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Venous ultrasound for acute deep venous thrombosis is performed every day, multiple times a day, in vascular laboratories across the country. Limiting the interrogation of the vessels to the proximal venous system is no longer clinically adequate. There is now sufficient evidence warranting the inclusion of calf vein imaging as part of the standard venous duplex examination. As specified in 3.2.1.1.1 of the current, 2007 ICAVL Standards, Part II: Vascular Laboratory Operations - Peripheral Venous, transverse, compression images of both the posterior tibial and peroneal veins in the evaluation of deep venous thrombosis are required.

When asked about the ICAVL's decision to require that the posterior tibial and peroneal veins be imaged on all patients undergoing a venous examination, Thom Rooke, MD, RVT, President of the ICAVL Board of Directors, reflected, "There is a clear trend toward the inclusion of calf veins in venous studies; this trend is based on both expert consensus and data. The Standards Committee also thought that inclusion of the gastrocnemius and soleus veins should be included in symptomatic patients but did not make this a strict requirement for a complete venous duplex exam at this time." According to the literature, the posterior tibial and peroneal veins are more likely to develop venous thrombosis.

Why Include Calf Vein Surveillance
Into The Routine Exam?

Pulmonary embolism occurs in approximately 600,000 patients each year, and 17% or >100,000 of these patients will not survive. 80% of all pulmonary emboli arise from the lower extremity veins. 90% or more of all proximal deep venous thrombosis have associated calf vein involvement, suggesting that the calf veins are the site of origin. 20-30% of isolated calf vein thrombi propagate to the proximal venous system.

The deep calf veins include the posterior tibial veins, peroneal veins, anterior tibial veins, gastrocnemius veins and soleus veins. The popliteal divides just below the knee into three deep-paired vessels of the calf. The first division is the anterior tibial veins (ATV) and the tibioperoneal trunk. The anterior tibial veins branch laterally and can be followed a short distance to mid calf. The tibioperoneal trunk bifurcates into the posterior tibial veins (PTV) and peroneal veins. The posterior tibial veins are found medially and can be followed to the ankle level. The peroneal veins are more lateral and can be followed to the lower calf. The soleus veins can be found branching off the posterior tibial and peroneal veins in the mid calf region. The gastrocnemius veins arise from the popliteal vein and can have multiple pairs.

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