Clinical ultrasonography in venous thromboembolism disease

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Imagen de ultrasonografía por compresión a nivel de vena femoral común (a), previa a la compresión (b) y se aprecia contenido en el interior de una vena no colapsable compatible con TVP (c)." ] ] ] "autores" => array:1 [ 0 => array:2 [ "autoresLista" => "E. Moya Mateo, N. Muñoz Rivas" "autores" => array:2 [ 0 => array:2 [ "nombre" => "E." "apellidos" => "Moya Mateo" ] 1 => array:2 [ "nombre" => "N." 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Moya Mateo, N. Muñoz Rivas" "autores" => array:2 [ 0 => array:4 [ "nombre" => "E." "apellidos" => "Moya Mateo" "email" => array:1 [ 0 => "evamoyamateo@gmail.com" ] "referencia" => array:3 [ 0 => array:2 [ "etiqueta" => "a" "identificador" => "aff0005" ] 1 => array:2 [ "etiqueta" => "b" "identificador" => "aff0010" ] 2 => array:2 [ "etiqueta" => "*" "identificador" => "cor0005" ] ] ] 1 => array:3 [ "nombre" => "N." 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Abbreviations: CT, computed tomography; PE, pulmonary embolism; RUSH, Rapid Ultrasound for Shock and Hypotension; RV, right ventricle; TTE, transthoracic echocardiogram." ] ] ] "textoCompleto" => "BackgroundVenous thromboembolism (VTE) includes deep vein thrombosis (DVT) and pulmonary embolism (PE), both of which cause significant morbidity and mortality. VTE is the third leading cardiovascular disease in terms of frequency, with an estimated 150 cases of DVT and 100 of PE per 100,000 inhabitants/year in Spain.<a class="elsevierStyleCrossRef" href="#bib0005">1</a>DVT is responsible for a considerable number of emergency department visits.<a class="elsevierStyleCrossRef" href="#bib0010">2</a> The clinical diagnosis of DVT is not simple and requires imaging techniques for confirmation.<a class="elsevierStyleCrossRef" href="#bib0015">3</a> The gold standard noninvasive diagnostic method is currently Doppler ultrasound, which has a sensitivity of 100% and 98% and a specificity of 95% and 75% for proximal and distal DVT, respectively.<a class="elsevierStyleCrossRef" href="#bib0020">4</a> However, several studies have shown that compression ultrasonography (CUS) is highly sensitive and specific for proximal DVT and can be time and cost effective when performed at the point of care in emergency departments.<a class="elsevierStyleCrossRef" href="#bib0025">5</a> This practice has been implemented in the past 15 years and is supported by the American College of Emergency Physicians,<a class="elsevierStyleCrossRef" href="#bib0030">6</a> such that numerous algorithms have been proposed that combine the clinical probability, the D-dimer and CUS for the diagnostic-therapeutic management of DVT.PE can go underdiagnosed due to its unspecific manifestations.<a class="elsevierStyleCrossRefs" href="#bib0005">1,7</a> Pathophysiologically, PE produces a blood flow obstruction in the pulmonary territory, and its spectrum includes increased pressure in the pulmonary arteries, right ventricular (RV) dysfunction and, if it progresses, left ventricular (LV) dysfunction and shock.<a class="elsevierStyleCrossRef" href="#bib0035">7</a> Delayed treatment is associated with greater mortality; a speedy diagnosis is therefore essential when managing PE. As with DVT, the assessment of suspected PE is based on estimating the clinical probability, determining the D-dimer and performing a confirmatory imaging test, the most employed of which is multislice computed tomography angiography (CTA).<a class="elsevierStyleCrossRef" href="#bib0035">7</a> In this article, we review how clinical ultrasonography can help in the diagnostic and prognostic assessment of our patients in daily practice.Necessary knowledge for applying ultrasonographyClinical ultrasonography requires technical expertise, such as handling the ultrasound machine, understanding the ultrasound technique that depends on the structure to be assessed and possessing the anatomical and functional knowledge of the organ to be examined.Deep vein thrombosisTo study the deep venous system of the legs, we use a high-frequency linear probe. The probe marker is placed to the right of the patient. The examination is performed with the patient in supine decubitus and with the leg in slight abduction and external rotation, with the knee slightly bent. Placing the patient in prone decubitus, if the patient’s condition allows, provides the best position for examining the popliteal axis.The deep venous system (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>) consists of the external iliac vein that passes through the inguinal ligament, where it becomes the common femoral vein, which lies medial to the common femoral artery. The great saphenous vein travels the length of the leg along the medial side and empties into the common femoral vein through the saphenous arch. Approximately 5cm below the inguinal ligament, the common femoral artery splits into its 2 branches: the deep and superficial femoral arteries. The superficial femoral vein is examined over the entire internal part of the thigh. Venous duplication is not uncommon at this level, and both vessels should be examined if this is the case. In the distal two-thirds of the thigh, the superficial femoral vein runs deep, penetrating the adductor canal (Hunter’s canal) and emerging from behind the knee as the popliteal vein. The popliteal vein is examined from the popliteal fossa (proximal and distal). At the popliteal level, the vein is more superficial than the popliteal artery. Distally, the popliteal vein trifurcates into the anterior tibial, posterior tibial and peroneal veins.<elsevierMultimedia ident="fig0005"></elsevierMultimedia>Unlike conventional Doppler ultrasonography of the legs, CUS does not obtain images from the entire trajectory of the deep veins but rather, a simplified CUS is performed on 2 or 3 points per area (2-point or 3-point CUS, respectively). Most cases of thrombosis occur in the bifurcations (junction of the saphenous and common femoral veins, junction of the common and superficial femoral veins and junction of the tibial and peroneal veins with the popliteal vein).In 2-point CUS, 2 territories are examined (the common femoral and popliteal veins), while 3-point CUS also examines the superficial femoral vein, which belongs to the deep venous system.<a class="elsevierStyleCrossRef" href="#bib0040">8</a> This last approach helps identify approximately 3% of patients with thrombosis due to isolated involvement of the superficial femoral vein, undetected by 2-point CUS.The technique offers high sensitivity (95%), high specificity (96%), a shorter examination time (<4min) and a shorter learning period.<a class="elsevierStyleCrossRef" href="#bib0045">9</a> The simplification is based on the number of territories examined and the signs of thrombosis that are assessed. The basic principle for detecting the presence of thrombosis is that the vein wall is weaker than the arterial wall and is collapsible in the absence of solid content in its interior (<a class="elsevierStyleCrossRef" href="#fig0010">Fig. 2</a>). A completely collapsible vein is not thrombosed, while a lack of compressibility is an indication that the vein is thrombosed.<elsevierMultimedia ident="fig0010"></elsevierMultimedia>In case of doubt, we can turn to color Doppler. Lack of blood flow is a sign of thrombosis but should be interpreted with caution because if the transducer is placed completely perpendicular to the vessel to be examined, the flow might not approach or recede from the transducer; in this case, no color is observed. The solution in this situation is to vary the inclination of the transducer by 40–60°. If it is not occlusive, the thrombus is very recent (central location in the vein lumen) or old (adhered to the wall), and varying degrees of flow can be observed. Color Doppler is useful in those areas in which compression is difficult (e.g., iliac veins, subclavian vein), increasing the sensitivity and specificity of the DVT diagnosis (especially distal DVT) and helping differentiate between occlusive and nonocclusive thrombi.Another sign of thrombosis is the presence of intraluminal echogenic content. The lumen of the veins is anechoic; however, the presence of echogenic content within the vessel can hinder the localization of the vein. The absence of echogenic content does not ensure the absence of thrombi, given that recent thrombi are usually anechoic and indistinguishable from liquid blood.Pulmonary embolismThe application of clinical ultrasonography in the management of PE is based on multiorgan ultrasonography, which has a greater diagnostic yield than that focused on a single system. Multiorgan ultrasonography includes the evaluation of the proximal veins of the legs, pulmonary ultrasonography and cardiac ultrasonography.<a class="elsevierStyleCrossRef" href="#bib0055">11</a>The previously described CUS reveals DVT in 30–50% of cases of PE.<a class="elsevierStyleCrossRefs" href="#bib0060">12–15</a> By itself, CUS cannot rule out PE and is not superior to CTA.<a class="elsevierStyleCrossRef" href="#bib0080">16</a>Pulmonary examinations can be performed with a low-frequency convex probe or a high-frequency linear probe. The examination should be systematic, using longitudinal and oblique planes following the intercostal spaces, in the anterior, lateral and posterior sides of the chest.<a class="elsevierStyleCrossRefs" href="#bib0055">11,17,18</a> The examination can be performed with the patient seated and their arms raised to the neck or with the patient supine in lateral decubitus on either side to examine the dorsal region, depending on the clinical situation. The examination will focus on searching for pulmonary infarctions, Which appear on the ultrasound as homogeneous subpleural hypoechoic areas with triangular morphology towards the hilum or rounded, measuring at least 0.5mm in diameter<a class="elsevierStyleCrossRefs" href="#bib0055">11,18</a> and reaching 60–70mm.<a class="elsevierStyleCrossRef" href="#bib0085">17</a> The infarctions are more frequent in the posterior-basal fields,<a class="elsevierStyleCrossRefs" href="#bib0055">11,17</a> with a mean of 1.6–2.3 lesions per patient.<a class="elsevierStyleCrossRefs" href="#bib0055">11,17,18</a> Pleural effusion<a class="elsevierStyleCrossRef" href="#bib0085">17</a> (local or basal) is also often visualized, as is alveolar consolidations with/without effusion in the posterior fields (posterior and/or lateral alveolar and/or pleural syndrome, PLAPS)<a class="elsevierStyleCrossRef" href="#bib0095">19</a> (Appendix B See additional material. Video 1. Patient with pulmonary thromboembolism and distal pulmonary infarction in whom the correlation between the chest CT image and lung ultrasound is shown. We can observe slight pleural effusion and pulmonary infarction that in the ultrasound is visualized as a hypodense area in the subpleural level with an isolated B-line).Cardiac ultrasonography or echocardioscopy is performed with a sector probe in 2D-mode, except when calculating RV systolic function, which requires M-mode. The patient is placed in supine decubitus, slightly turned to the left if their clinical situation permits. A small number of planes are usually sufficient and include the short and long parasternal axes, the apical 4-chamber plane and the subcostal-subxiphoid plane.<a class="elsevierStyleCrossRef" href="#bib0100">20</a> The objective is to detect indirect signs of pulmonary hypertension, assessing the presence of pressure overload and RV function. Its evaluation is complex and requires extensive training due to its half-moon morphology, with the diameter narrowing from the base to the apex. The RV is smaller than the LV, and the normal RV/LV ratio is 0.4–0.6.