Practical diagnostic management of patients with clinically suspected deep vein thrombosis by clinical probability test, compression ultrasonography, and D-dimer test

Tick, Lidwine W.; Ton, Evelien; Voorthuizen, Theo van; Hovens, Marcel M.C.; Leeuwenburgh, Ivonne; Lobatto, S.; Stijnen, Pieter; Heul, Cees van der; Huisman, Peter M.; Kramer, Mark H. H.; Huisman, Menno V.

doi:10.1016/s0002-9343(02)01347-5

Cited by 94 publications

(75 citation statements)

References 19 publications

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“…[22][23][24][25][26][27] The utility of algorithms in the diagnosis of DVT, however, depends on the availability of diagnostic testing, the expertise of the technologists performing the ultrasound examinations, the patient population, the cost and reimbursement of the different tests, and the interpretation of the results. What might be feasible for one institution may not be applicable to another, and each group should determine their own approach with some objective validation.…”

Section: Combined Approaches In the Diagnosis Of Dvtmentioning

confidence: 99%

“…However, there have been some rigorously performed cohort studies that have incorporated algorithms utilizing clinical pretest probability in combination with ultrasonography and/or D-dimer testing. [22][23][24][25][26][27] …”

Section: Combined Approaches In the Diagnosis Of Dvtmentioning

confidence: 99%

“…[22][23][24][25][26][27][28] The use of D-dimer is controversial and, more importantly, the precise role of D-dimer assays as an adjunct to ultrasound examination for DVT has not been definitively established. 15 D-dimer measurements have a lower sensitivity for isolated calf vein thrombi, and the negative predictive value of D-dimer varies with the pretest probability of disease.…”

Section: D-dimer Testingmentioning

confidence: 99%

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Ultrasonography and Diagnosis of Venous Thromboembolism

2004

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Abstract-Venous thromboembolism (VTE) consists of two related conditions: pulmonary embolism (PE) and deep vein thrombosis (DVT). Objective testing for VTE is crucial because the clinical diagnosis is nonspecific and insensitive, and the consequences of a missed diagnosis are serious. The purpose of this review is to discuss the utility of venous ultrasonography as the foundation for diagnosis of acute lower extremity DVT. The effectiveness and practicality of venous ultrasonography as a stand-alone examination versus theoretically attractive, but perhaps less practical, combined approaches of ultrasonography with clinical probability assessment and D-dimer testing in the diagnosis of acute DVT is also addressed. Finally, the role of venous ultrasonography in a diagnostic algorithm for suspected PE is discussed. Key Words: thrombosis Ⅲ pulmonary heart disease Ⅲ diagnosis Ⅲ ultrasonics Ⅲ veins Ⅲ prevention Current Treatment Standards for DVTGuidelines for antithrombotic therapy for the treatment of venous thromboembolism (VTE), developed in 2001 by the Sixth American College of Chest Physicians (ACCP), state that patients with acute VTE should be treated with low molecular weight heparin, unfractionated intravenous heparin, or adjusted-dose subcutaneous heparin. 1 Treatment is recommended for both proximal and symptomatic distal (isolated calf) DVT. If anticoagulation cannot be administered or is contraindicated for calf DVT, then the recommendations are for serial noninvasive studies over the next 10 to 14 days to assess for proximal progression of the thrombus. 1 These recommendations, in effect, require that an examination assessing the presence of DVT have both excellent sensitivity and specificity for diagnosis of both proximal (above knee) and distal (below knee) DVT. Currently, color flow duplex scanning performed by skilled operators provides the most practical and cost-effective method for assessing DVT of the proximal and distal lower extremity veins. Unfortunately, most duplex ultrasound-based algorithms for the diagnosis of DVT, and some vascular laboratories, still do not include an initial ultrasound evaluation of the calf veins as part of their routine evaluation for DVT, even in symptomatic patients. This is largely the result of outdated perceptions of the inaccuracy of ultrasound evaluation of DVT isolated to the calf veins. Failure to perform a complete initial examination necessitates serial ultrasound examinations or alternative strategies to detect possible extension of venous thrombi initially isolated to the calf veins. Such strategies are inefficient, and unlikely to be cost effective, compared with the modern practice of a single stand-alone color flow duplex study of the proximal and distal lower extremity veins in patients with suspected DVT. Limitations of Current Noninvasive DiagnosticMethods for DVT Impedance PlethysmographyThe objective diagnosis of DVT is not always straightforward. Venography was once accepted as the standard of accuracy for diagnosing DVT 2 and still has some li...

