagnosed in 19.2% of patients. In the long run, the deep veins thrombosis (TGV) leads to the formation of post-terrboflectric disease, manifested by chronic venous insufficiency, until the development of trophic ulcers, which significantly reduces the abilityality and quality of life of patients.

The main mechanisms of intravascular formation of thromboms known since R.VircHow are the slowdown of blood flow (stas), hypercoagulation, vessel wall injury (endothelium damage). Acute venous thrombosis quite often develops against the background of various oncological diseases (malignant tumors of the gastrointestinal tract, female sexual sphere, etc.) due to the fact that cancer intoxication causes the development of hypercoagulant changes and the oppression of fibrinolysis, as well as due to the mechanical compression of the veins, tumor and germination Its into the vascular wall. The predisposing factors of TGV are also considered obesity, pregnancy, taking oral hormonal contraceptives, hereditary thrombophilia (deficiency of antithrombin III, protein C and S, Leidenovskaya mutation, etc.), systemic diseases of connective tissue, chronic purulent infections, allergic reactions. Patients with the chronic venous insufficiency of lower extremities, as well as patients with myocardial infarction, decompensated heart failure, stroke, straggle, stroke, a stroke, proleell, gangrene, stroke, proleells, gangrene lower extremities, are subject to the greatest risk. Traumatological patients are particularly alarming, since the fractures of the femoral bone are mainly found in individuals of the elderly and senile age, the most burdened by somatic diseases. Thrombosis in traumatological patients may occur in any injury of lower extremities, since there are all the etiological factors of thrombosis (damage to the vessel, venous stagnation and changes in blood coagulation).

Reliable diagnosis of phlebotromability is one of the current clinical tasks. Physical examination methods allow you to put the 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 calf muscles with the preserved passability of the remaining veins often proceeds asymptomatic. Due to the danger, the clinicians often put this diagnosis in each case the appearance of pain in the ion muscles in each case. Special attention deserve "traumatological" patients who have pain, edema and changes in the color of the limb can be due to the injury itself, and not TGV. Sometimes a massive tel is the first and only manifestation of such thrombosis.

The tasks of the instrumental examination include not only confirmation or refutation of the presence of thrombus, but also determining its length and degree of embology. The release of embaning thrombas into a separate group and the study of their morphological structure is of great practical importance, since without this, the development of effective prevention of the pulmonary embolism and the choice of optimal treatment tactics is impossible. Thromboembolic complications are more often observed in the presence of a floting thrombus with a heterogeneous structure, an uneven hypochogenic contour, in contrast to thrombus having a hyperheogenic circuit and a homogeneous structure. An important criterion for enzymology thrombus is the degree of its mobility in the vessel. Emumblic complications are more often noted with a pronounced and moderate mobility of thrombomass.

Venous thrombosis is a fairly dynamic process. Over time, the processes of retraction, humoral and cell lysis contribute to a decrease in the dimensions of the thrombus. At the same time, the processes of its organization and recanalization are coming. In most cases, the vessels are gradually restored, the valve vein vehicle is destroyed, and the remnants of the blood clouds deform the vascular wall in the form of cluster superplots. Diagnostic difficulties can be in the occurrence of repeated acute thrombosis against the background of partially recanalyzed veins in patients with post-tomboflicic disease. In this case, a sufficiently reliable criterion is the difference of veins in diameter: in patients with signs of the recanalization of thrombomass, a decrease in veins in diameter due to the aid of the acute process; With the development of retrose, there is a significant increase in the diameter of veins with fuzzy ("blurred") circles of the walls and the surrounding tissues. These criteria are used with the differential diagnosis of acute intricate thrombosis with post-chrombotic changes in veins.

