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Isolated Pelvic Deep Venous Thrombosis: Relative Frequency As Charles E. Spritzer, MD Isolated Pelvic Deep Venous Michael A. Arata, MD Kelly S. Freed, MD Thrombosis: Relative Frequency as Detected Index terms: Magnetic resonance (MR), 1 comparative studies, 98.12942, with MR Imaging 98.1298 Magnetic resonance (MR), vascular studies, 98.12942 Veins, iliac, 98.751 PURPOSE: To determine the relative frequency of deep venous thrombosis (DVT) Veins, thrombosis, 98.751 isolated to the pelvic veins, as demonstrated with magnetic resonance (MR) imag- Veins, US, 98.1298 ing. Venae cavae, thrombosis, 982.751 Venography, 98.12942 MATERIALS AND METHODS: The reports of 769 MR examinations performed from June 1993 through December 1999 in patients with suspected DVT were Radiology 2001; 219:521–525 reviewed retrospectively. MR venography was performed by using a two-dimen- Abbreviation: sional gradient-recalled-echo sequence (typically repetition time, 34 msec; echo DVT ϭ deep venous thrombosis time, 13 msec; flip angle, 60°). The presence of DVT was categorized by location in the pelvis, thigh, or calf. 1 From the Department of Radiology, RESULTS: DVT was identified in 167 (21.7%) of the 769 MR examinations. Thirty- Duke University Medical Center, Box 3808, MRI Section, Rm 1800, Dur- four (20.4%) of the 167 studies demonstrated DVT isolated to the pelvic veins. ham, NC 27710. From the 1997 RSNA scientific assembly. Received June 13, CONCLUSION: The relative frequency of isolated pelvic DVT detected with MR 2000; revision requested July 24; revi- venography was higher than that reported in prior studies with ultrasonography sion received September 14; accepted (US) or ascending venography. MR venography should be performed in patients September 19. Address correspon- dence to C.E.S. (e-mail: chuck.spritzer with suspected pelvic DVT or when clinical suspicion persists despite a negative US @duke.edu). study. © RSNA, 2001 Deep venous thrombosis (DVT) is a common disease occurring in approximately 500,000– 600,000 patients annually (1). In addition to the morbidity directly related to venous thrombosis, DVT results in an increased risk of pulmonary embolism. Pulmonary emboli are estimated to result in 10,000–30,000 deaths annually. The majority of embolic events are due to thrombus arising from the veins of the pelvis and lower extremities. Most thrombi are presumed to arise in the calf veins (1–3). The calf thrombus then propagates proximally over time. With propagation into the larger veins of the thigh and pelvis, the risk of pulmonary embolism increases (1–3). Isolated pelvic DVT is thought to be uncommon, accounting for approximately 2% of lower extremity DVT (4,5). Ultrasonography (US) is limited in the evaluation of pelvic veins (4,6). The relative infrequency of isolated pelvic DVT forms the basis for using duplex Doppler US to identify femoral and popliteal clots. US is a highly accurate and inexpensive imaging modality for the detection of such thrombi and is the current modality of choice Author contributions: for the evaluation of suspected lower extremity DVT (6,7). Guarantors of integrity of entire study, C.E.S., K.S.F., M.A.A.; study concepts, Alternative modalities for the identification of thrombus include conventional ascend- C.E.S., K.S.F.; study design, C.E.S., ing venography and magnetic resonance (MR) venography. Ascending venography, while M.A.A.; literature research, C.E.S., long considered the standard of reference for the diagnosis of DVT, is perceived as invasive M.A.A.; clinical studies, C.E.S., M.A.A.; and therefore is less routinely used. More important, assessment of the pelvic veins may be data acquisition and analysis/interpre- tation, C.E.S., M.A.A.; manuscript technically challenging (8). preparation, C.E.S., M.A.A.; manu- MR venography is a noninvasive imaging modality that enables direct visualization of script definition of intellectual con- pelvic vessels. Several authors (9–11) suggest it as the reference standard for the evaluation tent, C.E.S., K.S.F.; manuscript editing of pelvic thrombus. and revision/review, C.E.S., K.S.F., M.A.A.; manuscript final version ap- We postulated that the true relative frequency of isolated pelvic DVT is underestimated proval, C.E.S., K.S.F. with duplex Doppler US and ascending venography and that the superior imaging of pelvic vessels with MR venography would allow a more accurate determination of its true 521 relative frequency. It was the purpose of Sequential transverse gradient-recalled- this study to determine the relative fre- echo imaging with use of 5-mm sections quency of isolated acute pelvic DVT on at 10-mm intervals was performed with a the basis of a retrospective review of our 24–36-cm field of view. Typical imaging institution’s considerable accumulated parameters were 33–34/13 (repetition experience with MR venography in the time msec/echo time