<a class="elsevierStyleCrossRef" href="#bib0105">21</a> At baseline, the normal end-diastolic RV diameter is 20–28mm, and the thickness of the free wall is <5mm.<a class="elsevierStyleCrossRefs" href="#bib0110">22,23</a> The interventricular septum is slightly inclined towards the RV.<a class="elsevierStyleCrossRef" href="#bib0105">21</a> The following aspects should be considered when assessing the RV:<ul class="elsevierStyleList" id="lis0005"><li class="elsevierStyleListItem" id="lsti0005">•Assess the presence of pressure overload. Subjectively and objectively estimate the dimensions and characteristics of the RV. The most appropriate plane is the apical 4-chamber, centered on the RV, with the apex of the LV in the center of the image, attempting to adequately visualize the free wall of the RV.<a class="elsevierStyleCrossRef" href="#bib0110">22</a> Subjectively, there is severe RV overload when it is enlarged and dilated, with its free wall widened towards the apex; qualitatively, we can infer an RV/LV ratio≥1.<a class="elsevierStyleCrossRefs" href="#bib0105">21,22,24</a> In the same plane in end-diastole, we can objectively measure the RV diameter at the base, just below and parallel to the tricuspid valve, from the inner face of the interventricular septum to the inner face of the free wall of the interventricular septum.<a class="elsevierStyleCrossRef" href="#bib0115">23</a> An RV diameter≥39mm indicates severe dilation, a diameter of 34–38mm indicates moderate dilation, and 29–33mm indicates slight dilation.<a class="elsevierStyleCrossRef" href="#bib0115">23</a> Similarly, we can measure the LV at its base, just below and parallel to the mitral valve, from the inner face of the interventricular septum in the LV to the inner face of the interventricular septum. We can therefore calculate the RV/LV ratio, which indicates severe RV dilation if ≥1.<a class="elsevierStyleCrossRef" href="#bib0115">23</a> Other options for assessing dilation include the parasternal long-axis plane (end-diastolic RV/LV ratio>0.6<a class="elsevierStyleCrossRef" href="#bib0125">25</a>) or subcostal plane if a diameter>30mm is observed at the end of the diastole.<a class="elsevierStyleCrossRef" href="#bib0055">11</a></li><li class="elsevierStyleListItem" id="lsti0010">•Assess RV function. RV function is estimated subjectively, observing whether there is hypokinesia in the movement of its free wall towards the interventricular septum.<a class="elsevierStyleCrossRef" href="#bib0110">22</a> RV function can be assessed in the apical 4-chamber, subcostal and parasternal long-axis planes. The interventricular septum in this scenario can also have a paradoxical movement<a class="elsevierStyleCrossRef" href="#bib0110">22</a> and be flattened or even bulging towards the LV due to the increased pressure in the right-side cavities, which can result in the involvement of the left cavities. In the parasternal short-axis plane, the RV has a “D” shape or even a more rounded “O” shape. McConnell’s sign has also been reported in patients with PE, which is visualized as hypokinesia/akinesia of the basal and medial segments of the RV free wall, preserving the mobility of the apex (sensitivity 77%, specificity 94%).<a class="elsevierStyleCrossRef" href="#bib0120">24</a> Objectively, the systolic excursion or vertical movement of the tricuspid ring (tricuspid annular plane systolic excursion, TAPSE) can be calculated. The measurement requires the use of M-mode in the apical 4-chamber plane, through the long axis of the RV, placing the cursor on the lateral face of the tricuspid ring (on the RV free wall) and measuring the change in height of the resulting trace.<a class="elsevierStyleCrossRef" href="#bib0110">22</a> The lower the mobility the greater the dysfunction. Values between 16 and 20mm are therefore normal, mild dysfunction is 11–15mm, moderate is 6–10mm, and severe is≤5mm.<a class="elsevierStyleCrossRef" href="#bib0125">25</a> In clinical ultrasonography, 20mm has been evaluated as the most sensitive cutoff for detecting RV dysfunction<a class="elsevierStyleCrossRef" href="#bib0130">26</a> (Appendix B See additional material. Video 2. Echocardiography in a patient with pulmonary thromboembolism with right ventricular overload [RV dilation and dysfunction, paradoxical deviation of the interventricular septum, decreased TAPSE and tricuspid regurgitation]. At 24h after applying effective fibrinolytic therapy, these parameters normalized). Mobile thrombi and those travelling in the right-side cavities are rarely (3%) visualized<a class="elsevierStyleCrossRef" href="#bib0135">27</a> (Appendix B See additional material. Video 3. Apical 4-chamber and subcostal plane in a patient with pulmonary thromboembolism and thrombus in transition in the right atrium).</li><li class="elsevierStyleListItem" id="lsti0015">•Assessing the diameter and collapsibility of the inferior vena cava during the respiratory cycle provides indirect information on the hemodynamic condition and central venous pressure. With the patient in supine decubitus, the sector probe can be employed from the subxiphoid plane, pointing to the right hypochondrium and rotating the probe 70–90° in the counterclockwise direction, searching for the entrance of the inferior vena cava into the right atrium. A convex probe can also be employed in the epigastric region through a transparietal hepatic paramedial longitudinal slice. Measurements are made 2cm below the entrance into the right atrium, helped by M-mode, and the diameter is calculated in expiration, as well as the collapsibility index, which will be reduced if there is a significant increase in pressure in the right-side cavities.10</li></ul>Clinical scenariosThis section describes common clinical situations and how to implement clinical ultrasonography using diagnostic-therapeutic algorithms, combined with the clinical probability and biochemical measurements.Suspected deep vein thrombosisThis is the most common clinical scenario of VTE in emergency departments. When a patient is admitted with symptoms of thrombosis in the legs (pain, edema, flushing), clinicians should establish the pretest probability using scales that include clinical findings and risk factors for developing DVT. The most widely used scale is the Wells scale.When DVT is unlikely, measuring D-dimer helps rule out the diagnosis due to its high negative predictive value. In this case, the patient can be safely discharged without anticoagulant therapy. When the D-dimer is positive, the recommendation is to perform CUS, preferably 3-point. If positive, the recommendation is to start anticoagulation and, if possible, confirm with Doppler ultrasound at 48h.When the pretest probability is high (Wells score≥2), most algorithms recommend performing CUS. If positive, the decision can be made to administer anticoagulation without the need for determining the D-dimer. In the event of a negative result, the recommendation is to repeat the technique in approximately 1 week to rule out the possibility of progression of a distal thrombosis (<a class="elsevierStyleCrossRef" href="#fig0015">Fig. 3</a>).<elsevierMultimedia ident="fig0015"></elsevierMultimedia>Suspected hemodynamically unstable pulmonary embolismThis is the presentation in 5–12% of cases of PE and is by definition high risk.<a class="elsevierStyleCrossRef" href="#bib0140">28</a> The condition is defined by the presence of a systolic blood pressure<90mm Hg or a drop>40mm Hg for more than 15min, excluding the presence of arrhythmias, sepsis and hypovolemia.<a class="elsevierStyleCrossRef" href="#bib0035">7</a> These patients should undergo CTA immediately or transthoracic echocardiography.<a class="elsevierStyleCrossRef" href="#bib0035">7</a> Lacking these options, echocardioscopy (in trained hands) can assess the signs of RV overload and dysfunction, which, if present, can support the diagnosis and immediate start of fibrinolytic treatment (<a class="elsevierStyleCrossRef" href="#fig0020">Fig. 4</a>). These aspects have been included in quick guidance multiorgan examination protocols for patients with shock (e.g., RUSH protocol), which also help assess other causes of hypotension.<a class="elsevierStyleCrossRef" href="#bib0145">29</a><elsevierMultimedia ident="fig0020"></elsevierMultimedia>Suspected hemodynamically stable pulmonary embolismIn this situation, the diagnosis starts with the application of validated clinical probability models such as the Wells and Geneva scales.<a class="elsevierStyleCrossRef" href="#bib0035">7</a> For outpatients or those in the emergency department with a low-intermediate (3-level scales) or unlikely probability (simplified versions), D-dimer should be determined; if it is negative, PE can be ruled out. Clinical ultrasonography directed by symptoms can provide an alternative diagnosis or rule out organicity.<a class="elsevierStyleCrossRefs" href="#bib0095">19,30</a> In the event of a positive D-dimer or a high clinical probability, a confirmatory imaging test should be conducted.<a class="elsevierStyleCrossRef" href="#bib0035">7</a> If imaging tests are not available or are contraindicated, multiorgan clinical ultrasonography can serve as a tool for diagnosing PE.<a class="elsevierStyleCrossRef" href="#bib0055">11</a> If PE is not confirmed, the tool can help assess other differential diagnoses<a class="elsevierStyleCrossRefs" href="#bib0055">11,18,31</a> and improve the selection of patients to undergo confirmation tests.<a class="elsevierStyleCrossRefs" href="#bib0055">11,18,26</a> For patients in whom DVT or RV dilation is demonstrated with medium to high probability, early anticoagulation may be started (<a class="elsevierStyleCrossRef" href="#fig0020">Fig. 4</a>).<a class="elsevierStyleCrossRef" href="#bib0120">24</a>The Wells scale assisted by ultrasonography has recently been suggested for assessing the pretest probability of PE. In this approach, the criterion “signs and symptoms of DVT” is replaced by CUS, and the criterion “an alternative diagnosis to pulmonary thromboembolism” is replaced by pulmonary ultrasonography that detects alternative diagnoses, such as pneumonia and interstitial lung disease, or confirms the presence of pulmonary infarctions. This new concept takes advantage of the greater sensitivity and specificity of clinical ultrasonography compared with the physical examination and subjective criteria. This scale has greater diagnostic accuracy than the classic Wells scale (sensitivity, 69.6% vs. 57.6%; specificity, 88.2% vs. 68.2%, respectively) and can reduce by 25% the number of cases that need invasive diagnostic tests such as CT, although this approach awaits confirmation through a larger cohort.<a class="elsevierStyleCrossRef" href="#bib0090">18</a>Ultrasonography in the prognosis of pulmonary embolismThere is no direct evidence regarding the use of clinical ultrasonography and the prognostic outcome of PE. However, the link between the two can be indirectly inferred because DVT detected by standardized Doppler ultrasound is an independent factor for recurrence and overall mortality in acute symptomatic PE.<a class="elsevierStyleCrossRef" href="#bib0070">14</a> Similarly, in acute stable PE, RV dysfunction detected by echocardiography is associated with a poorer prognosis.<a class="elsevierStyleCrossRef" href="#bib0035">7</a> Given that echocardioscopy can detect dilation and dysfunction,<a class="elsevierStyleCrossRefs" href="#bib0105">21,24,26</a> it is likely that it can help determine the severity and prognosis. The detection of thrombi in the right-side cavities is also associated with increased mortality.