Shades of Echogenicity: Is it a Thrombus?

A Case Review

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I have the following financial relationships to disclose:Consultant for: Teleflex, Inc.Speaker’s Bureau for: Teleflex, Inc.

I will not discuss off label use and/or investigational use in my presentation.

A Learning ExperienceCase Review• 53 y/o male, ICU patient with history of congestive heart failure• Vein assessment revealed bilateral non-compressible basilic veins with echogenic material identified• US Doppler requested and 20g PVAD placed using US• Previous CVAD which patient self-discontinued and no previous PVADs noted • Results of Doppler

– Occlusive thrombus in bilateral upper extremity basilic veins

Learning Objectives• Define ultrasound terms used to describe the appearance of blood vessels.• Identify the abnormal ultrasound findings indicative of thrombus and course of action to be taken.• Describe unprovoked or idiopathic thrombus, possible causes and plan of action when discovered.• Discuss the importance of vessel assessment when placing central venous access devices and the significance of

understanding ultrasound images.

Is it a thrombus? Yes!

Anechoic (normal) and

Hyperechoic (white)Right upper arm basilic vein

Fully compressed rightupper arm basilic vein

Hypoechoic (gray) Left upper arm basilic vein

Case review

Hyper-echoic (abnormal)

Idiopathic or Unprovoked Thrombus What is it?

Idiopathic SVT/DVT occurs in the absence of a known risk factor for thrombosis• Presence of IV catheter, thrombophilia or other underlying conditions

Idiopathic venous thrombotic event (IVTE) of the upper extremity venous system is not as common as in lower extremity, however

• Can be presenting symptom of malignancy1,2,3

• Baseline examination and tests have shown to detect cancer in about 10% of patients with first IVTE3

• Overall rates of occult malignancy with IVTE are consistent with data from many large, published studies3

Recommendations • Collaborate regarding alternative vascular access• Inform the nurse, as well as the family, of findings and plan for ultrasound of extremity• Optimum treatment is unknown for SVT, but it is reasonable to consider anticoagulation when patient is at risk for DVT4

• Baseline routine tests for malignancy should be offered3

• Testing should be limited to those with IVTE (20% of patients with VTE)3 • Restrict to patients over the age of 40 without cancer detected by routine investigation3

Importance of Vessel Assessment Key components of vessel assessment

– Assess the vein in its natural state• Allows accurate measurement of the inner diameter of vessel• The outer diameter of chosen catheter should fill 45% or less of the inner diameter of the vein 5

– Appropriate amount of gel• Air does not transmit US waves, so the gel must be thick enough to allow no air between the probe and the skin

– Probe position and pressure6

• It is important to understand probe position in relation to the US beam, which is about 1mm thick• Use as a flashlight by rocking and tilting to obtain visualization of the needle tip at all times• Rotating is used to view the vessel in the long access position to provide greater visualization of the entire

needle• Too much pressure can flatten the vein, cause discomfort and make it difficult to ascertain true depth• When deep veins are accessed with excessive probe pressure, there is risk for losing access.

– Gain control• Used to compensate for attenuation, or scatter by amplifying the returning sound waves• Important for obtaining clear images

Summary• On follow up, a subclavian CVAD was placed in this patient• Anticoagulation with Heparin was initiated

– Home on Warfarin

• Regardless of location, a first episode of IVTE may be a sign of malignancy1,2,3,

• Recent research is increasingly supportive of non-invasive testing for finding of IVTE2,3

• Knowledge of US and skill in using it are necessary to accurately assess the venous system• Ability to identify thrombus is a critical aspect of vein assessment• Collaboration with the team is essential• UESVT should be treated with anticoagulation given the evidence for treatment of LESVT and the likelihood of

propagation into DVT4

References 1. Piccioli A, Bernardi E, Dalla Valle F, Visonà A, Tropeano PF, Bova C, Bucherini E , Prandoni P. The value of CT scanning for detection of occult cancer in patients with idiopathic VTE. Cancer, thrombosis and low-molecular-weight heparins. PhD Thesis, 2015, Chapter 10; 95-106. 2. Oudega R, Moons KG, Nieuwenhuis HK, van Nierop FL, Hoes AW. Deep vein thrombosis in primary care: possible malignancy? The British Journal of General Practice. 2006;56(530):693-696.3. National Clinical Guideline Centre. Venous thromboembolic diseases: the management of venous thromboembolic diseases and the role of thrombophilia testing. Clinical Guideline: methods, evidence and recommendations, June 2012. The Royal College of Physicians, 11 St Andrews Place, Regents Park, London, NW14BT4. Bérubé C, Zehnder, JL. Catheter-related upper extremity venous thrombosis. UptoDate. 2016. http://www.uptodate.com/contents/catheter-related-upper-extremity-venous-thrombosis5. Infusion Nurses Society. (2016). Infusion Therapy Standards of Practice, 39(1S). S1-S159. Norwood, MA: Wolters Kluwer6. Ihnatsenka B and Boezaart AP. Ultrasound: Basic understanding and learning the language. International Journal of Shoulder Surgery. 2010;4(3):1-15

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