Article

The Importance of Monophasic Doppler Waveforms in the Common Femoral Vein

A Retrospective Study
Edward P. Lin, MD, Shwetta Bhatt, MD, Deborah Rubens, MD, Vikram S. Dogra, MD

Objective. The purpose of this study was to assess the importance of monophasic waveforms encountered in the common femoral vein during deep venous thrombosis evaluation by a retrospective review of lower extremity venous Doppler (VD) sonography and correlative studies, such as computed tomography (CT) and magnetic resonance imaging. Methods. A retrospective review was conducted of lower extremity VD studies performed from September 1, 2000, through September 1, 2005. All satisfactory VD studies, which were in compliance with the Intersocietal Commission for the Accreditation of Vascular Laboratories standard protocol, were evaluated for the presence of monophasic waveforms and correlated with CT of the abdomen and pelvis. Studies were evaluated for the causes of monophasic waveforms. Patients younger than 18 years were excluded. Results. A total of 2963 VD examinations were reviewed. One hundred twenty-four of 2963 showed monophasic waveforms. Eighty-nine of the 124 had additional CT examinations within 1 week; 19 had CT within 2 months; and 16 had no additional examinations. Forty-seven of 124 cases revealed deep venous thrombosis extending into the iliac veins, of which 23 were identied by VD sonography; 26 were due to extrinsic compression; 6 showed a hypoplastic or stenosed common iliac vein; and the remaining 45 had no apparent causes for the monophasic waveforms. Conclusions. Monophasic waveforms in the common femoral veins are reliable indicators of proximal venous obstruction. Because iliac vein thrombosis is clinically important, we recommend routine sonographic evaluation of external iliac veins in the presence of monophasic waveforms and CT or magnetic resonance imaging, if necessary, to determine the cause of the monophasic waveforms. Key words: color ow Doppler sonography; deep venous thrombosis; monophasic waveforms; sonography.

Abbreviations CT, computed tomography; DVT, deep venous thrombosis; IVC, inferior vena cava; MRI, magnetic resonance imaging; PE, pulmonary embolism; VD, venous Doppler

Received February 20, 2007, from the Department of Imaging Sciences, University of Rochester School of Medicine, Rochester, New York USA. Revision requested March 12, 2007. Revised manuscript accepted for publication March 21, 2007. Address correspondence to Vikram S. Dogra, MD, Department of Imaging Sciences, University of Rochester School of Medicine, 601 Elmwood Ave, Box 648, Rochester, NY 14642 USA. E-mail: vikram_dogra@urmc.rochester.edu

he normal common femoral venous waveform shows phasicity on spectral Doppler analysis. Phasic variation results from increasing and decreasing intrathoracic pressures secondary to respiration and is sometimes referred to as respirophasic. This rise and fall in pressure are transmitted from the central to peripheral veins and manifest as a cyclic change in blood ow velocity, which can be detected by spectral Doppler sonography. Loss of this phasic variation results in a monophasic waveform. Monophasic waveforms in the common femoral vein occur when the transmission of respiratory pressure to the vein is dampened or disrupted by extrinsic compression, proximal deep venous thrombosis (DVT), or intrinsic luminal narrowing of a more proximal vein.

2007 by the American Institute of Ultrasound in Medicine J Ultrasound Med 2007; 26:885891 0278-4297/07/$3.50

Monophasic Doppler Waveform in the Common Femoral Vein

Scattered reports have observed the usefulness of dampened venous waveforms as indicators of more central venous obstruction or extrinsic compression. One small study of patients with cancer reported an association between monophasic waveforms and proximal venous extrinsic compression or DVT.1 To our knowledge, however, no prior study has formally evaluated the importance of monophasic waveforms in the general population. The purpose of our study was to assess the importance of monophasic waveforms as encountered in the common femoral vein during lower extremity sonographic evaluation for DVT. We reviewed venous Doppler (VD) studies of the lower extremities and their correlative studies, such as computed tomography (CT) and magnetic resonance imaging (MRI), to determine the most common causes of monophasic waveforms.

monophasic waveforms as observed on VD studies. The CT and MRI studies were read by a different reader, who was blinded to the sonographic results. Computed tomographic scans used a 4-, 16-, or 40-slice scanner, and MRI was performed on a 1.5-T magnet. Patients younger than 18 years were excluded from the study.

