Clinical validity of a negative venogram in patients with clinically suspected venous thrombosis.

Abstract

SUMMARY Although it is generally accepted that negative venography excludes deep vein thrombosis (DVT) in patients in whom it is clinically suspected, there is no evidence to support this conclusion. To test the correctness of withholding anticoagulant therapy in these patients, we followed 160 consecutive patients who had clinically suspected DVT and method of Rabinov and Paulin' in two hospitals and by a previously described method8 in the other two. After the procedures were completed, the veins of each leg were flushed with 100 ml of saline. Venography was interpreted as previously described.6 The venographic findings were interpreted independently without knowledge of the clinical findings. In 158 patients, ascending venography showed a well-opacified deep vein system in both legs, and the posterior tibial veins, peroneal veins, the soleal plexus, the popliteal, superficial femoral, common femoral, external and common iliac veins were visualized. Careful attention was given to technique and injection of contrast medium was repeated if inadequate visualization occurred on the first attempt. In two patients, the external and common iliac veins were not adequately visualized by repeat injection and a direct femoral vein puncture was required for successful visualization.The patients were 17-84 years old, mean age 51 years. Sixty-five were males and 95 were females. In all cases, a consulting physician agreed, after examining the patient, that the clinical findings suggested DVT and that this diagnosis could not be confidently ruled out in favor of an alternate diagnosis.The history and physical findings were assessed in a standard fashion and recorded prospectively on the study data forms. The findings recorded included the presence or absence of pain, tenderness, swelling, edema, cord, Homan's sign, and localization of these symptoms and signs to the calf region only, the thigh only, or calf and thigh.In each patient, baseline impedance plethysmography and leg scanning were performed in both legs at the time of venography and repeated at 72 hours. The methods for performing and interpreting impedance plethysmography7 and leg scanning8 have been de-

Negative d-dimer result to exclude recurrent deep venous thrombosis: A management trial

“…The prognosis on follow-up in our patients with negative D-dimer test results is similar to the prognosis of patients with negative results on combined impedance plethysmography and fibrinogen leg scanning (4); it is also similar to the prognosis of patients with negative venography results (23). We believe that the assay for D-dimer is a useful addition to the physician's options for patients with suspected recurrent DVT when balanced against the limitations and risks of the currently available alternative diagnostic approaches and the risk of anticoagulant therapy (26).…”

D-Dimer Assays in Diagnosis and Management of Thrombotic and Bleeding Disorders

“…To safely rule out VTE, a negative D-dimer assay result when used alone or with other tests, should yield equivalent failure rates in clinical follow-up as reference standard tests such as negative venography for DVT and negative pulmonary angiography or a normal ventilationperfusion lung scan for PE (i.e., failure rates of 2% or less; negative predictive value of at least 98%). 3,[7][8][9][10][11][12][13][15][16][17] Multiple studies have investigated the use of D-dimer testing, either alone or in combination with noninvasive tests or clinical pretest probability assessment, to manage patients with suspected lower extremity DVT or PE. 3,9,10,13,18-42 Based on the results of these investigations, recent guidelines recommend the use of initial D-dimer testing when evaluating patients with either a low (with either a moderately or highly sensitive D-dimer assay) or moderate pretest probability (highly sensitive D-dimer only) of DVT.…”

Recanalization after acute deep vein thrombosis

“…While pain, edema and muscle rigidity have been identified in up to 86.7% of patients with DVT, these signs and symptoms can also present in other conditions, such as: lymphangitis , cellulites, ruptured Baker's cyst, congestive heart failure, nephrotic syndrome, traumas, muscle hematomas, myositis and muscle tears 1 . In view of this, a clinical diagnosis alone is not sufficient to confirm diagnosis in suspected cases of DVT 15,16 . Patients who go undiagnosed and are therefore treated inadequately can suffer chronic venous insufficiency (CVI) and even death caused by PE.…”