<a class="elsevierStyleCrossRef" href="#bib0135">27</a>In the prognostic stratification model that employs the PESI scale or its simplified version, the European guidelines include the assessment of RV function (by echocardiography or CTA) and the markers of myocardial damage (troponin and BNP), establishing 4 risk categories: low, low-intermediate, intermediate-high and high.<a class="elsevierStyleCrossRef" href="#bib0035">7</a> This model efficiently classifies acute PE and its mortality risk at 30 days.<a class="elsevierStyleCrossRef" href="#bib0140">28</a> In low-risk patients, detecting RV dysfunction is associated with early mortality.<a class="elsevierStyleCrossRef" href="#bib0155">31</a> In addition to this model, performing a Doppler ultrasound and detecting DVT in patients at low-intermediate risk (PESI>1 with RV dysfunction or increased troponin levels) can improve the stratification of complications in the short term.<a class="elsevierStyleCrossRef" href="#bib0075">15</a>Residual DVT has a known prognostic value in terms of VTE recurrence in the outpatient follow-up in the medium to long term.<a class="elsevierStyleCrossRef" href="#bib0160">32</a> There are no studies that have analyzed the usefulness of CUS in this clinical scenario.Other scenariosGiven the absence of specific symptoms in PE, various protocols employing clinical ultrasonography have been developed from a symptom-based orientation.Dyspnea with acute respiratory failureFifty percent of cases of PE present with dyspnea.<a class="elsevierStyleCrossRef" href="#bib0035">7</a> The BLUE protocol<a class="elsevierStyleCrossRef" href="#bib0095">19</a> evaluates patients with respiratory failure, in whom, after confirming the presence of pleural sliding, the presence of a bilateral pattern of A-lines with CUS indicating DVT can guide the diagnosis to PE (sensitivity 81%, specificity 99%, negative predictive value 98%, positive predictive value 94%). PE can also be detected as a posterolateral consolidation (pulmonary infarction), with or without pleural involvement.Pleuritic chest painPleuritic chest pain is present in 39% of patients with PE and can be its form of presentation.<a class="elsevierStyleCrossRef" href="#bib0035">7</a> In patients with normal chest radiography, pulmonary clinical ultrasonography can be performed on the painful area, which can help the diagnosis, detecting abnormal patterns, which include pulmonary infarctions.<a class="elsevierStyleCrossRef" href="#bib0150">30</a>Key aspects, use in real life and current evidenceSummarizing the aspects mentioned earlier, the utility of clinical ultrasonography in VTE includes the following:<ul class="elsevierStyleList" id="lis0010"><li class="elsevierStyleListItem" id="lsti0020">•CUS indicating DVT in a clinical scenario consistent with PE confirms the diagnosis, avoiding other examinations that involve iatrogenic effects and enabling the start of anticoagulant therapy.<a class="elsevierStyleCrossRefs" href="#bib0060">12,18</a> CUS has been shown to be efficient and cost-effective, Although its sensitivity varies in the published series. In recent studies, the comparison between 3-point and 2-point CUS showed better results for the former (sensitivity of 90.5% vs. 82.7% and specificity of 98.5% in both techniques).<a class="elsevierStyleCrossRefs" href="#bib0165">33–35</a></li><li class="elsevierStyleListItem" id="lsti0025">•The diagnostic yield of multiorgan clinical ultrasonography in PE is higher than that of single-organ clinical ultrasonography.<a class="elsevierStyleCrossRef" href="#bib0055">11</a> Proximal CUS is highly specific (96%) and poorly sensitive (41%)<a class="elsevierStyleCrossRef" href="#bib0065">13</a> for the diagnosis of PE. Therefore, a negative CUS does not rule out PE; however, a positive result has a high positive predictive value and could help avoid the need for more tests.<a class="elsevierStyleCrossRefs" href="#bib0060">12,18</a> If there are signs and symptoms of DVT, the yield of CUS increases (sensitivity 72%, specificity 99%).<a class="elsevierStyleCrossRefs" href="#bib0060">12,16</a> The presence of DVT is correlated with more proximal thrombi (central, lobar).<a class="elsevierStyleCrossRef" href="#bib0060">12</a> A complete CUS, which includes infrapopliteal veins, does not improve the yield because it increases the sensitivity (79%) but significantly decreases its specificity (84%).<a class="elsevierStyleCrossRef" href="#bib0065">13</a> Including CUS on proximal veins, within the diagnostic strategy indicated by the guidelines, in low and moderate risk, along with D-dimer and CTA, does not provide greater diagnostic yield,<a class="elsevierStyleCrossRef" href="#bib0080">16</a> although it could be used in patients with a contraindication for CT. Pulmonary clinical ultrasonography by itself also lacks good diagnostic yield in PE (sensitivity 87%, specificity 81.8%).<a class="elsevierStyleCrossRef" href="#bib0180">36</a></li><li class="elsevierStyleListItem" id="lsti0030">•Cardiac clinical ultrasonography in trained hands has a good correlation with echocardiography in detecting RV dilation and dysfunction<a class="elsevierStyleCrossRefs" href="#bib0105">21,24</a> and can help make a safe, subjective and objective TAPSE calculation.<a class="elsevierStyleCrossRef" href="#bib0130">26</a> Visualizing thrombi in transit in right-side cavities in a consistent clinical context confirms the diagnosis of PE.<a class="elsevierStyleCrossRef" href="#bib0135">27</a></li><li class="elsevierStyleListItem" id="lsti0035">•Multiorgan ultrasonography (lungs, heart, proximal veins) is more sensitive than that focused on a single organ (sensitivity 90%, specificity 86%, negative predictive value 74%, positive predictive value 95%).<a class="elsevierStyleCrossRef" href="#bib0055">11</a> Multiorgan clinical ultrasonography helps detect alternative diagnoses for a one-third to one-half of patients with suspected but unconfirmed PE (e.g., pneumonia, interstitial syndrome, pleural effusion, pericardial effusion and aortic dissection).<a class="elsevierStyleCrossRefs" href="#bib0055">11,18,31</a></li><li class="elsevierStyleListItem" id="lsti0040">•Clinical ultrasonography can help the diagnosis of PE in clinical conditions in which CTA is not immediate (e.g., shock) or is limited (e.g., allergy to contrast media, kidney failure, pregnant women and the young for whom radiation exposure should be avoided).</li><li class="elsevierStyleListItem" id="lsti0045">•Detecting RV dilation and/or dysfunction is not specific for PE. We should also remember that echocardioscopy without RV dilation or dysfunction does not rule out PE; however, its absence in patients with shock rules out this diagnosis as the underlying cause.<a class="elsevierStyleCrossRefs" href="#bib0100">20,24</a></li></ul>LimitationsClinical ultrasonography is an operator-dependent technique and requires initial and periodic training. There are patient limitations, due to poor acoustic windows, which can obstruct their assessment (more common in echocardioscopy). In patients with morbid obesity, CUS of the legs can be complex and can yield false negatives. Due to its location, iliac thrombosis is a candidate for Doppler ultrasound.In CUS, the presence of prior DVT or of residual thrombus can limit its diagnostic usefulness. In pulmonary clinical ultrasonography, the absence of specific presets for the lungs can limit the visualization of lesions that are not adjacent to the pleural surface. In cardiac clinical ultrasonography, the presence of prior RV dilation and dysfunction in patients with underlying cardiopulmonary diseases complicates the differentiation of chronic overload from acute overload. In this respect, several criteria have been described that direct the diagnosis to a chronic progression, Including the thickness of the RV free wall (pathological if >7mm).<a class="elsevierStyleCrossRef" href="#bib0125">25</a> The best plane for measuring the thickness is the subxiphoid plane.<a class="elsevierStyleCrossRef" href="#bib0110">22</a>Areas for future developmentIt would be advisable to establish the following future actions regarding clinical ultrasonography in VTE:<ul class="elsevierStyleList" id="lis0015"><li class="elsevierStyleListItem" id="lsti0050">•Evaluate, include and validate the utility of multiorgan clinical ultrasonography in the diagnostic protocol and management of PE with hemodynamic stability.</li><li class="elsevierStyleListItem" id="lsti0055">•Assess the usefulness of multiorgan clinical ultrasonography in the diagnostic protocol of PE in patients with a contraindication for CTA (pregnant women, those with kidney failure, those with contrast allergy and young patients who should avoid radiation).</li><li class="elsevierStyleListItem" id="lsti0060">•Assess multiorgan clinical ultrasonography within prognostic stratification models, supplementing the current clinical scales, especially in the low, low-intermediate and intermediate-high risk levels, both for the presence of pulmonary infarctions and DVT, such as the presence of overload and RV dysfunction.</li><li class="elsevierStyleListItem" id="lsti0065">•Assess the use of multiorgan clinical ultrasonography within the diagnostic algorithm for hospitalized patients.</li></ul>" "textoCompletoSecciones" => array:1 [ "secciones" => array:11 [ 0 => array:3 [ "identificador" => "xres1309613" "titulo" => "Abstract" "secciones" => array:1 [ 0 => array:1 [ "identificador" => "abst0005" ] ] ] 1 => array:2 [ "identificador" => "xpalclavsec1209183" "titulo" => "Keywords" ] 2 => array:3 [ "identificador" => "xres1309612" "titulo" => "Resumen" "secciones" => array:1 [ 0 => array:1 [ "identificador" => "abst0010" ] ] ] 3 => array:2 [ "identificador" => "xpalclavsec1209182" "titulo" => "Palabras clave" ] 4 => array:2 [ "identificador" => "sec0005" "titulo" => "Background" ] 5 => array:3 [ "identificador" => "sec0010" "titulo" => "Necessary knowledge for applying ultrasonography" "secciones" => array:2 [ 0 => array:2 [ "identificador" => "sec0015" "titulo" => "Deep vein thrombosis" ] 1 => array:2 [ "identificador" => "sec0020" "titulo" => "Pulmonary embolism" ] ] ] 6 => array:3 [ "identificador" => "sec0025" "titulo" => "Clinical scenarios" "secciones" => array:7 [ 0 => array:2 [ "identificador" => "sec0030" "titulo" => "Suspected deep vein thrombosis" ] 1 => array:2 [ "identificador" => "sec0035" "titulo" => "Suspected hemodynamically unstable pulmonary embolism" ] 2 => array:2 [ "identificador" => "sec0040" "titulo" => "Suspected hemodynamically stable pulmonary embolism" ] 3 => array:2 [ "identificador" => "sec0045" "titulo" => "Ultrasonography in the prognosis of pulmonary embolism" ] 4 => array:2 [ "identificador" => "sec0050" "titulo" => "Other scenarios" ] 5 => array:2 [ "identificador" => "sec0055" "titulo" => "Dyspnea with acute respiratory failure" ] 6 => array:2 [ "identificador" => "sec0060" "titulo" => "Pleuritic chest pain" ] ] ] 7 => array:2 [ "identificador" => "sec0065" "titulo" => "Key aspects, use in real life and current evidence" ] 8 => array:2 [ "identificador" => "sec0070" "titulo" => "Limitations" ] 9 => array:2 [ "identificador" => "sec0075" "titulo" => "Areas for future development" ] 10 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "fechaRecibido" => "2019-05-13" "fechaAceptado" => "2019-05-27" "PalabrasClave" => array:2 [ "en" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Keywords" "identificador" => "xpalclavsec1209183" "palabras" => array:5 [ 0 => "Venous thromboembolism disease" 1 => "Deep vein thrombosis" 2 => "Pulmonary embolism" 3 => "Compression ultrasonography" 4 => "Clinical multiorgan ultrasonography" ] ] ] "es" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Palabras