Results
A total of 2963 adult color ow Doppler examinations were reviewed. Monophasic waveforms were shown in 124 of the 2963 studies. The ages of patients ranged from 18 to 93 years with an average age of 51 years. Sixty-ve patients were female, and 59 were male. The most common causes of the monophasic waveforms observed in this study are summarized in Table 1. Of the 124 patients with monophasic waveforms, 41 had an underlying malignancy; 22 were postsurgical; 8 had an underlying coagulopathy; 6 had systemic infections; 5 were pregnant; 5 had a debilitating stroke or were paraplegic; and 4 had a history of recent trauma. The remaining 33 patients had other medical conditions that were not prone to thrombosis or were otherwise healthy. Eighty-nine of the 124 patients had correlative examinations, such as CT and MRI, within 1 week, and 19 of the 124 had such examinations within 2 months. Sixteen of the 124 patients had no correlative examinations within a 2-month period. Two patients with CT also underwent venography during inferior vena cava (IVC) lter placement. Forty-seven (38%) of the 124 cases revealed DVT extending into the iliac veins, of which 23 were identied by VD sonography (49%). The remaining 24 iliac vein DVT cases (51%) were diagnosed by CT or MRI. In 26 (21%) of the 124 patients, monophasic waveforms were due to extrinsic compression, such as pregnancy, lymTable 1. Most Common Causes of Monophasic Waveforms in 2963 Patients
Cases with monophasic waveform, n DVT involving iliac veins, n (%) Extrinsic compression, n (%) Intrinsic narrowing, n (%) No explanation, n (%) 124 47 26 6 45 (38) (21) (5) (36)

Materials and Methods

In a retrospective review of lower extremity VD examinations from September 1, 2000, through September 1, 2005, all VD studies, in compliance with the Intersocietal Commission for the Accreditation of Vascular Laboratories standard protocol, were evaluated for the presence of monophasic waveforms. Examinations were performed with a 5- to 7MHz linear array transducer (Sequoia, Siemens Medical Solutions, Mountain View, CA; or HDI 5000, Philips Medical Systems, Bothell, WA). Patients were examined in the supine position, and compression sonography was performed in the transverse plane from the common femoral to the popliteal veins. The calf veins were evaluated if the patient had calf pain or swelling. Spectral Doppler sonography was performed in the longitudinal plane with a Doppler angle of 60 or less. Spectral Doppler tracings were obtained in the common femoral, femoral, and popliteal veins. In addition, the presence of spontaneous ow, phasic variation, response to the Valsalva maneuver, and augmentation were recorded in all examinations. Correlative studies, such as CT and MRI of the abdomen and pelvis, were further investigated as reference standards after the sonographic studies were reviewed to evaluate the causes of the
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phocele, or hematoma. Six (5%) of the 124 cases had a hypoplastic or stenosed common iliac vein. The remaining 45 patients (36%) had no apparent causes for the monophasic waveforms. Of the 47 DVTs involving the iliac veins, 15 (32%) were isolated to the iliac veins, 1 of which extended into the IVC. Seventeen (36%) of the 47 extended from the common femoral vein into the iliac vein, and 15 (32%) extended from the popliteal vein into the iliac vein.

Discussion
Monophasic waveforms result when the transmission of uctuating intrathoracic pressures to distal venous structures is dampened. The loss of phasic variation may be due to (1) a nonocclusive thrombus in a more proximal vein; (2) extrinsic compression from a structure external to the vein, such as uid collections, lymphadenopathy, or intrauterine pregnancy; (3) intrinsic luminal narrowing secondary to a hypoplastic vein or sequelae from radiation or a prior thrombus; and (4) other causes, such as ascites and cardiac and technical factors (Figures 15).

Venous thrombosis involving the iliac veins was the most common cause (38%) of monophasic waveforms in our study, followed by extrinsic compression (21%) and intrinsic narrowing (5%). A considerable number of studies (36%) had no discernable explanation for the loss of phasic variation. Most DVTs arise from the deep calf veins, often along the valve cusps, and extend proximally.2,3 Approximately half of calf vein DVTs will resolve, and one sixth will continue to advance proximally.2 As a DVT ascends into the common femoral vein, the risk of pulmonary embolism (PE) increases.2,47 If left untreated, approximately 50% of patients will have a PE within 3 months.4,5 Borst-Krafek et al7 reported an equal incidence of PE associated with femoral vein, iliac vein, and IVC thrombosis.
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Figure 1. A and B, Spectral Doppler tracings of the right common femoral vein (CFV) in a healthy 66-year-old female patient with normal phasic variation (A) and in a 21-year-old male patient with factor V Leiden deciency and a monophasic waveform in the right common femoral vein (B). C, Subsequent noncontrast CT shows a large hematoma compressing the right common iliac vein (arrow).

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Figure 2. A, Spectral Doppler evaluation of a 54-year-old male patient after cardiac surgery shows a monophasic waveform in the distal left external iliac vein (IL A/V). B, Color ow image shows absent ow within a more proximal segment of the external iliac vein, representing DVT.

The incidence of iliac vein thrombosis was initially reported to be in the range of 1% to 4%.8,9 However, with the increased use of less invasive imaging modalities such as MRI and CT venography, iliac vein thrombosis is more common than previously thought. In a study of 769 patients, Spritzer et al10 reported an acute DVT isolated to the iliac vein or IVC in 20% of the patients and involving the femoral and iliac veins in 18%.

