Ultrasound Case 054

Presentation

A 70 year old man with known severe emphysema is brought in by ambulance with profound hypotension, he is peri-arrest. He has known pulmonary hypertension.

An echo reveals a dilated and poorly functioning right ventricle with RV wall thickness of 6mm (≤5mm). You wonder whether this is a massive pulmonary embolism or just the changes of chronic pulmonary hypertension.

You look at his common femoral vessels to see if there is evidence of deep venous thrombosis.


Describe and interpret these scans

IMAGE INTERPRETATION

Image 1: Transverse view of common femoral vessels, with intermittent transducer pressure.

The patient is profoundly hypotensive and in a peri-arrest situation. Transducer pressure easily compresses the common femoral artery which is not particularly pulsatile either.

At the same time a round heterogeneous filling defect fills the common femoral vein. It is non-compressible and consistent with deep venous thrombus (DVT).


CLINICAL CORRELATION

Massive PE and DVT

Excluding pulmonary embolism (PE) in the setting of known chronic pulmonary hypertension using echo alone is difficult – unless thrombus is actually seen in transit. Confirming the presence of DVT when there is clinical suspicion makes acute PE highly probable.

When a patient is profoundly hypotensive transducer pressure can compress arteries as it normally does veins. Do not confuse a compressing artery for a vein without thrombus.


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