clave" "identificador" => "xpalclavsec1209182" "palabras" => array:5 [ 0 => "Enfermedad tromboembólica venosa" 1 => "Trombosis venosa profunda" 2 => "Embolia pulmón" 3 => "Ultrasonografía por compresión" 4 => "Ecografía clínica multiórgano" ] ] ] ] "tieneResumen" => true "resumen" => array:2 [ "en" => array:2 [ "titulo" => "Abstract" "resumen" => "The use of clinical ultrasonography has grown exponentially in the past decade in various medical settings. As with other areas of activity in the field of internal medicine, clinical ultrasonography has been implemented in venous thromboembolism disease (VTE), both in deep vein thrombosis (DVT) and pulmonary embolism (PE). In this review, we cover the diagnostic techniques, both for DVT through compression ultrasonography (CUS) and for multiorgan ultrasonography, which include CUS, pulmonary ultrasonography in the search for pulmonary infarctions and echocardiography for detecting dilation and right ventricular dysfunction for the diagnosis of PE. We also establish the most common clinical scenarios in which clinical ultrasonography can be of assistance in actual clinical practice, as well as its limitations and current evidence." ] "es" => array:2 [ "titulo" => "Resumen" "resumen" => "La ecografía clínica (EC) se ha desarrollado exponencialmente en la última década en distintos ámbitos de la medicina. De igual manera que ha ocurrido en otros campos de actuación de la Medicina Interna, su uso se ha implantado en la enfermedad tromboembólica venosa (ETV), tanto en la trombosis venosa profunda (TVP) como en la embolia de pulmón (EP). En esta revisión se repasan las técnicas para el diagnóstico, tanto de la TVP a través de la ultrasonografía por compresión (USC), como de la ecografía multiórgano que incluye la USC, la ecografía pulmonar en busca de infartos pulmonares y la ecocardioscopia para la detección de dilatación y/o disfunción del ventrículo derecho, para el diagnóstico de la EP. Además, se plantean los escenarios clínicos más frecuentes en los que puede ser de ayuda la EC en la vida real, así como sus limitaciones y la evidencia existente." ] ] "NotaPie" => array:1 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "Please cite this article as: Moya Mateo E, Muñoz Rivas N. Ecografía clínica en la enfermedad tromboembólica venosa. Rev Clin Esp. 2020;220:126–134." ] ] "apendice" => array:1 [ 0 => array:1 [ "seccion" => array:1 [ 0 => array:4 [ "apendice" => "The following are Supplementary data to this article:<elsevierMultimedia ident="upi0005"></elsevierMultimedia><elsevierMultimedia ident="upi0010"></elsevierMultimedia><elsevierMultimedia ident="upi0015"></elsevierMultimedia>" "etiqueta" => "Appendix A" "titulo" => "Supplementary data" "identificador" => "sec0085" ] ] ] ] "multimedia" => array:7 [ 0 => array:8 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 1459 "Ancho" => 1579 "Tamanyo" => 110155 ] ] "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0005" "detalle" => "Figure " "rol" => "short" ] ] "descripcion" => array:1 [ "en" => "Anatomy of the deep venous system." ] ] 1 => array:8 [ "identificador" => "fig0010" "etiqueta" => "Figure 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 1886 "Ancho" => 2167 "Tamanyo" => 194778 ] ] "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0010" "detalle" => "Figure " "rol" => "short" ] ] "descripcion" => array:1 [ "en" => "The veins collapse easily with pressure (left) and do not collapse if there are thrombi in their interior<a class="elsevierStyleCrossRef" href="#bib0050">10</a> (right). Compression ultrasound image of the common femoral vein (a), prior to compression (b). Content can be observed in the interior of a noncollapsible vein compatible with DVT (c)." ] ] 2 => array:8 [ "identificador" => "fig0015" "etiqueta" => "Figure 3" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr3.jpeg" "Alto" => 1237 "Ancho" => 2500 "Tamanyo" => 117139 ] ] "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0015" "detalle" => "Figure " "rol" => "short" ] ] "descripcion" => array:1 [ "en" => "Diagnostic-therapeutic algorithm for deep vein thrombosis (DVT) based on compression ultrasound of the proximal deep venous system. Taken from Bornemann et al.<a class="elsevierStyleCrossRef" href="#bib0045">9</a> Abbreviation: DVT, deep vein thrombosis." ] ] 3 => array:8 [ "identificador" => "fig0020" "etiqueta" => "Figure 4" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr4.jpeg" "Alto" => 1876 "Ancho" => 2917 "Tamanyo" => 287960 ] ] "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0020" "detalle" => "Figure " "rol" => "short" ] ] "descripcion" => array:1 [ "en" => "Proposed algorithm for managing suspected pulmonary embolism (PD), including clinical ultrasonography (CUS), both in conditions of hemodynamic stability and instability. Abbreviations: CT, computed tomography; PE, pulmonary embolism; RUSH, Rapid Ultrasound for Shock and Hypotension; RV, right ventricle; TTE, transthoracic echocardiogram." ] ] 4 => array:5 [ "identificador" => "upi0005" "tipo" => "MULTIMEDIAECOMPONENTE" "mostrarFloat" => false "mostrarDisplay" => true "Ecomponente" => array:3 [ "fichero" => "mmc1.mp4" "ficheroTamanyo" => 965120 "Video" => array:2 [ "flv" => array:5 [ "fichero" => "mmc1.flv" "poster" => "mmc1.jpg" "tiempo" => 0 "alto" => 0 "ancho" => 0 ] "mp4" => array:5 [ "fichero" => "mmc1.m4v" "poster" => "mmc1.jpg" "tiempo" => 0 "alto" => 0 "ancho" => 0 ] ] ] ] 5 => array:5 [ "identificador" => "upi0010" "tipo" => "MULTIMEDIAECOMPONENTE" "mostrarFloat" => false "mostrarDisplay" => true "Ecomponente" => array:3 [ "fichero" => "mmc2.mp4" "ficheroTamanyo" => 937701 "Video" => array:2 [ "flv" => array:5 [ "fichero" => "mmc2.flv" "poster" => "mmc2.jpg" "tiempo" => 0 "alto" => 0 "ancho" => 0 ] "mp4" => array:5 [ "fichero" => "mmc2.m4v" "poster" => "mmc2.jpg" "tiempo" => 0 "alto" => 0 "ancho" => 0 ] ] ] ] 6 => array:5 [ "identificador" => "upi0015" "tipo" => "MULTIMEDIAECOMPONENTE" "mostrarFloat" => false "mostrarDisplay" => true "Ecomponente" => array:3 [ "fichero" => "mmc3.mp4" "ficheroTamanyo" => 942276 "Video" => array:2 [ "mp4" => array:5 [ "fichero" => "mmc3.m4v" "poster" => "mmc3.jpg" "tiempo" => 0 "alto" => 0 "ancho" => 0 ] "flv" => array:5 [ "fichero" => "mmc3.flv" "poster" => "mmc3.jpg" "tiempo" => 0 "alto" => 0 "ancho" => 0 ] ] ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0005" "bibliografiaReferencia" => array:36 [ 0 => array:3 [ "identificador" => "bib0005" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Venous thromboembolism (VTE) in Europe. 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Clinical ultrasonography in venous thromboembolism disease

Ecografía clínica en la enfermedad tromboembólica venosa

E. Moya Mateoa,b,

Corresponding author

evamoyamateo@gmail.com

Corresponding author.

, N. Muñoz Rivasa,b

a Servicio de Medicina Interna, Hospital Universitario Infanta Leonor, Madrid, Spain

b Grupo de Trabajo de Ecografía Clínica, Sociedad Española de Medicina Interna, Spain

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          "en" => "<p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">Proposed algorithm for managing suspected pulmonary embolism &#40;PD&#41;&#44; including clinical ultrasonography &#40;CUS&#41;&#44; both in conditions of hemodynamic stability and instability&#46;</p> <p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">Abbreviations&#58; CT&#44; computed tomography&#59; PE&#44; pulmonary embolism&#59; RUSH&#44; Rapid Ultrasound for Shock and Hypotension&#59; RV&#44; right ventricle&#59; TTE&#44; transthoracic echocardiogram&#46;</p>"
        ]
      ]
    ]
    "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Background</span><p id="par0005" class="elsevierStylePara elsevierViewall">Venous thromboembolism &#40;VTE&#41; includes deep vein thrombosis &#40;DVT&#41; and pulmonary embolism &#40;PE&#41;&#44; both of which cause significant morbidity and mortality&#46; VTE is the third leading cardiovascular disease in terms of frequency&#44; with an estimated 150 cases of DVT and 100 of PE per 100&#44;000 inhabitants&#47;year in Spain&#46;<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a></p><p id="par0010" class="elsevierStylePara elsevierViewall">DVT is responsible for a considerable number of emergency department visits&#46;<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a> The clinical diagnosis of DVT is not simple and requires imaging techniques for confirmation&#46;<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a> The gold standard noninvasive diagnostic method is currently Doppler ultrasound&#44; which has a sensitivity of 100&#37; and 98&#37; and a specificity of 95&#37; and 75&#37; for proximal and distal DVT&#44; respectively&#46;<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a> However&#44; several studies have shown that compression ultrasonography &#40;CUS&#41; is highly sensitive and specific for proximal DVT and can be time and cost effective when performed at the point of care in emergency departments&#46;<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">5</span></a> This practice has been implemented in the past 15 years and is supported by the American College of Emergency Physicians&#44;<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">6</span></a> such that numerous algorithms have been proposed that combine the clinical probability&#44; the D-dimer and CUS for the diagnostic-therapeutic management of DVT&#46;</p><p id="par0015" class="elsevierStylePara elsevierViewall">PE can go underdiagnosed due to its unspecific manifestations&#46;<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1&#44;7</span></a> Pathophysiologically&#44; PE produces a blood flow obstruction in the pulmonary territory&#44; and its spectrum includes increased pressure in the pulmonary arteries&#44; right ventricular &#40;RV&#41; dysfunction and&#44; if it progresses&#44; left ventricular &#40;LV&#41; dysfunction and shock&#46;<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">7</span></a> Delayed treatment is associated with greater mortality&#59; a speedy diagnosis is therefore essential when managing PE&#46; As with DVT&#44; the assessment of suspected PE is based on estimating the clinical probability&#44; determining the D-dimer and performing a confirmatory imaging test&#44; the most employed of which is multislice computed tomography angiography &#40;CTA&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">7</span></a> In this article&#44; we review how clinical ultrasonography can help in the diagnostic and prognostic assessment of our patients in daily practice&#46;</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0030">Necessary knowledge for applying ultrasonography</span><p id="par0020" class="elsevierStylePara elsevierViewall">Clinical ultrasonography requires technical expertise&#44; such as handling the ultrasound machine&#44; understanding the ultrasound technique that depends on the structure to be assessed and possessing the anatomical and functional knowledge of the organ to be examined&#46;</p><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Deep vein thrombosis</span><p id="par0025" class="elsevierStylePara elsevierViewall">To study the deep venous system of the legs&#44; we use a high-frequency linear probe&#46; The probe marker is placed to the right of the patient&#46; The examination is performed with the patient in supine decubitus and with the leg in slight abduction and external rotation&#44; with the knee slightly bent&#46; Placing the patient in prone decubitus&#44; if the patient&#8217;s condition allows&#44; provides the best position for examining the popliteal axis&#46;</p><p