msec), a 60° flip evaluation of patients with suspected angle, and a 256 ϫ 128 matrix. Gradient DVT. moment nulling was used in all in- stances. With the body coil, four signals MATERIALS AND METHODS were acquired in the pelvis and two were acquired in the thigh. By using the Our MR database identified 796 consecu- phased-array lower extremity coil, the Transverse gradient-recalled-echo MR image tive studies performed for the evaluation number of signals acquired was reduced (34/13, 60° flip angle) of the pelvis in a 19-year- of pelvic and lower extremity DVT from to two in the pelvis and to one to two in old woman with pleuritic chest pain and he- June 1, 1993, to December 31, 1999. The the thigh (9,13). Respiratory compensa- moptysis. The patient was taking birth control reports of these studies, as in our data- tion was routinely used in the pelvis. The pills. Subsequent work-up demonstrated acti- vated protein C resistance. Acute thrombus (ar- base, and not the images themselves were protocol used has been validated in prior row) is seen in the left common iliac vein. A reviewed. Our institutional review board studies (9,13,14), and the rationale for focal area of decreased signal intensity in the did not require its approval or patient the chosen imaging parameters is avail- right iliac vein is a combination of flow artifact informed consent for a study of this type able in those reports. (arrowhead) and partial-volume artifact; this at the time the information was re- At our institution, MR imaging of the finding was confirmed on more caudal images viewed. Ten of these patients have been entire calf is performed when therapy (not shown). described previously (12). Of the 796 would be initiated for thrombus isolated studies, 27 examinations were performed to this region. In the calf, 130 examina- explicitly to follow up previously docu- tions were performed by using a head pelvis). Isolated involvement of the pel- mented venous thrombus and were ex- receive and transmit coil, an extremity vic veins was further categorized into iso- cluded from further analysis, resulting in receive and transmit coil, or the lower lated external iliac vein, internal iliac a total of 769 examinations performed portion of the extremity phased-array vein, common iliac vein, or involvement in 742 patients (323 men, 419 women; coil described earlier. Sequential trans- of the common iliac vein and involve- mean age, 53 years; age range, 11–89 verse images were acquired with a 5-mm ment of either or both the external iliac years). A total of 24 patients had two (21 thickness at 10-mm intervals. The field of vein and the internal iliac vein. Presence patients) or three (three patients) MR ex- view varied from 16 to 30 cm, with ma- of clot in the inferior vena cava or go- aminations performed for the onset of trices varying from 256 ϫ 128 to 256 ϫ nadal vessels also was noted. new symptoms. The interval between suc- 256. To accommodate slow flow, the rep- For those cases with acute thrombus cessive examinations was 1–34 months, etition time was increased to 75 or 100 isolated to the pelvis and detected with with a mean of 10.6 months and a median msec. The echo time was 13 msec and MR venography, the hospital database of 6.5 months. Patients underwent MR one to two signals were acquired. Addi- was searched for correlative duplex venography when proximal or calf DVT tional pulse sequences such as phase con- Doppler US examinations performed was clinically suspected, when exclusion of trast, spin echo, or fast spin echo were within 48 hours. thrombus in the entire lower extremity performed at the discretion of the inter- and pelvis was desired, and when US was preting radiologist. inconclusive or technically limited. Typi- Cases were called positive for DVT if RESULTS cal symptoms included unilateral or bilat- there was complete obstruction or near eral lower extremity edema, erythema, ten- complete obstruction of a distended vein Acute DVT was identified in 167 of the 769 derness, or swelling; dyspnea; frank chest by a low-signal-intensity intravascular MR examinations, for a prevalence of pain; or abnormal oxygen saturation in mass on the gradient-recalled-echo im- 21.7%. Thrombus was isolated to the pelvis which pulmonary embolism was suspected ages (13,14) (Figure). Vessel abnormali- in 34 cases, representing 20.4% of the total but a definitive study of the lungs was de- ties indicative of prior venous thrombus, positive examinations. Isolated thrombus ferred. such as webs, focal or diffuse wall thick- in the thigh was more common, seen in 49 All MR venographic examinations were ening, and reduced vessel caliber, were cases (29.3%), and thrombus isolated to performed with a 1.5-T unit (Signa; GE considered negative for acute DVT for the the calf was detected in another 23 cases Medical Systems, Milwaukee, Wis) whose purposes of this study (12).
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