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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