Of all the non-invasive methods used to diagnose thrombosis, the ultrasonic scanning of the venous system is increasingly used in recent times. The Triplex Angioscaning method proposed by Barber in 1974 includes a study of vessels in in-mode, an analysis of the Doppler frequency shift in the form of classical spectral analysis and flow (in high-speed and energy modes). The use of spectral made it possible to accurately measure the bloodstream inside the lumen of the veins. The use of the method () provided the ability to quickly distinguish occlusive thrombosis from the non-cluster, identify the initial stages of the recombination of thrombus, as well as determine the location and size of venous collaterals. During studies in dynamics, the ultrasound method allows to ensure fairly accurate control over the effectiveness of thrombolytic therapy. In addition, with the help of an ultrasound study, the causes of the appearance of clinical symptoms similar to that with vessel pathology can be established, for example, to reveal a biker cyst, an intertensive hematoma or tumor. The introduction of an expert class ultrasound instruments into the practice of frequency sensors from 2.5 to 14 MHz made it possible to achieve almost 99% of diagnostic accuracy.

Material and methods

The survey included inspection of patients with clinical signs of venous thrombosis and TEL. Patients presented complaints on swelling and pain in the lower (upper) limb, pain in the calf muscle (more often sawing), "pulling" pain in the popliteal region, pain and seal along the subcutaneous veins. During the inspection, moderate cyanosis of the shin and feet, dense swelling, pain in palpation of the leg muscles, in most patients is the positive symptoms of Homans and Moshares.

The entire examined was conducted triplex scanning of the venous system on modern ultrasonic devices with a linear sensor with a frequency of 7 MHz. At the same time, the state of the thigh, the popliteal vein, the veins of the leg, as well as the large and low subcutaneous veins, was estimated. An convex sensor with a frequency of 3.5 MHz was used to visualize the iliac venues and the NPV. When scanning an NPV, iliac, large subcutaneous veins, a femoral veins and a veins of the leg in the distal section of the lower extremities, the patient was in a position lying on his back. The study of the fallen veins, the veins of the upper third of the leg and the low subcutaneous vein was carried out in the patient's position lying on his belly with a roller under the area of \u200b\u200bthe ankle joints. Diagnosis difficulties occurred when visualizing the distal surface of the femoral vein in obese patients, visualization of the veins of the shin with pronounced trophic and industrial changes in tissues. In these cases, a convex sensor was also used. The depth of scanning, the enhancement of the echo signal and other parameters of the study were selected individually for each patient and remained unchanged during the entire survey, including observations in dynamics.

Scanning began in cross section to eliminate the presence of a floting tip of the thrombus, as evidenced by the complete contact of the venous walls during a slight compression by the sensor. After convincing the absence of a free floting tipper tomb, the compression sample was performed from the segment to the segment, from the proximal departments to distal. The proposed method is the most accurate not only for the detection of thrombosis, but also to determine its length (excluding iliac veins and NPS, where the veins are determined in the CDC mode). veins confirmed the presence and characteristics of venous thrombosis. In addition, the longitudinal section was used to locate the anatomical fusion of veins. During the survey, the state of the walls, the lumen of the veins, the Localization of the thrombus, its length, degree of fixation to the vascular wall was estimated.

The ultrasound characteristic of venous thromboms was carried out in relation to the lumen of the vessel: they differed as intricate, occlusive and fluttering blood clots. The signs of the cloth thrombosis were considered the visualization of the thrombus with the presence of free blood flow in the lumen of the veins, the absence of a complete set of the walls in the compression of the vein by the sensor, the presence of a defect of filling during CDC, the presence of spontaneous blood flow during spectral dopplerography (Fig. 1).

Fig. one. Non-conclusive thrombosis of the popliteal veins. Longitudinal scan of veins. Enveling blood flow in power coding mode.

Ultrasonic criteria for floting thrombubs were considered: thrombus visualization as an echogenic structure located in the lumen of the veins with the presence of free space, the oscillatory movements of the tomb of the tomb, the absence of the veins of the veins when compression by the sensor, the presence of free space when performing breathing samples, envelope the type of blood flow under the CDC, the presence of spontaneous blood flow with spectral dopplerography. When the flushing thrombus is detected, the degree of its mobility was estimated: pronounced - in the presence of spontaneous thrombus movements with calm breathing and / or breathing delay; moderate - when the thrombus oscillatory movements are detected during the functional samples (coughing sample); Minor - with minimal thromba mobility in response to functional samples.

