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The Utility Of Duplex Ultrasonography For Evaluation Of Lower Extremity Edema
Callie E. Dowdy, MD, Matthew J. Dougherty, MD, Samantha Jacoby, RVT, Lili Sadri, MD, Christopher Cappellini, DO, Kunal T. Vani, DO, Douglas A. Troutman, DO, Keith D. Calligaro, MD.
Pennsylvania Hospital, Philadelphia, PA, USA.

OBJECTIVE: Lower extremity (LE) edema is a frequent symptom prompting referral for vascular evaluation. In cases of bilateral LE edema, venous insufficiency is often assumed. We believe most cases of bilateral LE edema do not require intervention beyond compression, elevation, and treatment for underlying causes of fluid retention. We sought to examine the clinical benefit of duplex ultrasound (DU) in cases of bilateral LE edema and determine potential cost savings of avoiding routine use of DU in these cases.
METHODS: We retrospectively reviewed de-identified data from venous DU studies performed for LE edema in our IAC accredited non-invasive vascular laboratory between 2015-2020 to determine if treatment other than conservative therapy was performed based on DU results.
RESULTS: Of 2,270 venous DUs performed, 1,653 (72.8%) were performed for symptoms of bilateral lower extremity edema. Patients with bilateral symptoms were significantly less likely to have an abnormal venous DU [2.0% (34/1653)] than patients with unilateral symptoms [26.6% (164/617) (p < 0.001)]. Only 3 of the 34 abnormal bilateral scans showed changes that resulted in further treatment (two cases of anticoagulation for acute bilateral iliofemoral vein deep vein thrombosis (DVT); one endovascular intervention for chronic occlusive disease of both common iliac veins). Therefore, only 0.2% (3/1,653) of venous DU scans performed for bilateral LE edema resulted in treatment beyond conservative therapy vs. 11.2% (69/617) of scans performed for unilateral edema (p < 0.001). The most common abnormal finding requiring additional treatment in unilateral edema cases was acute DVT (91.3% [63/69]). Average reimbursement for bilateral LE venous DU in our lab is approximately $230/study. Avoiding routine use of DU for bilateral LE edema would have potentially resulted in cost savings of over $350,000 during this time period.
CONCLUSIONS: Our study shows a significant relationship between bilateral vs. unilateral LE edema and the likelihood of an abnormal DU result. We propose that pursuing venous DU as an initial diagnostic tool for unilateral LE edema is appropriate, but doing so for bilateral LE edema is of minimal clinical benefit and avoiding these studies for this indication would result in significant cost savings.


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