Deep vein thrombosis diagnostic approach: Difference between revisions

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'''Editors-in-Chief:''' [[C. Michael Gibson, M.S., M.D.]] '''Associate Editor-In-Chief''': [[User:Ujjwal Rastogi|Ujjwal Rastogi, MBBS]] [mailto:urastogi@perfuse.org]
__NOTOC__
 
{| class="infobox" style="float:right;"
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| [[File:Siren.gif|30px|link=Deep vein thrombosis resident survival guide]]|| <br> || <br>
| [[Deep vein thrombosis resident survival guide|'''Resident'''<br>'''Survival'''<br>'''Guide''']]
|}
'''Editor(s)-In-Chief:''' {{ATI}}, [[C. Michael Gibson, M.S., M.D.]] [mailto:charlesmichaelgibson@gmail.com]; '''Associate Editor(s)-In-Chief:''' {{CZ}} ; [[User:Kashish Goel|Kashish Goel, M.D.]]; {{Rim}}; '''Assistant Editor(s)-In-Chief:''' [[User:Justine Cadet|Justine Cadet]]
{{Deep vein thrombosis}}
{{Deep vein thrombosis}}


==Overview==
==Overview==
The assessment of deep vein thrombosis (DVT) begins with the estimation of the pretest probability of DVT according to scoring systems such as the [[Wells score for DVT|Wells score]].  The initial diagnostic test for a suspected DVT is either [[D-dimer]], proximal [[ultrasound]], or whole leg [[ultrasound]] depending on the pretest probability of the disease. Further tests might be required depending on the findings of the initial test and the pretest probability of [[DVT]].
==Diagnostic Approach==
This page contains algorithms that depicts the diagnostic approach to [[DVT]] in the following situations:
* [[Deep vein thrombosis diagnostic approach#First Episode of Suspected Lower Extremity DVT|First episode of suspected lower extremity DVT]]
** [[Deep vein thrombosis diagnostic approach#Low Pretest Probability|Low pretest probability]]
** [[Deep vein thrombosis diagnostic approach#Moderate Pretest Probability|Moderate pretest probability]]
** [[Deep vein thrombosis diagnostic approach#High Pretest Probability|High pretest probability]]
** [[Deep vein thrombosis diagnostic approach#Risk Stratification Not Performed|Risk stratification not performed]]
* [[Deep vein thrombosis diagnostic approach#Suspected Recurrent Lower Extremity DVT|Suspected recurrent lower extremity DVT]]
* [[Deep vein thrombosis diagnostic approach#Suspected Upper Extremity DVT|Suspected upper extremity DVT]]
==Complete Diagnostic Approach for First Episode of Suspected Lower Extremity DVT==
===Low Pretest Probability===
Shown below are the different diagnostic approaches to the diagnosis of [[DVT]] depending in case of low pre-test probability of the disease.<ref name="pmid22315267">{{cite journal| author=Bates SM, Jaeschke R, Stevens SM, Goodacre S, Wells PS, Stevenson MD et al.| title=Diagnosis of DVT: Antithrombotic Therapy and Prevention of Thrombosis, 9th ed: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines. | journal=Chest | year= 2012 | volume= 141 | issue= 2 Suppl | pages= e351S-418S | pmid=22315267 | doi=10.1378/chest.11-2299 | pmc=PMC3278048 | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=22315267  }} </ref>


