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April 2020

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Subject:
From:
Larry Needleman <[log in to unmask]>
Reply To:
UVM Flownet <[log in to unmask]>
Date:
Fri, 10 Apr 2020 23:34:19 -0400
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COVID patients are hyper coagulable. D-dimer is elevated without and with VTED. 

DVT then stop protocol for COVID positive patients - to MINIMIZE EXPOSURE
No screening. No r/o PE without leg signs. Symptomatic patients only with objective signs (swelling, pain over venous system etc). 

IF bilateral signs, most symptomatic leg first 

Complete study stopped when top of an acute DVT is seen (see next paragraphs).
CFV to popliteal vein (start at inguinal ligament, end at tibioperoneal trunk where PTV and peroneal veins come together). 
No calf except for rare symptomatic calf that requires imaging (not swollen leg/calf only) - confirm with referring physician.
Scan entire vein compressing every 1-2 cm down leg. 
CFV without and with compression
Femoral without and with compression (no routine Doppler)
Popliteal without and with compression (no routine Doppler)
CFV spectral Doppler from long axis picture
Document gray scale without and with compression: CFV, proximal FV, mid FV, distal FV, popliteal vein. Document CFV spectral Doppler.

Once acute DVT is found:  stop scanning distally (keep scanning if indeterminate or chronic scar).
If top (end) of clot is seen, STOP
If top of clot is not seen, such as in some CFV acute DVT, document external iliac vein
With curved array, take additional  additional gray scale and color Doppler images of external iliac vein above inguinal ligament and abdominal side wall
If CFV waveform is absolutely flat, no undulations or phasic variation, document external iliac vein
With curved array, take additional  additional gray scale and color Doppler images and spectral Doppler image  of external iliac vein above inguinal ligament and abdominal side wall
Add color if visualization of vein difficult only
Popliteal spectral Doppler for selected patients only
Add popliteal spectral Doppler if visualization limited (more than 3 cm of a vein is not visualized). 
Add popliteal Doppler if CFV spectral Doppler is not performed (e.g. overlying bandage or lines)

Larry

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