Figure 3. A and B, Spectral Doppler tracings from a 60-year-old female patient with a malignant spindle cell tumor show monophasic waveforms in the right (A) and left (B) common femoral veins (CFV). C, Selected axial postintravenous contrast CT of the abdomen shows a thrombus (arrow) within the right common iliac vein extending into the IVC.

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Postphlebitic syndrome is a common complication of pelvic and lower extremity DVT.11 Inammation and scarring of venous valves often lead to valve incompetence and reux, resulting in venous congestion, decreased muscle perfusion, and increased tissue permeability.12,13 Patients with postphlebitic syndrome have pain, swelling, heaviness, cramps, and tingling in the affected limb.14 The incidence of postphlebitic syndrome may be equal or possibly increased compared with calf or thigh DVT.12,15,16 Monophasic waveforms are reliable indicators of proximal iliac vein or IVC thrombosis. Approximately 40% of monophasic waveforms in this series were secondary to iliac vein thrombosis. Most (68%) of these iliac vein thromboses extended from leg veins, and one third were isolated to the iliac vein. Although the actual incidence of iliac vein thrombosis in the study population was not investigated, a future prospective study may evaluate the incidence of iliac vein thrombosis in acute DVTs and the percentage of iliac vein thrombosis that have monophasic waveforms.

A considerable portion (21%) of the patients with monophasic waveforms were also found to have lymph nodes, tumors, and hematomas, which compressed more proximal veins. These ndings are clinically relevant to patient treatment and stress the importance of following monophasic waveforms when initially encountered. Asymmetry of waveforms, with normal phasic variation on one side and loss of phasic variation on the other side, may help localize abnormalities to the side of the monophasic waveform. Bilateral monophasic waveforms suggest an IVC thrombus or a large structure, such as an intrauterine pregnancy, compressing both iliac veins or the IVC. The waveforms of both common femoral veins should be compared with each other in all lower extremity VD sonograms.

Figure 4. A and B, Spectral Doppler waveforms of the left (A) and right (B) common femoral veins (CFV) in a 71-year-old female patient with metastatic bladder carcinoma show asymmetry of waveforms, with monophasicity in the left common femoral vein. C, Follow-up postintravenous contrast CT shows large necrotic lymph nodes compressing the left external iliac vein (arrow).

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This study was limited by its retrospective design and the substantial number of monophasic waveforms that remained unexplained (36%). Technical factors and the presence of ascites and cardiac conditions were not explored. For example, monophasic waveforms in pregnancy may be position dependent; shifting the patient to the contralateral decubitus position has been observed, at our center, to elicit respirophasic variation in a vein that initially had a monophasic waveform. External iliac veins are not imaged during routine evaluation of lower extremity veins. In addition, the evaluation of iliac veins has not been addressed by the American College of Radiology

or the American Institute of Ultrasound in Medicine. In our study, 23 (49%) of the 47 iliac vein DVTs were initially discovered by VD sonography. Routine sonographic evaluation of external iliac veins should therefore be performed when monophasic waveforms are present. If the sonographic evaluation is inconclusive, we recommend further evaluation with CT or MR venography. In conclusion, monophasic waveforms in the common femoral veins are reliable indicators of proximal venous obstruction, particularly iliac vein thrombosis. Iliac vein thrombosis is clinically important because it has an equal incidence of PE and postphlebitic syndrome

Figure 5. Images from a 37-year-old female patient with a history of a DVT in the left common iliac vein during a remote pregnancy. A and B, Spectral Doppler waveforms of the common femoral veins show asymmetry of waveforms, with a monophasic waveform in the left common femoral vein (FVS; A) and normal phasic variation in the right common femoral vein (CFV; B). C, Follow-up postintravenous contrast CT shows a stenotic segment (arrow) of the left common iliac vein secondary to a sequela of the prior DVT. LA indicates left common iliac artery; RA, right common iliac artery; and RV, right common iliac vein.

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compared with thigh DVT. It should also be recognized that the incidence of iliac vein thrombosis is likely higher than previously thought. In light of these ndings, we recommend routine evaluation of external iliac veins in the presence of monophasic waveforms and additional imaging, if necessary, to determine the cause of monophasic waveforms.

13. 14.

Kahn SR. The post-thrombotic syndrome: progress and pitfalls. Br J Haematol 2006; 134:357365. Lindner DJ, Edwards JM, Phinney ES, Taylor LM, Porter JM. Long-term hemodynamic and clinical sequelae of lower extremity deep vein thrombosis. J Vasc Surg 1986; 4:436 442. Monreal M, Martorell A, Callejas J, et al. Venographic assessment of deep vein thrombosis and risk of developing post-thrombotic syndrome: a prospective study. J Intern Med 1993; 233:233238. Browse NL, Clemenson G, Thomas ML. Is the postphlebitic leg always postphlebitic? Relation between postphlebitic phlebographic appearances of deep-vein thrombosis and late sequelae. Br Med J 1980; 281:11671170.

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