{{familytree/start |summary=DVT Diagnosis Algorithm.}}
{{Family tree/start}}
{{familytree | | | | GMa | GMa=Suspected (Symptomatic) [[DVT|Acute DVT]]}}  
{{familytree | | | | | | | | | | | | | | | A01 | | | | | | | | | | | | | | | | | | | A01= '''The patient has a low pre-test probability for DVT'''}}
{{familytree | | | | |!| }}
{{familytree | | | | | | | | | | | | | | | |!| | | | | | | | | | | | | | | | | | | | }}
{{familytree | | | | GPa | GPa=[[Deep vein thrombosis ultrasound|Compression Ultrasonography]]}}  
{{familytree | | | | | | | | | | | | | | | B01 | | | | | | | | | | | | | | | | | | | B01= '''Proceed with one of the following:'''<br>
{{familytree | |,|-|-|+|-|-|-|.| | | }}
❑ Highly or moderately sensitive [[D-dimer test]] (1st line)<br> ❑ Proximal US (2nd line)<br> ❑ Whole leg US (less preferred)}}
{{familytree |JOE| |ME| |SIS| | | JOE=Normal|ME=Inconclusive study|SIS=[[DVT]] present}}
{{familytree | | | | | |,|-|-|-|-|-|-|-|-|-|^|-|-|v|-|-|-|-|-|-|-|-|.| | | | | | | | }}
{{familytree | |!| | | |!| | | |!| }}
{{familytree | | | | | C01 | | | | | | | | | | | C02 | | | | | | | C03 | | | | | | | C01= [[D-dimer]] (1st line)| C02= Proximal US (2nd line)| C03= Whole leg US (less preferred)}}
{{familytree |MOM| | ME | | SIS | | |MOM=[[Deep vein thrombosis ultrasound|Serial Ultrasound]] or  [[Deep vein thrombosis other imaging findings|impedance plethysmography]]|ME=[[Venography]] or [[Deep vein thrombosis MRI|MRI]]|SIS=[[Deep vein thrombosis treatment algorithm|Treatment]]}}
{{familytree | |,|-|-|-|^|-|-|-|.| | | | | | |,|-|^|-|.| | | |,|-|-|^|-|-|.| | | | | }}
{{familytree | |!| |,|-|^|-|.| |!| }}  
{{familytree | D01 | | | | | | D02 | | | | | D03 | | D04 | | D05 | | | | D06 | | | | D01= Negative| D02= Positive| D03= Negative| D04= Positive| D05= Negative| D06= Positive}}
{{familytree | |!|GPa| |JOE|'|GPa=Negative for DVT|JOE=DVT present}}
{{familytree | |!| | | | | | | |!| | | | | | |!| | | |!| | | |!| | | | | |!| | | | |}}
{{familytree |,|^|.| |!| | | }}
{{familytree | |!| | | | | | | D07 | | | | | |!| | | |!| | | |!| | | | | D08 | | | |D07= '''Proceed with either:'''<br>❑ Proximal US (1st line)<br> OR <br> ❑ Whole leg US (less preferred)| D08= What is the location of the DVT?}}
{{familytree |!|SIS |^|-|-|-|.|SIS=DVT Absent}}
{{familytree | |!| | | |,|-|-|-|^|-|-|.| | | |!| | | |!| | | |!| | | |,|-|^|-|.| | | }}
{{familytree |!| | | | | | |JOE|JOE=No Treatment}}
{{familytree | E01 | | E02 | | | | | E03 | | E04 | | E05 | | E06 | | E07 | | E08 | | E01= DVT is excluded| E02= ❑ Proximal US (1st line)| E03= ❑ Whole leg US (less preferred)| E04= DVT is excluded| E05= ❑ Treat DVT| E06= DVT is excluded| E07= Proximal DVT| E08= Isolated distal DVT}}
{{familytree |SIS|SIS=DVT present|}}
{{familytree | | | |,|-|^|-|.| | | |,|^|-|-|.| | | | | | | | | | | | |!| | | |!|}}
{{familytree | |!| }}
{{familytree | | | F01 | | F02 | | F03 | | F04 | | | | | | | | | | | F05 | | F06 | F01= Negative| F02= Positive| F03= Negative| F04= Positive| F05= Treat DVT| F06= Perform serial US (1st line)<br> OR <br> Treat DVT}}
{{familytree |MOM | MOM=[[Deep vein thrombosis treatment algorithm|Treatment]]}}
{{familytree | | | |!| | | |!| | | |!| | | |!| | | | | | | | | | | | | | | | | | | |}}
{{familytree | | | |!| | | |!| | | |!| | | F05 | | | | | | | | | | | | | | | | F05= What is the location of the DVT?}}
{{familytree | | | |!| | | |!| | | |!| | | |)|-|-|-|.| | | | | | | | | | | | | }}
{{familytree | | | G01 | | G02 | | G03 | | G04 | | G05 | | | | | | | | | | | | G01= DVT is excluded| G02= Treat DVT| G03= DVT is excluded| G04= Proximal DVT| G05= Isolated distal DVT}}
{{familytree | | | | | | | | | | | | | | | |!| | | |!| | | | | | | | | | | | | }}
{{familytree | | | | | | | | | | | | | | | H01 | | H02 | | | | | | | | | | | | H01= ❑ Treat DVT| H02= ❑ Perform serial US (1st line)<br> OR <br> ❑ Treat DVT}}
{{Family tree/end}}
 
