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Of 1330 outpatients with suspected deep vein thrombosis (DVT), a normal enzyme-linked immunosorbent assay (ELISA) d-dimer (VIDAS) of <500 ng/mL was true negative in 382 of 384 and false negative in compression ultrasonography (CUS) in 2, indicating a sensitivity of 99.52% and a negative predictive value (NPV) of 99.48%, with a specificity of 36% irrespective of clinical score. In 1059 outpatients with no DVT, the CUS was positive for the alternative diagnoses (AD): Bakers cyst, muscle hematoma, or old DVT in 62 (5.8%); superficial vein thrombosis without DVT in 78 (7.4%), and leg edema or varices in 17%. A second CUS in 641 patients was positive in 26 (4.0%), indicating an NPV of 96% after a first negative CUS. The NPV of the combination of a negative first CUS and a ELISA d-dimer test <1000 ng/mL was 99.1% at a specificity of 66.9%. As this strategy is cost effective by reduction in the need to repeat CUS by 67%, we designed a novel algorithm for the safe exclusion and diagnosis of DVT and AD for subsequent evaluation in a large prospective study.

Duplex ultrasonography (DUS) does pick up alternative diagnoses (AD) includingBaker's cyst, muscle hematomas, old deep vein thrombosis (DVT), and superficial vein thrombosis. The sequential use of DUS followed by a sensitive D-dimer test and a clinical score assessment is a safe and effective noninvasive strategy to exclude and diagnose DVT and AD in patients with suspected DVT. DVT patients are recommended to wear medical elastic stockings (MECS) for symptomatic relief of swollen legs during the acute phase of DVT, or when postthrombotic syndrome (PTS) is present. In routine daily practice, discontinuation of anticoagulation at 6 months post-DVT is followed by a subsequent 20%-30% DVT recurrence rate; this is the main cause of PTS after 1-5 years of follow-up. To bridge the gap between DVT and PTS, the frequent occurrence of PTS is best prevented by prolonged anticoagulation, if indicated, based on objective risk factors for DVT recurrence. Post-DVT rapid and complete recanalization on DUS within 1-3 months and no reflux is associated with no development of PTS, obviating the need of MECS; furthermore, anticoagulation can be discontinued after 3-6 months post-DVT. Absence of residual venous thrombosis (complete recanalization) at 3 months post-DVT with no reflux and with a low PTS score is associated with no recurrence of DVT (1.2% of 100 patient/years). The presence of reflux due to valve destruction, irrespective of the degree of recanalization on DUS at 3-6 months post-DVT, is associated with a high risk of DVT recurrence and symptomatic PTS, indicating the need to wear MECS and extend anticoagulation. Appearance of reflux on DUS at 6 months or 9 months post-DVT in symptomatic PTS patients is associated with increased DVT recurrence in about one-third of post-DVT patients after the discontinuation of anticoagulation. We designed a prospective safety outcome management study to bridge the gap between DVT and PTS, with the aim of reducing the overall DVT recurrence rate to ,3% patient/years during long-term follow-up.

Complete compression ultrasonography (CCUS) rules in and out acute deep vein thrombosis (DVT) and picks up alternative diagnoses (AD) including Baker's cyst, muscle hematomas, old DVT, and superficial vein thrombosis. CCUS from the ileofemoral region to the popliteal and calf veins has become the objective test in routine daily practice to diagnose acute DVT and to classify distal, proximal and inguinal Leg Extremity Thrombosis (LET class I, II and III DVT) extension.Acute DVT patients are recommended to wear medical elastic stockings (MECS) for symptomatic relief of swollen legs for a few weeks. Objective testing with colour duplex ultrasonography (DUS) at time points 1, 3 and 6 months post-DVT for residual vein thrombosis is of critically importance to assess the risk for DVT recurrence and post-thrombotic syndrome (PTS) evolution. Prospective studies clearly indicate that MECS only relieves subjective symptoms of PTS but do not reduce DVT recurrence and do not improve the objective signs of PTS after long-term and lifelong follow-up.Rapid and complete recanalization on DUS within 1 to 3 months post-DVT is associated with no reflux and low risk on DVT and PTS on the basis of which MECS and anticoagulation with vitamin K antagonist or Direct Oral anti-Xa or IIa Coagulant (DOAC) inhibitor can be withhold at 3 months post-DVT. Delayed recanalisation with residual vein thrombosis (RVT) on DUS at 3 months post-DVT is assocated with reflux due to valve destruction and a high risk of DVT recurrence and PTS indicating the need to extend anticoagulation for 6 momths to 1 year in the absence of PTS and for 2 years in the presence of PTS. Direct Anticoagulants: DOACs preferentially apixaban twice daily have become the first line treatment option of acute DVT and PE for effective reduction of venous thromboembolism (VTE). Apixaban BID is superior to rivaroxaban OD for 3 to 6 months acute DVT/PE treatment in terms of significantly less major bleeds (MB) clinical relevant non-major (CRNM) bleeds. Low dose apixaban BID daily is the treatment of choice for extended anticoagulation in post-DVT patients at high risk of DVT recurrence. Patients with acute DVT in the ileofemoral veins are at highest risk of DVT recurrence. Catheter Directed Thrombolysis (CDT) on top of anticoagulation for the invasive treatment of acute iliofemoral deep-vein thrombosis compared with standard anticoagulant therapy (vitamine K antagnist or DOAC) alone is noninferior and absolutely not superior in terms of post-thrombotic syndrome sequelae after 1 year.A prospective safety-efficacy DVT-PTS Bridging the Gap management study is proposed in patients with a first distal, proximal and iliofemoral thrombosis to reduce the overall DVT recurrence rate from about 30% to less than 5% patient/years to prevent PTS significantly during long-term follow-up.

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