Results of research

From 2003 to 2006, 236 patients aged from 20 to 78 years of age were examined, of which 214 with the clinic of acute thrombosis and 22 with the tel clinic.

In the first group in 82 (38.3%) cases, the permeability of deep and superficial veins was not violated and clinical symptoms were due to other reasons (Table 1).

Table 1. States having similar symptoms with TGV.

The diagnosis of thrombosis was confirmed in 132 (61.7%) patients, while in most cases (94%) thrombosis was detected in the NPV system. The TGV was discovered in 47% of cases, the surface veins - in 39%, the defeat of both a deep and surface venous system was observed in 14%, including 5 patients with the involvement of perforate veins.

The probable causes (risk factors) of the development of venous thrombosis are presented in Table. 2.

table 2. Risk factors for the development of thrombosis.

Risk factor	Number of patients
Risk factor	abs.	%
Injury (including long-term gypsum immobilization)	41	31,0
Varicose disease	26	19,7
Malignant neoplasms	23	17,4
Operations	16	12,1
Reception of hormonal drugs	9	6,8
Thrombophilia	6	4,5
Chronic ischemia limbs	6	4,5
Yatrogenic reasons	5	4,0

In our observations, the common form of thrombosis was most often detected, as well as the defeat of the veins at the level of the detachment-beam and femoral-poned segments (Table 3).

Table 3.. Localization of the TGV.

More often (63%) there were thrombosis, fully occlusive clearance of the vessel, in second place in terms of frequency (30.2%) were intricate blood clomes. Floting thrombus are diagnosed in 6.8% of cases: in 1 patient - in saphenofemoral substitution with an upward thrombosis of the trunk of a large subcutaneous vein, in 1 - Ileofemral thrombosis with a floting top in a common iliac vein, in 5 - in the common femur vein during femur thrombosis segment and 2 - in the popliteal vein at the TGV of the shin.

The length of the non-fixed (floting) part of the thrombus, according to ultrasound data, varied from 2 to 8 cm. The moderate mobility of thrombotic masses (5 patients) was detected, in 3 cases, the thrombus mobility was minimal. In 1 patient, with a calm breath, spontaneous thrombus movements were visualized in a vessel list (high degree of mobility). In our observations, floting thrombus with an inhomogeneous echoostructure (7 people) were often detected, while the hyperheogenic component was prevailed in the distal department, and in the region of the thrombus head - hypo echogenic (Fig. 2).

Fig. 2. Floting thrombus in the common femoral vein. B-mode, longitudinal vein scanning. Thromb of heterochogenic structure with a clear hyperheogenic contour.

In the dynamics, 82 patients were examined in the dynamics of the flow of the thrombotic process, of which 63 (76.8%) were noted a partial recanalization of thrombotic masses. In this group, 28 (44.4%) of patients were observed a central type of recanalization (with longitudinal and transverse scanning in the CDC mode, the reccript channel was visualized in the center of the vessel); In 23 (35%) patients were diagnosed by the cloth reconnaissance of thrombotic masses (more often the blood flow was determined along the vein wall, directly adjacent to the artery of the same name); In 13 (20.6%) patients detected incomplete recanalization with fragmentary asymmetric staining in the MDC mode. The thrombotic occlusion of the lumen of the veins was observed in 5 (6.1%) patients, in 6 (7.3%) cases noted the restoration of the lumen of the vein. Signs of retrojects persisted in 8 (9.8%) examined.

findings

A comprehensive ultrasound study, including angiosication using spectral, color and energy doppler regimes and soft tissue echography, is a highly informative and safe method that allows the most reliably and quickly solve the issues of differential diagnosis and therapeutic tactics in the outpatient phlebological practice. This study is advisable to conduct on an outpatient stage for earlier detection of patients who are not shown (and sometimes contraindicated) thrombolytic therapy, and their directions in profile branches; In confirming the presence of venous thrombosis, it is necessary to identify persons with a high risk of developing thromboembolic complications; Watch in dynamics over the flow of a thrombotic process and thereby adjusting the therapeutic tactics.