id="par0030" class="elsevierStylePara elsevierViewall">The deep venous system &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Fig&#46; 1</a>&#41; consists of the external iliac vein that passes through the inguinal ligament&#44; where it becomes the common femoral vein&#44; which lies medial to the common femoral artery&#46; The great saphenous vein travels the length of the leg along the medial side and empties into the common femoral vein through the saphenous arch&#46; Approximately 5<span class="elsevierStyleHsp" style=""></span>cm below the inguinal ligament&#44; the common femoral artery splits into its 2 branches&#58; the deep and superficial femoral arteries&#46; The superficial femoral vein is examined over the entire internal part of the thigh&#46; Venous duplication is not uncommon at this level&#44; and both vessels should be examined if this is the case&#46; In the distal two-thirds of the thigh&#44; the superficial femoral vein runs deep&#44; penetrating the adductor canal &#40;Hunter&#8217;s canal&#41; and emerging from behind the knee as the popliteal vein&#46; The popliteal vein is examined from the popliteal fossa &#40;proximal and distal&#41;&#46; At the popliteal level&#44; the vein is more superficial than the popliteal artery&#46; Distally&#44; the popliteal vein trifurcates into the anterior tibial&#44; posterior tibial and peroneal veins&#46;</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0035" class="elsevierStylePara elsevierViewall">Unlike conventional Doppler ultrasonography of the legs&#44; CUS does not obtain images from the entire trajectory of the deep veins but rather&#44; a simplified CUS is performed on 2 or 3 points per area &#40;2-point or 3-point CUS&#44; respectively&#41;&#46; Most cases of thrombosis occur in the bifurcations &#40;junction of the saphenous and common femoral veins&#44; junction of the common and superficial femoral veins and junction of the tibial and peroneal veins with the popliteal vein&#41;&#46;</p><p id="par0040" class="elsevierStylePara elsevierViewall">In 2-point CUS&#44; 2 territories are examined &#40;the common femoral and popliteal veins&#41;&#44; while 3-point CUS also examines the superficial femoral vein&#44; which belongs to the deep venous system&#46;<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">8</span></a> This last approach helps identify approximately 3&#37; of patients with thrombosis due to isolated involvement of the superficial femoral vein&#44; undetected by 2-point CUS&#46;</p><p id="par0045" class="elsevierStylePara elsevierViewall">The technique offers high sensitivity &#40;95&#37;&#41;&#44; high specificity &#40;96&#37;&#41;&#44; a shorter examination time &#40;&#60;4<span class="elsevierStyleHsp" style=""></span>min&#41; and a shorter learning period&#46;<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">9</span></a> The simplification is based on the number of territories examined and the signs of thrombosis that are assessed&#46; The basic principle for detecting the presence of thrombosis is that the vein wall is weaker than the arterial wall and is collapsible in the absence of solid content in its interior &#40;<a class="elsevierStyleCrossRef" href="#fig0010">Fig&#46; 2</a>&#41;&#46; A completely collapsible vein is not thrombosed&#44; while a lack of compressibility is an indication that the vein is thrombosed&#46;</p><elsevierMultimedia ident="fig0010"></elsevierMultimedia><p id="par0050" class="elsevierStylePara elsevierViewall">In case of doubt&#44; we can turn to color Doppler&#46; Lack of blood flow is a sign of thrombosis but should be interpreted with caution because if the transducer is placed completely perpendicular to the vessel to be examined&#44; the flow might not approach or recede from the transducer&#59; in this case&#44; no color is observed&#46; The solution in this situation is to vary the inclination of the transducer by 40&#8211;60&#176;&#46; If it is not occlusive&#44; the thrombus is very recent &#40;central location in the vein lumen&#41; or old &#40;adhered to the wall&#41;&#44; and varying degrees of flow can be observed&#46; Color Doppler is useful in those areas in which compression is difficult &#40;e&#46;g&#46;&#44; iliac veins&#44; subclavian vein&#41;&#44; increasing the sensitivity and specificity of the DVT diagnosis &#40;especially distal DVT&#41; and helping differentiate between occlusive and nonocclusive thrombi&#46;</p><p id="par0055" class="elsevierStylePara elsevierViewall">Another sign of thrombosis is the presence of intraluminal echogenic content&#46; The lumen of the veins is anechoic&#59; however&#44; the presence of echogenic content within the vessel can hinder the localization of the vein&#46; The absence of echogenic content does not ensure the absence of thrombi&#44; given that recent thrombi are usually anechoic and indistinguishable from liquid blood&#46;</p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">Pulmonary embolism</span><p id="par0060" class="elsevierStylePara elsevierViewall">The application of clinical ultrasonography in the management of PE is based on multiorgan ultrasonography&#44; which has a greater diagnostic yield than that focused on a single system&#46; Multiorgan ultrasonography includes the evaluation of the proximal veins of the legs&#44; pulmonary ultrasonography and cardiac ultrasonography&#46;<a class="elsevierStyleCrossRef" href="#bib0055"><span class="elsevierStyleSup">11</span></a></p><p id="par0065" class="elsevierStylePara elsevierViewall">The previously described CUS reveals DVT in 30&#8211;50&#37; of cases of PE&#46;<a class="elsevierStyleCrossRefs" href="#bib0060"><span class="elsevierStyleSup">12&#8211;15</span></a> By itself&#44; CUS cannot rule out PE and is not superior to CTA&#46;<a class="elsevierStyleCrossRef" href="#bib0080"><span class="elsevierStyleSup">16</span></a></p><p id="par0070" class="elsevierStylePara elsevierViewall">Pulmonary examinations can be performed with a low-frequency convex probe or a high-frequency linear probe&#46; The examination should be systematic&#44; using longitudinal and oblique planes following the intercostal spaces&#44; in the anterior&#44; lateral and posterior sides of the chest&#46;<a class="elsevierStyleCrossRefs" href="#bib0055"><span class="elsevierStyleSup">11&#44;17&#44;18</span></a> The examination can be performed with the patient seated and their arms raised to the neck or with the patient supine in lateral decubitus on either side to examine the dorsal region&#44; depending on the clinical situation&#46; The examination will focus on searching for pulmonary infarctions&#44; Which appear on the ultrasound as homogeneous subpleural hypoechoic areas with triangular morphology towards the hilum or rounded&#44; measuring at least 0&#46;5<span class="elsevierStyleHsp" style=""></span>mm in diameter<a class="elsevierStyleCrossRefs" href="#bib0055"><span class="elsevierStyleSup">11&#44;18</span></a> and reaching 60&#8211;70<span class="elsevierStyleHsp" style=""></span>mm&#46;<a class="elsevierStyleCrossRef" href="#bib0085"><span class="elsevierStyleSup">17</span></a> The infarctions are more frequent in the posterior-basal fields&#44;<a class="elsevierStyleCrossRefs" href="#bib0055"><span class="elsevierStyleSup">11&#44;17</span></a> with a mean of 1&#46;6&#8211;2&#46;3 lesions per patient&#46;<a class="elsevierStyleCrossRefs" href="#bib0055"><span class="elsevierStyleSup">11&#44;17&#44;18</span></a> Pleural effusion<a class="elsevierStyleCrossRef" href="#bib0085"><span class="elsevierStyleSup">17</span></a> &#40;local or basal&#41; is also often visualized&#44; as is alveolar consolidations with&#47;without effusion in the posterior fields &#40;posterior and&#47;or lateral alveolar and&#47;or pleural syndrome&#44; PLAPS&#41;<a class="elsevierStyleCrossRef" href="#bib0095"><span class="elsevierStyleSup">19</span></a> &#40;Appendix B See additional material&#46; Video 1&#46; Patient with pulmonary thromboembolism and distal pulmonary infarction in whom the correlation between the chest CT image and lung ultrasound is shown&#46; We can observe slight pleural effusion and pulmonary infarction that in the ultrasound is visualized as a hypodense area in the subpleural level with an isolated B-line&#41;&#46;</p><p id="par0075" class="elsevierStylePara elsevierViewall">Cardiac ultrasonography or echocardioscopy is performed with a sector probe in 2D-mode&#44; except when calculating RV systolic function&#44; which requires M-mode&#46; The patient is placed in supine decubitus&#44; slightly turned to the left if their clinical situation permits&#46; A small number of planes are usually sufficient and include the short and long parasternal axes&#44; the apical 4-chamber plane and the subcostal-subxiphoid plane&#46;<a class="elsevierStyleCrossRef" href="#bib0100"><span class="elsevierStyleSup">20</span></a> The objective is to detect indirect signs of pulmonary hypertension&#44; assessing the presence of pressure overload and RV function&#46; Its evaluation is complex and requires extensive training due to its half-moon morphology&#44; with the diameter narrowing from the base to the apex&#46; The RV is smaller than the LV&#44; and the normal RV&#47;LV ratio is 0&#46;4&#8211;0&#46;6&#46;<a class="elsevierStyleCrossRef" href="#bib0105"><span class="elsevierStyleSup">21</span></a> At baseline&#44; the normal end-diastolic RV diameter is 20&#8211;28<span class="elsevierStyleHsp" style=""></span>mm&#44; and the thickness of the free wall is &#60;5<span class="elsevierStyleHsp" style=""></span>mm&#46;<a class="elsevierStyleCrossRefs" href="#bib0110"><span class="elsevierStyleSup">22&#44;23</span></a> The interventricular septum is slightly inclined towards the RV&#46;<a class="elsevierStyleCrossRef" href="#bib0105"><span class="elsevierStyleSup">21</span></a> The following aspects should be considered when assessing the RV&#58;<ul class="elsevierStyleList" id="lis0005"><li class="elsevierStyleListItem" id="lsti0005"><span class="elsevierStyleLabel">&#8226;</span><p id="par0080" class="elsevierStylePara elsevierViewall">Assess the presence of pressure overload&#46; Subjectively and objectively estimate the dimensions and characteristics of the RV&#46; The most appropriate plane is the apical 4-chamber&#44; centered on the RV&#44; with the apex of the LV in the center of the image&#44; attempting to adequately visualize the free wall of the RV&#46;<a class="elsevierStyleCrossRef" href="#bib0110"><span class="elsevierStyleSup">22</span></a> Subjectively&#44; there is severe RV overload when it is enlarged and dilated&#44; with its free wall widened towards the apex&#59; qualitatively&#44; we can infer an RV&#47;LV ratio<span class="elsevierStyleHsp" style=""></span>&#8805;1&#46;<a class="elsevierStyleCrossRefs" href="#bib0105"><span class="elsevierStyleSup">21&#44;22&#44;24</span></a> In the same plane in end-diastole&#44; we can objectively measure the RV diameter at the base&#44; just below and parallel to the tricuspid valve&#44; from the inner face of the interventricular septum to the inner face of the free wall of the interventricular septum&#46;<a class="elsevierStyleCrossRef" href="#bib0115"><span class="elsevierStyleSup">23</span></a> An RV diameter<span class="elsevierStyleHsp" style=""></span>&#8805;39<span class="elsevierStyleHsp" style=""></span>mm indicates severe dilation&#44; a diameter of 34&#8211;38<span class="elsevierStyleHsp" style=""></span>mm indicates moderate dilation&#44; and 29&#8211;33<span class="elsevierStyleHsp" style=""></span>mm indicates slight dilation&#46;<a class="elsevierStyleCrossRef" href="#bib0115"><span class="elsevierStyleSup">23</span></a> Similarly&#44; we can measure the LV at its