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I'm just saying...if it were myself or my family member or friend, I'd want my money's worth, not to mention a thorough exam.  Just do it.  More energy is expended trying to get out of something than just may be useful in determining best care.
Connie Mccoy
Sent from my Verizon Wireless Phone

----- Reply message -----
From: "Andrew Bebry" <[log in to unmask]>
To: <[log in to unmask]>
Subject: Entire leg vs to knee venous
Date: Sun, Oct 28, 2012 11:47 am
My vote is for groin to ankle, I guess that is the same for most serious vascular techs.  I have the same stories about calf clots that others did not find (because the calf was not important enough to scan I guess).  A Bebry


On Sun, Oct 28, 2012 at 11:24 AM, Larry Needleman <[log in to unmask]> wrote:

Let me preface this by saying I work with both the IAC and Radiology

standards and my own lab scans from thigh to ankle.  Medical staff, not

administrators (or anyone with a stop watch), should determine how medical

testing gets performed.



But not everyone who scans to the knee (and not below it) is jeopardizing

patients or even doing a bad job.



BTW, the AIUM-ACR standard DOES recommend scanning below the knee

when the study does not explain the patient's symptoms, e.g. calf pain with a

negative femoropopliteal study.

"Symptomatic areas such as the calf generally require additional evaluation

and additional images if the cause of the symptoms is not readily elucidated

by the standard examination."

"The patient presentation, clinical indication, or clinical management pathways

may require protocol adjustments such as more detailed evaluation of the

superficial venous system, evaluation of the deep calf veins, or a bilateral

study."



While it is true that many DVT are totally or in part below the knee, there are

reasonable people who think scanning below the knee is NOT necessary for all

patients.



Many centers, especially Europeans and North American internal medicine

groups, use 2 thigh to knee ultrasounds a week apart. This requires two scans

for moderate to high risk groups and no further scanning for low risk groups

or those with negative d-dimer (I recognize how few patients get good

evaluation before coming to a lab and this is one reason while I personally

support the complete examination). This approach is well researched and is

safe.



The current anticoagulation guidelines from the Chest Physicians support this.

The chapters are hundreds of pages long and have a VERY long chapter on

diagnosing DVT. The guidelines do not recommend treating everyone with calf

DVT and support tailoring imaging to diagnose treatable conditions rather than

all DVT (i.e. calf DVT)



How did they come to this conclusion.

1) Very few people evaluated have DVT, they have something else.

2) The minority of patients with calf DVT will propagate to above the knee

(about 20%).

3) Larger veins are more likely to cause symptomatic PE, calf veins not at all

or only rarely.

4) There is weak evidence that treating calf DVT affects the rate of chronic

venous insufficiency or recurrent DVT. (Obviously more work needs to be done

since it makes some sense that treating a disease earlier should help).

5) The risks of anticoagulation are real and the risks of overtreating

insignificant calf DVT may outweigh the benefit of treating calf DVTs which

have a more aggressive natural history.



1.      Guyatt GH, Akl EA, Crowther M, Gutterman DD, Schuunemann HJ, for

the American College of Chest Physicians Antithrombotic Therapy and

Prevention of Thrombosis Panel. Executive Summary: Antithrombotic Therapy

and Prevention of Thrombosis, 9th ed: American College of Chest Physicians

Evidence-Based Clinical Practice Guidelines. Chest. 2012Feb.6;141(2

suppl):7S–47S.

2.      Bates SM, Jaeschke R, Stevens SM, Goodacre S, Wells PS, Stevenson

MD, et al. Diagnosis of DVT: Antithrombotic Therapy and Prevention of

Thrombosis, 9th ed: American College of Chest Physicians Evidence-Based

Clinical Practice Guidelines. Chest. 2012Feb.6;141(2 suppl):e351S–e418S.



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