Literature

Lindblad, Sternby N.H., Bergqvist D. Incidence of Verious Thromboembolism Verified by Necropsy Over 30 years. // Br.med.j. 1991. V. 302. P. 709-711.
Saveliev V.S. Light artery thromboembolism - classification, forecast and surgical tactics. // Chest and Cardiovascular Surgery 1985. N ° 5. P. 10-12.
Barkagan Z.S. Hemorrhagic diseases and syndromes. Ed. 2nd, recreation. and add. M.: Medicine 1988; 525 p.
Bergqvist D. Postoperative ThromBoembolism. // NEW YORK 1983. P. 234.
Saveliev V.S. Phlebology. M.: Medicine 2001; 664 p.
Kokhan E.P., Zavarina I.K. Selected lectures on angiology. M.: Science 2000. P. 210, 218.
Hull R., Hirsh J., Sackett D.L. et al. Combined Use Of Leg Scenning and Impedance Plethysmography in Suspected Venous Thrombosis. An alternative to venography. // n.Engl.j.med. 1977. N ° 296. P. 1497-1500.
Savelyev V.S., Dumpe E.P., Yablokov E.G. Diseases of the main veins. M., 1972. P. 144-150.
Albitsky A.V., Bogachev V.Yu., Leontiev S.G. et al. Ultrasonic duplex angiosication in the diagnosis of deep vein retroms of the lower limbs. // Kremlin medicine 2006. N ° 1. P. 60-67.
Kharchenko V.P., Zubarev A.R., Kotlyarov P.M. Ultrasonic phlebology. M.: Zoa "Enica". 176 p.

Ultrasonic diagnosis of sharp venous thrombosis

Acute venous thrombosis of the system of the lower veins system is divided into ehmbowen hazardous (floting or non-conclusive) and occlusive. Neokelusive thrombosis is the source of pulmonary artery thromboembolism. The system of the upper hollow vein gives only 0.4% of the pulmonary arteries thromboembolism, the right heart departments are 10.4%, while the lower hollow vein is the main source of this formidable complication (84.5%).

A prominent diagnosis of acute venous thrombosis can be installed only in 19.2% of patients who died from the thromboembolism of the pulmonary artery. These authors indicate that the frequency of proper diagnosis of venous thrombosis before the development of the death embolism of the pulmonary artery is low and ranges from 12.2 to 25%.

Postoperative venous thrombosis represent a very serious problem. According to B.C. Savelyeva, postoperative venous thrombosis is developing after community interventions on average in 29% of patients, in 19% of cases after gynecological interventions and in 38% of lampsier adenomectomy. In traumatology and orthopedics, this percentage is even higher and reaches 53-59%. A special role is assigned to the early postoperative diagnosis of acute venous thrombosis. Consequently, all patients representing a certain risk in terms of postoperative venous thrombosis should be carried out by a full examination of the system of the lower hollow vein at least twice: before and after surgery.

It is fundamentally important to identifying violations of the mainstream veins in patients with the arterial failure of the lower extremities. This is especially necessary for a patient who suggests operational intervention in order to restore blood circulation in the limb, the effectiveness of such surgical intervention is reduced in the presence of various forms of obstruction of the main veins. Therefore, all patients with limb ischemia should be examined both arterial and venous vessels.

Despite the significant successes achieved in recent years in the diagnosis and treatment of acute venous thrombosis of the lower hollow vein and the peripheral veins of the lower extremities, interest in this problem has not only not decreased in recent years, but is constantly increasing. A special role is still given to the issues of early diagnosis of acute venous thrombosis.