base&#44; just below and parallel to the mitral valve&#44; from the inner face of the interventricular septum in the LV to the inner face of the interventricular septum&#46; We can therefore calculate the RV&#47;LV ratio&#44; which indicates severe RV dilation if &#8805;1&#46;<a class="elsevierStyleCrossRef" href="#bib0115"><span class="elsevierStyleSup">23</span></a> Other options for assessing dilation include the parasternal long-axis plane &#40;end-diastolic RV&#47;LV ratio<span class="elsevierStyleHsp" style=""></span>&#62;0&#46;6<a class="elsevierStyleCrossRef" href="#bib0125"><span class="elsevierStyleSup">25</span></a>&#41; or subcostal plane if a diameter<span class="elsevierStyleHsp" style=""></span>&#62;30<span class="elsevierStyleHsp" style=""></span>mm is observed at the end of the diastole&#46;<a class="elsevierStyleCrossRef" href="#bib0055"><span class="elsevierStyleSup">11</span></a></p></li><li class="elsevierStyleListItem" id="lsti0010"><span class="elsevierStyleLabel">&#8226;</span><p id="par0085" class="elsevierStylePara elsevierViewall">Assess RV function&#46; RV function is estimated subjectively&#44; observing whether there is hypokinesia in the movement of its free wall towards the interventricular septum&#46;<a class="elsevierStyleCrossRef" href="#bib0110"><span class="elsevierStyleSup">22</span></a> RV function can be assessed in the apical 4-chamber&#44; subcostal and parasternal long-axis planes&#46; The interventricular septum in this scenario can also have a paradoxical movement<a class="elsevierStyleCrossRef" href="#bib0110"><span class="elsevierStyleSup">22</span></a> and be flattened or even bulging towards the LV due to the increased pressure in the right-side cavities&#44; which can result in the involvement of the left cavities&#46; In the parasternal short-axis plane&#44; the RV has a &#8220;D&#8221; shape or even a more rounded &#8220;O&#8221; shape&#46; McConnell&#8217;s sign has also been reported in patients with PE&#44; which is visualized as hypokinesia&#47;akinesia of the basal and medial segments of the RV free wall&#44; preserving the mobility of the apex &#40;sensitivity 77&#37;&#44; specificity 94&#37;&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0120"><span class="elsevierStyleSup">24</span></a> Objectively&#44; the systolic excursion or vertical movement of the tricuspid ring &#40;tricuspid annular plane systolic excursion&#44; TAPSE&#41; can be calculated&#46; The measurement requires the use of M-mode in the apical 4-chamber plane&#44; through the long axis of the RV&#44; placing the cursor on the lateral face of the tricuspid ring &#40;on the RV free wall&#41; and measuring the change in height of the resulting trace&#46;<a class="elsevierStyleCrossRef" href="#bib0110"><span class="elsevierStyleSup">22</span></a> The lower the mobility the greater the dysfunction&#46; Values between 16 and 20<span class="elsevierStyleHsp" style=""></span>mm are therefore normal&#44; mild dysfunction is 11&#8211;15<span class="elsevierStyleHsp" style=""></span>mm&#44; moderate is 6&#8211;10<span class="elsevierStyleHsp" style=""></span>mm&#44; and severe is<span class="elsevierStyleHsp" style=""></span>&#8804;5<span class="elsevierStyleHsp" style=""></span>mm&#46;<a class="elsevierStyleCrossRef" href="#bib0125"><span class="elsevierStyleSup">25</span></a> In clinical ultrasonography&#44; 20<span class="elsevierStyleHsp" style=""></span>mm has been evaluated as the most sensitive cutoff for detecting RV dysfunction<a class="elsevierStyleCrossRef" href="#bib0130"><span class="elsevierStyleSup">26</span></a> &#40;Appendix B See additional material&#46; Video 2&#46; Echocardiography in a patient with pulmonary thromboembolism with right ventricular overload &#91;RV dilation and dysfunction&#44; paradoxical deviation of the interventricular septum&#44; decreased TAPSE and tricuspid regurgitation&#93;&#46; At 24<span class="elsevierStyleHsp" style=""></span>h after applying effective fibrinolytic therapy&#44; these parameters normalized&#41;&#46; Mobile thrombi and those travelling in the right-side cavities are rarely &#40;3&#37;&#41; visualized<a class="elsevierStyleCrossRef" href="#bib0135"><span class="elsevierStyleSup">27</span></a> &#40;Appendix B See additional material&#46; Video 3&#46; Apical 4-chamber and subcostal plane in a patient with pulmonary thromboembolism and thrombus in transition in the right atrium&#41;&#46;</p></li><li class="elsevierStyleListItem" id="lsti0015"><span class="elsevierStyleLabel">&#8226;</span><p id="par0090" class="elsevierStylePara elsevierViewall">Assessing the diameter and collapsibility of the inferior vena cava during the respiratory cycle provides indirect information on the hemodynamic condition and central venous pressure&#46; With the patient in supine decubitus&#44; the sector probe can be employed from the subxiphoid plane&#44; pointing to the right hypochondrium and rotating the probe 70&#8211;90&#176; in the counterclockwise direction&#44; searching for the entrance of the inferior vena cava into the right atrium&#46; A convex probe can also be employed in the epigastric region through a transparietal hepatic paramedial longitudinal slice&#46; Measurements are made 2<span class="elsevierStyleHsp" style=""></span>cm below the entrance into the right atrium&#44; helped by M-mode&#44; and the diameter is calculated in expiration&#44; as well as the collapsibility index&#44; which will be reduced if there is a significant increase in pressure in the right-side cavities&#46;10</p></li></ul></p></span></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">Clinical scenarios</span><p id="par0095" class="elsevierStylePara elsevierViewall">This section describes common clinical situations and how to implement clinical ultrasonography using diagnostic-therapeutic algorithms&#44; combined with the clinical probability and biochemical measurements&#46;</p><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0050">Suspected deep vein thrombosis</span><p id="par0100" class="elsevierStylePara elsevierViewall">This is the most common clinical scenario of VTE in emergency departments&#46; When a patient is admitted with symptoms of thrombosis in the legs &#40;pain&#44; edema&#44; flushing&#41;&#44; clinicians should establish the pretest probability using scales that include clinical findings and risk factors for developing DVT&#46; The most widely used scale is the Wells scale&#46;</p><p id="par0105" class="elsevierStylePara elsevierViewall">When DVT is unlikely&#44; measuring D-dimer helps rule out the diagnosis due to its high negative predictive value&#46; In this case&#44; the patient can be safely discharged without anticoagulant therapy&#46; When the D-dimer is positive&#44; the recommendation is to perform CUS&#44; preferably 3-point&#46; If positive&#44; the recommendation is to start anticoagulation and&#44; if possible&#44; confirm with Doppler ultrasound at 48<span class="elsevierStyleHsp" style=""></span>h&#46;</p><p id="par0110" class="elsevierStylePara elsevierViewall">When the pretest probability is high &#40;Wells score<span class="elsevierStyleHsp" style=""></span>&#8805;<span class="elsevierStyleHsp" style=""></span>2&#41;&#44; most algorithms recommend performing CUS&#46; If positive&#44; the decision can be made to administer anticoagulation without the need for determining the D-dimer&#46; In the event of a negative result&#44; the recommendation is to repeat the technique in approximately 1 week to rule out the possibility of progression of a distal thrombosis &#40;<a class="elsevierStyleCrossRef" href="#fig0015">Fig&#46; 3</a>&#41;&#46;</p><elsevierMultimedia ident="fig0015"></elsevierMultimedia></span><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0055">Suspected hemodynamically unstable pulmonary embolism</span><p id="par0115" class="elsevierStylePara elsevierViewall">This is the presentation in 5&#8211;12&#37; of cases of PE and is by definition high risk&#46;<a class="elsevierStyleCrossRef" href="#bib0140"><span class="elsevierStyleSup">28</span></a> The condition is defined by the presence of a systolic blood pressure<span class="elsevierStyleHsp" style=""></span>&#60;90<span class="elsevierStyleHsp" style=""></span>mm Hg or a drop<span class="elsevierStyleHsp" style=""></span>&#62;40<span class="elsevierStyleHsp" style=""></span>mm Hg for more than 15<span class="elsevierStyleHsp" style=""></span>min&#44; excluding the presence of arrhythmias&#44; sepsis and hypovolemia&#46;<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">7</span></a> These patients should undergo CTA immediately or transthoracic echocardiography&#46;<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">7</span></a> Lacking these options&#44; echocardioscopy &#40;in trained hands&#41; can assess the signs of RV overload and dysfunction&#44; which&#44; if present&#44; can support the diagnosis and immediate start of fibrinolytic treatment &#40;<a class="elsevierStyleCrossRef" href="#fig0020">Fig&#46; 4</a>&#41;&#46; These aspects have been included in quick guidance multiorgan examination protocols for patients with shock &#40;e&#46;g&#46;&#44; RUSH protocol&#41;&#44; which also help assess other causes of hypotension&#46;<a class="elsevierStyleCrossRef" href="#bib0145"><span class="elsevierStyleSup">29</span></a></p><elsevierMultimedia ident="fig0020"></elsevierMultimedia></span><span id="sec0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0060">Suspected hemodynamically stable pulmonary embolism</span><p id="par0120" class="elsevierStylePara elsevierViewall">In this situation&#44; the diagnosis starts with the application of validated clinical probability models such as the Wells and Geneva scales&#46;<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">7</span></a> For outpatients or those in the emergency department with a low-intermediate &#40;3-level scales&#41; or unlikely probability &#40;simplified versions&#41;&#44; D-dimer should be determined&#59; if it is negative&#44; PE can be ruled out&#46; Clinical ultrasonography directed by symptoms can provide an alternative diagnosis or rule out organicity&#46;<a class="elsevierStyleCrossRefs" href="#bib0095"><span class="elsevierStyleSup">19&#44;30</span></a> In the event of a positive D-dimer or a high clinical probability&#44; a confirmatory imaging test should be conducted&#46;<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">7</span></a> If imaging tests are not available or are contraindicated&#44; multiorgan clinical ultrasonography can serve as a tool for diagnosing PE&#46;<a class="elsevierStyleCrossRef" href="#bib0055"><span class="elsevierStyleSup">11</span></a> If PE is not confirmed&#44; the tool can help assess other differential diagnoses<a class="elsevierStyleCrossRefs" href="#bib0055"><span class="elsevierStyleSup">11&#44;18&#44;31</span></a> and improve the selection of patients to undergo confirmation tests&#46;<a class="elsevierStyleCrossRefs" href="#bib0055"><span class="elsevierStyleSup">11&#44;18&#44;26</span></a> For patients in whom DVT or RV dilation is demonstrated with medium to high probability&#44; early anticoagulation may be started &#40;<a class="elsevierStyleCrossRef" href="#fig0020">Fig&#46; 4</a>&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0120"><span class="elsevierStyleSup">24</span></a></p><p id="par0125" class="elsevierStylePara elsevierViewall">The Wells scale assisted by ultrasonography has recently been suggested for assessing the pretest probability of PE&#46; In this approach&#44; the criterion &#8220;signs and symptoms of DVT&#8221; is replaced by CUS&#44; and the criterion &#8220;an alternative diagnosis to pulmonary thromboembolism&#8221; is