Learning Objectives:

  1. Describe the indications and limitations of CUS for the detection of deep venous thrombosis. 

  2. Understand the differences between focused lower extremity venous CUS and radiology or vascular lab-performed “Duplex evaluation” 

  3. Perform CUS protocols for the detection of deep venous thrombosis of the lower extremity, including: 

    1. Vessel identification, compression, and doppler imaging of respiratory variation and augmentation. 

  4. Identify relevant US anatomy of the lower extremities, including the deep venous and arterial systems, major nerves, and lymph nodes. 

  5. Recognize the relevant findings and pitfalls when evaluating for deep venous thrombosis. 

  6. Integrate EUS for deep venous thrombosis into individual patient management and departmental workflow. 


Indications:

  • Evaluation for acute proximal DVT in the lower extremities.

Extended Indications:

  • Chronic DVT

  • Distal DVT

  • Superficial venous thrombosis

  • Diagnosis of other causes of lower extremity pain and swelling under consideration in the evaluation of DVT such as cellulitis, subcutaneous abscess, muscle hematoma, pyomyositis, lymphadenitis, aneurysm, fasciitis, and Baker’s cyst.

Required Views:

  • Saphenofemoral junction: Non-compressed and Compressed 

  • Popliteal vein (before trifurcation): Non-compressed and Compressed 

  • Femoral vein (as applicable): Non-compressed and Compressed

ANATOMY:

How to Scan:

ACEP Sonoguide: DVT

Five Minute Sono: DVT

Five Minute Sono: Upper Extremity DVT

POCUS 101: DVT Ultrasound Made Easy

Tips/Tricks/Pitfalls:

  • Always compress at an angle perpendicular to the vein to ensure compression is adequate. 

  • Be sure to increase your depth to confirm you are not imaging a superficial vein. 

  • If a patient has a large body habitus you can switch to the curvilinear probe for deeper visualization.

  • You can increase sensitivity of the exam by performing systematic compressions of the entire lower extremity.

  • For difficult exams, you can use your “non-probe” hand to compress the soft tissue from behind the leg (posteriorly🡪anteriorly) to assist in completely compressing the vessel you are investigating.

Pathology:

  • DVT 

  • Superficial thrombophlebitis 

  • False positives (ex: Baker’s Cyst, inguinal LNs, pseudoaneurysm, etc) 

Key Literature:

  1. Hercz D, Mechanic OJ, Varella M, Fajardo F, Levine RL. Ultrasound Performed by Emergency Physicians for Deep Vein Thrombosis: A Systematic Review. West J Emerg Med. 2024 Mar;25(2):282-290. doi: 10.5811/westjem.18125. PMID: 38596931; PMCID: PMC11000565.

  2. Kang SY, Jo IJ, Heo S, Chang H, Lee G, Park JE, Kim T, Lee SU, Kim MJ, Yoon H. Emergency medicine residents' learning curve in diagnosing deep vein thrombosis with 3-point venous point-of-care ultrasound. Int J Emerg Med. 2024 Jun 17;17(1):75. doi: 10.118

  3. Serial 2-point ultrasonography plus D-dimer vs whole-leg color-coded Doppler ultrasonography for diagnosing suspected symptomatic deep vein thrombosis: a randomized controlled trial. JAMA. 2008 Oct 8;300(14):1653-9. doi: 10.1001/jama.300.14.1653. PMID: 18

  4. Adhikari S, Zeger W, Thom C, Fields JM. Isolated Deep Venous Thrombosis: Implications for 2-Point Compression Ultrasonography of the Lower Extremity. Ann Emerg Med. 2015 Sep;66(3):262-6. doi: 10.1016/j.annemergmed.2014.10.032. Epub 2014 Nov 20. PMID: 2546

  5. Speranza G, Mischkewitz S, Al-Noor F, Kainz B. Value of clinical review for AI-guided deep vein thrombosis diagnosis with ultrasound imaging by non-expert operators. NPJ Digit Med. 2025 Mar 1;8(1):135. doi: 10.1038/s41746-025-01518-0. PMID: 40025255; PMCI.

  6. Filipiak-Strzecka D, Kasprzak JD, Lipiec P. Brief cardiovascular imaging with pocket-size ultrasound devices improves the accuracy of the initial assessment of suspected pulmonary embolism. Int J Cardiovasc Imaging. 2018 Oct;34(10):1595-1605. doi: 10.1007

Additional Resources:

The POCUS Atlas: Vascular

US GEL Articles

Author: Niyi Soetan, MD

Peer editing by: David Murray, MD