Acute venous thrombosis on its localization is divided into thrombosis of orquate segments, a femoral-populated segment and veins thrombosis. In addition, large and small subcutaneous veins may be susceptible to thrombotic damage.

The proximal boundary of acute venous thrombosis may be in the infrared division of the lower vein, supremal, reach the right atrium and is in its cavity (echocardiography). Therefore, the examination of the lower vein is recommended to start with the field of right atrium and then gradually descend down to the infrared department and the place of imposition to the lower hollow vein of the iliac venue. It should be noted that the closest attention should be attached not only to examine the barrel of the lower hollow vein, but also veins flowing into it. First of all, they include renal veins. Usually, the thrombotic damage to the renal veins is due to the volume formation of the kidney. It should not be forgotten that the cause of the flow of the lower vein can be ovarian veins or testicular veins. It is theoretically believed that these veins in view of their small diameters cannot lead to pulmonary thromboembolism, especially since the prevalence of thrombus to the left renal vein and the lower veins of the vein on the left ovary or testicular vein due to the uraniality of the latter looks causual. However, it is always necessary to strive for the inspection of these veins, at least their mouths. In the presence of thrombotic occlusion, these veins increase slightly in size, the lumen becomes inhomogeneous and they are not bad in their anatomical regions.

With ultrasound triplex scanning, venous thrombosis is divided into the lumenity of the vessel on the onset, occlusive and flotizing blood clomes.

The ultrasonic signs of the cloth thrombosis are considered to be the visualization of blood cloth with the presence of free blood flow in this area of \u200b\u200bthe modified lumen of the vein, the absence of a complete set of the walls in the compression of the veins by the sensor, the presence of a defect of filling at CDC, the presence of spontaneous blood flow during spectral doppler.

The occlusive is considered thrombosis, the signs of which is the absence of the walls in the compression of the vein of the sensor, as well as the visualization in the lumen of the inclusions of various echogencies, the absence of blood flow and the bladeing of the veins in spectral dopplerography modes and CDCs. Ultrasonic criteria for floting thromboms are considered: thrombus visualization, as an echogenic structure located in the lumen of the veins with the presence of free space, the oscillatory movements of the tomb of the tomb, the absence of contacting the veins walls during the compression by the sensor, the presence of free space when performing breathing samples, envelope the type of blood flow in flow color coding , The presence of spontaneous blood flow in spectral dopplerography.

Constant interest is the possibilities of ultrasound technologies in the diagnosis of the pressure of thrombotic masses. The identification of signs of fluttering thrombosis in all stages of the organization of thrombosis makes it possible to increase the effectiveness of the diagnosis. The most early diagnosis of fresh thrombosis is especially valuable, which makes it possible to take measures for early prevention of pulmonary artery thromboembolism.

After comparing the ultrasound data of fluttering thrombus with the results of morphological studies, we came to the following conclusions.

Ultrasonic signs of red thrombus are a hypo echogenic fuzzy contour, thrombus anecho in the top of the top and hypo echogenicity of the distal separator with separate echogenic inclusions. Signs of mixed thrombus is the heterogeneous structure of the thrombus with a hyperheogenic clear contour. In the structure of the thrombus in the distal departments, heterochogenic inclusions are dominated, in proximal departments - mainly hypo echogenic inclusions. Signs of white thrombus - floting thrombus with clear contours, mixed structure with a predominance of hyperheogenic inclusions, and the CDC register fragmentary streams through the thrombotic masses.

The thrombotic damage to the venous channel of the lower extremities, primarily deep veins, is an acute state, developing as a result of a complex action of a number of factors. According to statistical reports of the Ministry of Health of the Russian Federation, our country annually registers 80,000 new cases of this disease. In the elderly and old age, the frequency of the deep vein thrombosis increases several times. In Western European countries, this pathology occurs in 3.13% of the population. Venous thrombosis is the main cause of pulmonary arterial thromboembolism. The massive thromboembolism of pulmonary arteries is developing in 32-45% of patients with acute thrombosis of the deep veins of the lower limbs and ranks third in the overall structure of sudden mortality.