replaced by pulmonary ultrasonography that detects alternative diagnoses&#44; such as pneumonia and interstitial lung disease&#44; or confirms the presence of pulmonary infarctions&#46; This new concept takes advantage of the greater sensitivity and specificity of clinical ultrasonography compared with the physical examination and subjective criteria&#46; This scale has greater diagnostic accuracy than the classic Wells scale &#40;sensitivity&#44; 69&#46;6&#37; vs&#46; 57&#46;6&#37;&#59; specificity&#44; 88&#46;2&#37; vs&#46; 68&#46;2&#37;&#44; respectively&#41; and can reduce by 25&#37; the number of cases that need invasive diagnostic tests such as CT&#44; although this approach awaits confirmation through a larger cohort&#46;<a class="elsevierStyleCrossRef" href="#bib0090"><span class="elsevierStyleSup">18</span></a></p></span><span id="sec0045" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0065">Ultrasonography in the prognosis of pulmonary embolism</span><p id="par0130" class="elsevierStylePara elsevierViewall">There is no direct evidence regarding the use of clinical ultrasonography and the prognostic outcome of PE&#46; However&#44; the link between the two can be indirectly inferred because DVT detected by standardized Doppler ultrasound is an independent factor for recurrence and overall mortality in acute symptomatic PE&#46;<a class="elsevierStyleCrossRef" href="#bib0070"><span class="elsevierStyleSup">14</span></a> Similarly&#44; in acute stable PE&#44; RV dysfunction detected by echocardiography is associated with a poorer prognosis&#46;<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">7</span></a> Given that echocardioscopy can detect dilation and dysfunction&#44;<a class="elsevierStyleCrossRefs" href="#bib0105"><span class="elsevierStyleSup">21&#44;24&#44;26</span></a> it is likely that it can help determine the severity and prognosis&#46; The detection of thrombi in the right-side cavities is also associated with increased mortality&#46;<a class="elsevierStyleCrossRef" href="#bib0135"><span class="elsevierStyleSup">27</span></a></p><p id="par0135" class="elsevierStylePara elsevierViewall">In the prognostic stratification model that employs the PESI scale or its simplified version&#44; the European guidelines include the assessment of RV function &#40;by echocardiography or CTA&#41; and the markers of myocardial damage &#40;troponin and BNP&#41;&#44; establishing 4 risk categories&#58; low&#44; low-intermediate&#44; intermediate-high and high&#46;<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">7</span></a> This model efficiently classifies acute PE and its mortality risk at 30 days&#46;<a class="elsevierStyleCrossRef" href="#bib0140"><span class="elsevierStyleSup">28</span></a> In low-risk patients&#44; detecting RV dysfunction is associated with early mortality&#46;<a class="elsevierStyleCrossRef" href="#bib0155"><span class="elsevierStyleSup">31</span></a> In addition to this model&#44; performing a Doppler ultrasound and detecting DVT in patients at low-intermediate risk &#40;PESI<span class="elsevierStyleHsp" style=""></span>&#62;<span class="elsevierStyleHsp" style=""></span>1 with RV dysfunction or increased troponin levels&#41; can improve the stratification of complications in the short term&#46;<a class="elsevierStyleCrossRef" href="#bib0075"><span class="elsevierStyleSup">15</span></a></p><p id="par0140" class="elsevierStylePara elsevierViewall">Residual DVT has a known prognostic value in terms of VTE recurrence in the outpatient follow-up in the medium to long term&#46;<a class="elsevierStyleCrossRef" href="#bib0160"><span class="elsevierStyleSup">32</span></a> There are no studies that have analyzed the usefulness of CUS in this clinical scenario&#46;</p></span><span id="sec0050" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0070">Other scenarios</span><p id="par0145" class="elsevierStylePara elsevierViewall">Given the absence of specific symptoms in PE&#44; various protocols employing clinical ultrasonography have been developed from a symptom-based orientation&#46;</p></span><span id="sec0055" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0075">Dyspnea with acute respiratory failure</span><p id="par0150" class="elsevierStylePara elsevierViewall">Fifty percent of cases of PE present with dyspnea&#46;<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">7</span></a> The BLUE protocol<a class="elsevierStyleCrossRef" href="#bib0095"><span class="elsevierStyleSup">19</span></a> evaluates patients with respiratory failure&#44; in whom&#44; after confirming the presence of pleural sliding&#44; the presence of a bilateral pattern of A-lines with CUS indicating DVT can guide the diagnosis to PE &#40;sensitivity 81&#37;&#44; specificity 99&#37;&#44; negative predictive value 98&#37;&#44; positive predictive value 94&#37;&#41;&#46; PE can also be detected as a posterolateral consolidation &#40;pulmonary infarction&#41;&#44; with or without pleural involvement&#46;</p></span><span id="sec0060" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0080">Pleuritic chest pain</span><p id="par0155" class="elsevierStylePara elsevierViewall">Pleuritic chest pain is present in 39&#37; of patients with PE and can be its form of presentation&#46;<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">7</span></a> In patients with normal chest radiography&#44; pulmonary clinical ultrasonography can be performed on the painful area&#44; which can help the diagnosis&#44; detecting abnormal patterns&#44; which include pulmonary infarctions&#46;<a class="elsevierStyleCrossRef" href="#bib0150"><span class="elsevierStyleSup">30</span></a></p></span></span><span id="sec0065" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0085">Key aspects&#44; use in real life and current evidence</span><p id="par0160" class="elsevierStylePara elsevierViewall">Summarizing the aspects mentioned earlier&#44; the utility of clinical ultrasonography in VTE includes the following&#58;<ul class="elsevierStyleList" id="lis0010"><li class="elsevierStyleListItem" id="lsti0020"><span class="elsevierStyleLabel">&#8226;</span><p id="par0165" class="elsevierStylePara elsevierViewall">CUS indicating DVT in a clinical scenario consistent with PE confirms the diagnosis&#44; avoiding other examinations that involve iatrogenic effects and enabling the start of anticoagulant therapy&#46;<a class="elsevierStyleCrossRefs" href="#bib0060"><span class="elsevierStyleSup">12&#44;18</span></a> CUS has been shown to be efficient and cost-effective&#44; Although its sensitivity varies in the published series&#46; In recent studies&#44; the comparison between 3-point and 2-point CUS showed better results for the former &#40;sensitivity of 90&#46;5&#37; vs&#46; 82&#46;7&#37; and specificity of 98&#46;5&#37; in both techniques&#41;&#46;<a class="elsevierStyleCrossRefs" href="#bib0165"><span class="elsevierStyleSup">33&#8211;35</span></a></p></li><li class="elsevierStyleListItem" id="lsti0025"><span class="elsevierStyleLabel">&#8226;</span><p id="par0170" class="elsevierStylePara elsevierViewall">The diagnostic yield of multiorgan clinical ultrasonography in PE is higher than that of single-organ clinical ultrasonography&#46;<a class="elsevierStyleCrossRef" href="#bib0055"><span class="elsevierStyleSup">11</span></a> Proximal CUS is highly specific &#40;96&#37;&#41; and poorly sensitive &#40;41&#37;&#41;<a class="elsevierStyleCrossRef" href="#bib0065"><span class="elsevierStyleSup">13</span></a> for the diagnosis of PE&#46; Therefore&#44; a negative CUS does not rule out PE&#59; however&#44; a positive result has a high positive predictive value and could help avoid the need for more tests&#46;<a class="elsevierStyleCrossRefs" href="#bib0060"><span class="elsevierStyleSup">12&#44;18</span></a> If there are signs and symptoms of DVT&#44; the yield of CUS increases &#40;sensitivity 72&#37;&#44; specificity 99&#37;&#41;&#46;<a class="elsevierStyleCrossRefs" href="#bib0060"><span class="elsevierStyleSup">12&#44;16</span></a> The presence of DVT is correlated with more proximal thrombi &#40;central&#44; lobar&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0060"><span class="elsevierStyleSup">12</span></a> A complete CUS&#44; which includes infrapopliteal veins&#44; does not improve the yield because it increases the sensitivity &#40;79&#37;&#41; but significantly decreases its specificity &#40;84&#37;&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0065"><span class="elsevierStyleSup">13</span></a> Including CUS on proximal veins&#44; within the diagnostic strategy indicated by the guidelines&#44; in low and moderate risk&#44; along with D-dimer and CTA&#44; does not provide greater diagnostic yield&#44;<a class="elsevierStyleCrossRef" href="#bib0080"><span class="elsevierStyleSup">16</span></a> although it could be used in patients with a contraindication for CT&#46; Pulmonary clinical ultrasonography by itself also lacks good diagnostic yield in PE &#40;sensitivity 87&#37;&#44; specificity 81&#46;8&#37;&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0180"><span class="elsevierStyleSup">36</span></a></p></li><li class="elsevierStyleListItem" id="lsti0030"><span class="elsevierStyleLabel">&#8226;</span><p id="par0175" class="elsevierStylePara elsevierViewall">Cardiac clinical ultrasonography in trained hands has a good correlation with echocardiography in detecting RV dilation and dysfunction<a class="elsevierStyleCrossRefs" href="#bib0105"><span class="elsevierStyleSup">21&#44;24</span></a> and can help make a safe&#44; subjective and objective TAPSE calculation&#46;<a class="elsevierStyleCrossRef" href="#bib0130"><span class="elsevierStyleSup">26</span></a> Visualizing thrombi in transit in right-side cavities in a consistent clinical context confirms the diagnosis of PE&#46;<a class="elsevierStyleCrossRef" href="#bib0135"><span class="elsevierStyleSup">27</span></a></p></li><li class="elsevierStyleListItem" id="lsti0035"><span class="elsevierStyleLabel">&#8226;</span><p id="par0180" class="elsevierStylePara elsevierViewall">Multiorgan ultrasonography &#40;lungs&#44; heart&#44; proximal veins&#41; is more sensitive than that focused on a single organ &#40;sensitivity 90&#37;&#44; specificity 86&#37;&#44; negative predictive value 74&#37;&#44; positive predictive value 95&#37;&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0055"><span class="elsevierStyleSup">11</span></a> Multiorgan clinical ultrasonography helps detect alternative diagnoses for a one-third to one-half of patients with suspected but unconfirmed PE &#40;e&#46;g&#46;&#44; pneumonia&#44; interstitial syndrome&#44; pleural effusion&#44; pericardial effusion and aortic dissection&#41;&#46;<a class="elsevierStyleCrossRefs" href="#bib0055"><span class="elsevierStyleSup">11&#44;18&#44;31</span></a></p></li><li class="elsevierStyleListItem" id="lsti0040"><span class="elsevierStyleLabel">&#8226;</span><p id="par0185" class="elsevierStylePara elsevierViewall">Clinical ultrasonography can help the diagnosis of PE in clinical conditions in which CTA is not immediate &#40;e&#46;g&#46;&#44; shock&#41; or is limited &#40;e&#46;g&#46;&#44; allergy to contrast media&#44; kidney failure&#44; pregnant women and the young for whom radiation exposure should be avoided&#41;&#46;</p></li><li class="elsevierStyleListItem" id="lsti0045"><span class="elsevierStyleLabel">&#8226;</span><p id="par0190" class="elsevierStylePara elsevierViewall">Detecting RV dilation and&#47;or dysfunction is not specific for PE&#46; We should also remember that echocardioscopy without RV dilation or dysfunction does not rule out PE&#59; however&#44; its absence in patients with shock rules out this diagnosis as the