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Section: Combined Approaches In the Diagnosis Of Dvtmentioning

confidence: 99%

Section: Combined Approaches In the Diagnosis Of Dvtmentioning

confidence: 99%

Section: D-dimer Testingmentioning

confidence: 99%

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Ultrasonography and Diagnosis of Venous Thromboembolism

2004

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“…D-dimer measurement has gained a prominent role for ruling out DVT because of its high sensitivity [47,48,58,59]. The specificity of D-dimer is low because its concentrations can be raised in various other conditions, such as inflammation, pregnancy, or cancer [60][61][62][63][64][65][66][67][68][69][70][71][72]. The qualitative D-Dimer test SimpliRed has a sensitivity of 89%, a specificity of 77% and a NPV of 96% for the exclusion of DVT [67].…”

Section: Qualitative and Quantitiative D-dimer Testing For Dvt Exclusionmentioning

confidence: 99%

“…First, a negative CCUS and a negative VIDAS test (<500 ng/ml) exclude DVT with a sensitivity and specificity of 99.99% irrespective of clinical score assessment. After a first negative CCUS the prevalence of DVT in routine daily practice is uniformly low, 2% to 3% [47,48,[69][70][71][72]. The general application of two non-specific and rather insensitive methods for DVT and AD exclusion by the combination of a negative SimpliRed (Simplify) and low clinical score should be estimated as not safe enough mainly because the prevalence of DVT in the low clinical score group may vary widely (3% to 12%) [48,65].…”

Section: Ccus D-dimer and Clinical Score Strategy To Rule In And Outmentioning

confidence: 99%

Complete Compression Ultrsonography, Clinical Score, Underlying Risk

Michiels¹,

Strijkers²,

Michiels³

et al. 2015

J Hematol Thrombo Dis

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Primary Superficial Thrombophlebitis (SVT)The incidence of superficial thrombophlebitis (SVT) is approximately 1.6 per 1000 persons per year. Several studies have confirmed the association of SVT and VTE. In a systematic review of patients with SVT, 6% to 44% of cases was associated with deep vein thrombosis (DVT), 20% to 33% with asymptomatic pulmonary embolism (PE) and 2% to 13% with symptomatic PE. Assessment of risk factor in the MEGA study a history of clinical SVT was associated with a 6.3-fold risk of DVT and a 3.9 risk of PE. In a study of 263 SVT patients, 30 (11.4%) developed DVT. Among 125 patients with SVT located in the great saphena vein, 16.8% developed DVT. Out of 138 patients with isolated SVT below the knee only 4.5% developed DVT. In a lower limb ultrasound study in 2646 patients 36 (9.3%) of the patients had combined DVT and PTS. These data indicate that primary SVT should be considered an integral part of DVT. The presence of inherited hypercoagulability or venous thrombophilia in both SVT and DVT strongly supports a similar etiology and pathphysiology. In… patients with primar SVT hereditary protein C and s deficiency was detected in 6.45% in the absence of DVT and in 62.5% in SVT patient who had developed DVT. In our experience hereditary heterozygous antithrombin defiencoiency (AT) is associated with a high risk on DVT and PE not preceded by SVT. Congenital protein C (PC) or protein S (PS) deficiency in 27 DVT patients (15 males, 12 females) in 6 unrelated Dutch families had a history of SVT 19 cases (70%) as the hall mark of congenital PC/PS deficiency. The prevalence of FV Leiden, FII A20210 mutation, and PC or PS deficiency in 63 evaluated SVT patients was 16%, 906% and 10% respectively (total 36%) as compared to 3%, 2.4% and 0.6% in 537 controls. The incidence of inherited thrombophilic risk factors in patients with a first DVT is high (31%) as compared to 5 to 6% in the general population (Table 1). In 1668 patients with a first DVT in the Leiden prospective study the incidence of congenital thrombophilia was 25%. In this study 417 (25%) of 1668 patients with a first DVT were on oral contraceptives below the age of 50 years. In 400 Czech young women with VTE on oral contraceptives (distal DVT 58%, proximal DVT 16%, PE 5%, thrombosis at unusual sites 20%) inherited thrombophilia was diagnosed in 195 (49%): FV Leiden 35% FIIA20210 mutation 5%,AT,PC PS deficiency 3.6% and antiphopholipid syndrome 5.3%. We conclude that thrombophilia screening is manadatory in SVT and DVT patients and in women on contraceptive pills in particular for the education of clinicians abling them to much better counsel their SVT and DVT patients and their relatives. AbstractSuperficial vein thrombosis is an integral part of venous thromboembolism (VTE) together with deep vein thrombosis (DVT) and pulmonary embolism (PE). The incidence of SVT is 1.6 per 1000 persons per year. The incidence of DVT is about 1.0 per 1000 persons per year in the general population, 1.8 per 1000 persons per year at age 65 to 69 years...

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Does This Patient Have Deep Vein Thrombosis?

Anand

Wells

Hunt

et al. 2006

JAMA

423

262

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Diagnostic accuracy for DVT improves when clinical probability is estimated before diagnostic tests. Patients with low clinical probability on the predictive rule have prevalence of DVT of less than 5%. In low-probability patients with negative D-dimer results, diagnosis of DVT can be excluded without ultrasound; in patients with high clinical suspicion for DVT, results should not affect clinical decisions.

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Practical diagnostic management of patients with clinically suspected deep vein thrombosis by clinical probability test, compression ultrasonography, and D-dimer test

Cited by 94 publications

References 19 publications

Ultrasonography and Diagnosis of Venous Thromboembolism

Ultrasonography and Diagnosis of Venous Thromboembolism

Complete Compression Ultrsonography, Clinical Score, Underlying Risk

Does This Patient Have Deep Vein Thrombosis?

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