A single complete ultrasound investigation of the venous network for the diagnostic management of patients with a clinically suspected first episode of deep venous thrombosis of the lower limbs

Abstract

SummaryIn patients clinically suspected of deep-vein thrombosis (DVT) of the lower limbs, it is safe to withhold anticoagulant therapy after a negative ultrasound (US) limited to the popliteal and the femoral veins, provided that this can either be repeated or combined with other diagnostic procedures. To assess the safety of withholding anticoagulants after a single negative complete US, we performed a multicenter, prospective, cohort study including consecutive ambulatory outpatients from institutional and private practice settings, with a clinically suspected first episode of DVT. Patients fulfilling the inclusion criteria were enrolled after careful clinical assessment. A complete US examination of the proximal and the distal veins was performed according to a standardized and detailed protocol. Anticoagulant therapy was administered in patients with proximal or isolated distal DVT and withheld in those with negative results. The main outcome measure was the occurrence of objectively documented clinical thromboembolic events during a three-month follow-up after a negative US.Out of 623 patients,401 (64.4%) had a baseline negative US, were not anticoagulated and could be followed-up for three months. Two patients presented a calf DVT within three months. The incidence of venous thromboembolic events, including distal DVT, was 0.5% [95% confidence interval: 0.1-1.8]. No proximal DVT, or non-fatal or fatal pulmonary embolism occurred (incidence: 0.0% [95% confidence interval: 0.0-0.9]).In conclusion, it is safe to withhold anticoagulant therapy in patients with clinically suspected DVT after a single, negative, complete US. Integrating this method within diagnostic strategies for DVT could improve management and be more acceptable for patients and physicians.

Should we diagnose and treat distal deep vein thrombosis?

“…25 Some studies by highly skilled ultrasonographers who used the best ultrasound machines reported much higher accuracy. 26 The improvement in ultrasound technology and increased experience in the field have led to a reliable diagnosis of distal DVT in experienced hands when the most reliable diagnostic criterion is used: the lack of compressibility of a venous segment.…”

“…Seven prospective outcome studies that used a single complete (ie, proximal, distal) CUS have been published (Table 2). 11,26,[31][32][33][34][35] Patients were treated if CUS showed a proximal or distal DVT and were left untreated if proximal and distal veins were normal without further testing. These studies confirmed the safety of a single complete CUS, with a pooled estimate of the 3-month thromboembolic risk of 0.6% (95% CI, 0.3%-0.9%).…”

Risk Factors and Anticoagulation Therapy in Patients With Isolated Distal Deep Vein Thrombosis in the Early Post-operative Period After Thoracic Surgery

“…DVTs are classified based on the anatomical site of involved venous segments. A proximal DVT may involve popliteal, femoral, and iliac veins, and the inferior vena cava (IVC) (8), while isolated distal deep vein thrombosis (IDDVT), or calf DVT, that represents around 30-50% of all lower-limb DVTs, does not extend to proximal veins (9)(10)(11). Although there is evidence that IDDVT may spontaneously resolve (12), there are reports of it extending proximally and leading to PE with a combined risk of proximal propagation and PE ranging between 7.8 and 11.4% (13)(14)(15).…”