underlying cause&#46;<a class="elsevierStyleCrossRefs" href="#bib0100"><span class="elsevierStyleSup">20&#44;24</span></a></p></li></ul></p></span><span id="sec0070" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0090">Limitations</span><p id="par0195" class="elsevierStylePara elsevierViewall">Clinical ultrasonography is an operator-dependent technique and requires initial and periodic training&#46; There are patient limitations&#44; due to poor acoustic windows&#44; which can obstruct their assessment &#40;more common in echocardioscopy&#41;&#46; In patients with morbid obesity&#44; CUS of the legs can be complex and can yield false negatives&#46; Due to its location&#44; iliac thrombosis is a candidate for Doppler ultrasound&#46;</p><p id="par0200" class="elsevierStylePara elsevierViewall">In CUS&#44; the presence of prior DVT or of residual thrombus can limit its diagnostic usefulness&#46; In pulmonary clinical ultrasonography&#44; the absence of specific presets for the lungs can limit the visualization of lesions that are not adjacent to the pleural surface&#46; In cardiac clinical ultrasonography&#44; the presence of prior RV dilation and dysfunction in patients with underlying cardiopulmonary diseases complicates the differentiation of chronic overload from acute overload&#46; In this respect&#44; several criteria have been described that direct the diagnosis to a chronic progression&#44; Including the thickness of the RV free wall &#40;pathological if &#62;7<span class="elsevierStyleHsp" style=""></span>mm&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0125"><span class="elsevierStyleSup">25</span></a> The best plane for measuring the thickness is the subxiphoid plane&#46;<a class="elsevierStyleCrossRef" href="#bib0110"><span class="elsevierStyleSup">22</span></a></p></span><span id="sec0075" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0095">Areas for future development</span><p id="par0205" class="elsevierStylePara elsevierViewall">It would be advisable to establish the following future actions regarding clinical ultrasonography in VTE&#58;<ul class="elsevierStyleList" id="lis0015"><li class="elsevierStyleListItem" id="lsti0050"><span class="elsevierStyleLabel">&#8226;</span><p id="par0210" class="elsevierStylePara elsevierViewall">Evaluate&#44; include and validate the utility of multiorgan clinical ultrasonography in the diagnostic protocol and management of PE with hemodynamic stability&#46;</p></li><li class="elsevierStyleListItem" id="lsti0055"><span class="elsevierStyleLabel">&#8226;</span><p id="par0215" class="elsevierStylePara elsevierViewall">Assess the usefulness of multiorgan clinical ultrasonography in the diagnostic protocol of PE in patients with a contraindication for CTA &#40;pregnant women&#44; those with kidney failure&#44; those with contrast allergy and young patients who should avoid radiation&#41;&#46;</p></li><li class="elsevierStyleListItem" id="lsti0060"><span class="elsevierStyleLabel">&#8226;</span><p id="par0220" class="elsevierStylePara elsevierViewall">Assess multiorgan clinical ultrasonography within prognostic stratification models&#44; supplementing the current clinical scales&#44; especially in the low&#44; low-intermediate and intermediate-high risk levels&#44; both for the presence of pulmonary infarctions and DVT&#44; such as the presence of overload and RV dysfunction&#46;</p></li><li class="elsevierStyleListItem" id="lsti0065"><span class="elsevierStyleLabel">&#8226;</span><p id="par0225" class="elsevierStylePara elsevierViewall">Assess the use of multiorgan clinical ultrasonography within the diagnostic algorithm for hospitalized patients&#46;</p></li></ul></p></span></span>"
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          "titulo" => "Abstract"
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        1 => array:2 [
          "identificador" => "xpalclavsec1209183"
          "titulo" => "Keywords"
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        3 => array:2 [
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          "titulo" => "Palabras clave"
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        4 => array:2 [
          "identificador" => "sec0005"
          "titulo" => "Background"
        ]
        5 => array:3 [
          "identificador" => "sec0010"
          "titulo" => "Necessary knowledge for applying ultrasonography"
          "secciones" => array:2 [
            0 => array:2 [
              "identificador" => "sec0015"
              "titulo" => "Deep vein thrombosis"
            ]
            1 => array:2 [
              "identificador" => "sec0020"
              "titulo" => "Pulmonary embolism"
            ]
          ]
        ]
        6 => array:3 [
          "identificador" => "sec0025"
          "titulo" => "Clinical scenarios"
          "secciones" => array:7 [
            0 => array:2 [
              "identificador" => "sec0030"
              "titulo" => "Suspected deep vein thrombosis"
            ]
            1 => array:2 [
              "identificador" => "sec0035"
              "titulo" => "Suspected hemodynamically unstable pulmonary embolism"
            ]
            2 => array:2 [
              "identificador" => "sec0040"
              "titulo" => "Suspected hemodynamically stable pulmonary embolism"
            ]
            3 => array:2 [
              "identificador" => "sec0045"
              "titulo" => "Ultrasonography in the prognosis of pulmonary embolism"
            ]
            4 => array:2 [
              "identificador" => "sec0050"
              "titulo" => "Other scenarios"
            ]
            5 => array:2 [
              "identificador" => "sec0055"
              "titulo" => "Dyspnea with acute respiratory failure"
            ]
            6 => array:2 [
              "identificador" => "sec0060"
              "titulo" => "Pleuritic chest pain"
            ]
          ]
        ]
        7 => array:2 [
          "identificador" => "sec0065"
          "titulo" => "Key aspects&#44; use in real life and current evidence"
        ]
        8 => array:2 [
          "identificador" => "sec0070"
          "titulo" => "Limitations"
        ]
        9 => array:2 [
          "identificador" => "sec0075"
          "titulo" => "Areas for future development"
        ]
        10 => array:1 [
          "titulo" => "References"
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    "fechaRecibido" => "2019-05-13"
    "fechaAceptado" => "2019-05-27"
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        0 => array:4 [
          "clase" => "keyword"
          "titulo" => "Keywords"
          "identificador" => "xpalclavsec1209183"
          "palabras" => array:5 [
            0 => "Venous thromboembolism disease"
            1 => "Deep vein thrombosis"
            2 => "Pulmonary embolism"
            3 => "Compression ultrasonography"
            4 => "Clinical multiorgan ultrasonography"
          ]
        ]
      ]
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        0 => array:4 [
          "clase" => "keyword"
          "titulo" => "Palabras clave"
          "identificador" => "xpalclavsec1209182"
          "palabras" => array:5 [
            0 => "Enfermedad tromboemb&#243;lica venosa"
            1 => "Trombosis venosa profunda"
            2 => "Embolia pulm&#243;n"
            3 => "Ultrasonograf&#237;a por compresi&#243;n"
            4 => "Ecograf&#237;a cl&#237;nica multi&#243;rgano"
          ]
        ]
      ]
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        "titulo" => "Abstract"
        "resumen" => "<span id="abst0005" class="elsevierStyleSection elsevierViewall"><p id="spar0035" class="elsevierStyleSimplePara elsevierViewall">The use of clinical ultrasonography has grown exponentially in the past decade in various medical settings&#46; As with other areas of activity in the field of internal medicine&#44; clinical ultrasonography has been implemented in venous thromboembolism disease &#40;VTE&#41;&#44; both in deep vein thrombosis &#40;DVT&#41; and pulmonary embolism &#40;PE&#41;&#46; In this review&#44; we cover the diagnostic techniques&#44; both for DVT through compression ultrasonography &#40;CUS&#41; and for multiorgan ultrasonography&#44; which include CUS&#44; pulmonary ultrasonography in the search for pulmonary infarctions and echocardiography for detecting dilation and right ventricular dysfunction for the diagnosis of PE&#46; We also establish the most common clinical scenarios in which clinical ultrasonography can be of assistance in actual clinical practice&#44; as well as its limitations and current evidence&#46;</p></span>"
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        "resumen" => "<span id="abst0010" class="elsevierStyleSection elsevierViewall"><p id="spar0040" class="elsevierStyleSimplePara elsevierViewall">La ecograf&#237;a cl&#237;nica &#40;EC&#41; se ha desarrollado exponencialmente en la &#250;ltima d&#233;cada en distintos &#225;mbitos de la medicina&#46; De igual manera que ha ocurrido en otros campos de actuaci&#243;n de la Medicina Interna&#44; su uso se ha implantado en la enfermedad tromboemb&#243;lica venosa &#40;ETV&#41;&#44; tanto en la trombosis venosa profunda &#40;TVP&#41; como en la embolia de pulm&#243;n &#40;EP&#41;&#46; En esta revisi&#243;n se repasan las t&#233;cnicas para el diagn&#243;stico&#44; tanto de la TVP a trav&#233;s de la ultrasonograf&#237;a por compresi&#243;n &#40;USC&#41;&#44; como de la ecograf&#237;a multi&#243;rgano que incluye la USC&#44; la ecograf&#237;a pulmonar en busca de infartos pulmonares y la ecocardioscopia para la detecci&#243;n de dilataci&#243;n y&#47;o disfunci&#243;n del ventr&#237;culo derecho&#44; para el diagn&#243;stico de la EP&#46; Adem&#225;s&#44; se plantean los escenarios cl&#237;nicos m&#225;s frecuentes en los que puede ser de ayuda la EC en la vida real&#44; as&#237; como sus limitaciones y la evidencia existente&#46;</p></span>"
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      0 => array:2 [
        "etiqueta" => "&#9734;"
        "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as&#58; Moya Mateo E&#44; Mu&#241;oz Rivas N&#46; Ecograf&#237;a cl&#237;nica en la enfermedad tromboemb&#243;lica venosa&#46; Rev Clin Esp&#46; 2020&#59;220&#58;126&#8211;134&#46;</p>"
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            "apendice" => "<p id="par0235" class="elsevierStylePara elsevierViewall">The following are Supplementary data to this article&#58;<elsevierMultimedia ident="upi0005"></elsevierMultimedia><elsevierMultimedia ident="upi0010"></elsevierMultimedia><elsevierMultimedia ident="upi0015"></elsevierMultimedia></p>"
            "etiqueta" => "Appendix A"
            "titulo" => "Supplementary data"
            "identificador" => "sec0085"
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          "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Anatomy of the deep venous system&#46;</p>"
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          "en" => "<p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">The veins collapse easily with pressure &#40;left&#41; and do not collapse if there are thrombi in their interior<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">10</span></a> &#40;right&#41;&#46; Compression ultrasound image of the common femoral vein &#40;a&#41;&#44; prior to compression &#40;b&#41;&#46; Content can be observed in the interior of a noncollapsible vein compatible with DVT &#40;c&#41;&#46;</p>"
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Article information

ISSN: 22548874
Original language: English

DOI:10.1016/j.rceng.2019.05.008

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