Thrombosis of deep veins - This is the formation of a blood clots inside the vessel. In the formation of thrombus, an obstacle of blood outflow occurs. Venous thrombosis may occur with circulatory disorders (blood stagnation), damage to the inner wall of the vessel, an increased blood ability to form a thrombus, as well as combining these reasons. The formation of thrombus can begin on any site of the venous system, but most often - in the deep veins of the leg.

Ultrasonic compression duplex angiosication is the main method of examination with suspected venous thrombosis. The main tasks are the detection of thrombus, the description of its density (this feature is important for the diagnosis of thrombosis period), fixation to the walls of veins, length, the presence of fluttering sections (capable of separation from the vascular wall and move with blood flow), the degree of obstruction.

Also, ultrasound examination allows dynamic observation of blood cloth in the treatment process. Active search for deep veins thrombosis with duplex scanning seems appropriate in the preoperative period, as well as oncological patients. The significance of ultrasound methods in the diagnosis of thrombosis is considered sufficiently high: sensitivity ranges in the range of 64-93%, and specificity - 83-95%.

Ultrasound examination of the lower limbs is carried out using linear sensors 7 and 3.5 MHz. The study begins with the groin area in the transverse and longitudinal section in relation to the vascular beam. The mandatory scope includes inspection of subcutaneous and deep veins of both lower extremities. When obtaining an image of veins, the following parameters are estimated: diameter, compressibility (compression by the sensor until the blood flow is cessation in vein while maintaining blood flow in artery), features of the stroke of the vessel, the state of the internal lumen, the safety of the valve apparatus, changes in the walls, the condition of the surrounding tissues. Bloodstock is necessarily evaluated in a number of lying artery. The condition of venous hemodynamics is also estimated by using special functional samples: respiratory and cough sample or sample with a fitting (Valzalvy test). It is primarily used to assess the state of deep and subcutaneous vein valves. In addition, the use of functional samples facilitates visualization and assessment of veins in areas with low blood flow. Some of the functional samples may be useful to clarify the proximal boundary of venous thrombosis. The main signs of the presence of thrombosis include the presence of echoposive thrombotic masses in the lumen of the vessel, the echo absorption increases as the limitation of the thrombus increases. The valve flaps are ceased to differentiate, the transfer arterial pulsation disappears, the diameter of the thrombied vein is increased by 2-2.5 times compared with the contralateral vessel, it is not squeezed with a sensor compression.

Three types of venous thrombosis are isolated: floting thrombosis, occlusive thrombosis, tromboration (non-conducive) thrombosis.

Occlusive thrombosis is characterized by a complete fixation of the thrombomass to the venous stack, which prevents the conversion of the blood clomba to the embol. The signs of the trombic thrombosis include the presence of a thrombus with free blood flow in the absence of a complete falling off the venous walls in a compression sample. The criteria of the floting thrombub are considered to be visualization of the thrombus in the lumen of the veins with the presence of free space, the oscillatory movements of the thrombus head, the absence of contacting the walls of the vein with the sensor compression, the presence of free space when performing respiratory samples. For the final clarification of the character, the thrombus uses a special test of the waltasalver, which should be carried out with caution in view of the addition flotation.

Ultrasound examination is a diagnostic method of the first line if the thrombosis of the deep veins of the lower limbs is suspected. This contributes to the relatively low cost, availability and safety of the technique. In GBUZ "Tambov Regional Clinical Hospital named after V.D. Babenko "Ultrasonic duplex angiosication of peripheral veins is held since 2010. About 2000 studies are performed annually. High quality diagnostics allows you to save the life of a large number of people. Our institution is the only institution in the area in which there is a separation of vascular surgery, which makes it possible to determine the tactics of treatment immediately after establishing the diagnosis. Highly qualified doctors successfully use modern methods for the treatment of venous thrombosis.