===Moderate Pretest Probability===
{{Family tree/start}}
{{familytree | | | | | | | | | | | | | | | | A01 | | | | | | | | | | | | | | | | | A01= '''The patient has a moderate pre-test probability of DVT'''}}
{{familytree | | | | | | | | | | | | | | | | |!| | | | | | | | | | | | | | | | | | }}
{{familytree | | | | | | | | | | | | | | | | B01 | | | | | | | | | | | | | | | | | B01='''Proceed with one of the following:'''<br>
❑ D-dimer test<br>
❑ Proximal US<br>
❑ Whole leg US}}
{{familytree | | | | |,|-|-|-|-|-|-|-|-|-|-|-|^|-|-|-|-|-|-|-|-|-|v|-|-|-|-|-|-|-|.| | }}
{{familytree | | | | C01 | | | | | | | | | | | | | | | | | | | | C02 | | | | | | C03 | | | | |C01= Highly sensitive [[D-dimer]] test| C02= Proximal US| C03= Whole leg US}}
{{familytree | |,|-|-|^|-|-|.| | | | | | | | | | | | | | |,|-|-|-|^|-|-|.| | | |,|^|-|-|.| }}
{{familytree | D01 | | | | D02 | | | | | | | | | | | | | D03 | | | | | D04 | | D05 | | D06 | | | D01= Negative| D02= Positive| D03= Negative| D04=Positive| D05= Negative| D06= Positive}}
{{familytree | |!| | | | | |!| | | | | | | | | | | | | | |!| | | | | | |!| | | |!| | | |!| | | |}}
{{familytree | |!| | | | | D07 | | | | | | | | | | | | | D08 | | | | | D09 | | D10 | | D11 | D07= '''Proceed with either:'''<br>❑ Proximal US <br> OR <br> ❑ Whole leg US| D08= ❑ Repeat proximal US <br> OR <br> ❑ Moderately/highly sensitive [[D-dimer]]| D09= ❑ Treat DVT| D10= DVT is excluded| D11= Where is the location of the DVT?}}
{{familytree | |!| | | |,|-|^|-|-|-|.| | | | | | | |,|-|-|^|-|-|.| | | | | | | | | |,|-|^|-|.| }}
{{familytree | E01 | | E02 | | | | E03 | | | | | | E04 | | | | E05 | | | | | | | | E06 | | E07 | E01= DVT is excluded| E02= Proximal US| E03= Whole leg US| E04= ❑ Repeat proximal US within 1 week|E05= Moderately/highly sensitive D-dimer| E06= Proximal DVT | E07= Isolated distal DVT}}
{{familytree | |,|-|-|-|(| | | |,|-|^|-|.| | | |,|-|^|-|.| | | |)|-|-|-|.| | | | | |!| | | |!| |}}
{{familytree | F01 | | F02 | | F03 | | F04 | | F05 | | F06 | | F07 | | F08 | | | | F09 | | F10 | F01= Negative| F02= Positive| F03= Negative| F04= Positive| F05= Negative| F06= Positive| F07= Negative| F08= Positive| F09= Treat DVT| F10= Perform serial US (1st line)<br> OR <br>Treat DVT}}
{{familytree | |!| | | |!| | | |!| | | |!| | | |!| | | |!| | | |!| | | |!| | | | | | | | | | | | | }}
{{familytree | G01 | | G02 | | G03 | | G04 | | G05 | | G06 | | G07 | | G08 | | | | | | | | | | | | | G01= ❑ Repeat proximal US within 1 week|G02= Treat DVT| G03= DVT is excluded| G04= What is the location of the DVT?| G05= DVT is excluded| G06=Treat DVT| G07= DVT is excluded| G08=❑ Repeat proximal US within 1 week}}
{{familytree | |)|-|-|-|.| | | | | |,|-|^|-|.| | | | | | | | | | | |,|-|^|-|.| | }}
{{familytree | H01 | | H02 | | | | H03 | | H04 | | | | | | | | | | H05 | | H06 | H01= Negative| H02= Positive| H03=Proximal DVT| H04= Isolated distal DVT| H05= Negative| H06= Positive}}
{{familytree | |!| | | |!| | | | | |!| | | |!| | | | | | | | | | | |!| | | |!| | }}
{{familytree | I01 | | I02 | | | | I03 | | I04 | | | | | | | | | | I03 | | I04 | I01= DVT is excluded| I02= ❑ Treat DVT| I03= ❑ Treat DVT| I04=❑ Perform serial US (1st line)<br>OR <br>❑ Treat DVT| I05= DVT is excluded| I06= ❑ Treat DVT}}
{{familytree/end}}
{{familytree/end}}
===High Pretest Probability===
{{Family tree/start}}
{{familytree | | | | | | | | | | | | | | | | A01 | | | | | | | | A01= '''The patient has a high pre-test probability for DVT'''}}
{{familytree | | | | | | | | | | | | | | | | |!| | | | | | | | | }}
{{familytree | | | | | | | | | | | | | | | | B01 | | | | | | | | B01= Proceed with either:<br>❑ Proximal US <br> OR <br> ❑ Whole leg US}}
{{familytree | | | | | | | | | | | | |,|-|-|-|^|-|-|-|.| | }}
{{familytree | | | | | | | | | | | | C01 | | | | | | C02 | | | C01= Proximal US| C02= Whole leg US}}
{{familytree | | | | | | | | | | |,|-|^|-|.| | | |,|-|^|-|.| | | | | | | | | }}
{{familytree | | | | | | | | | | D01 | | D02 | | D03 | | D04 | | | | | | | | D01= Negative| D02= Positive| D03= Negative| D04= Positive}}
{{familytree | | | | | | | | | | |!| | | |!| | | |!| | | |!| | | | | | | | | }}
{{familytree | | | | | | | | | | E01 | | E02 | | E03 | | E04 | | | | | | | | E01= '''Proceed with ONE of the following:'''<br>❑ Repeat proximal US <br>❑ Highly sensitive D-dimer<br>❑ Whole leg US <br> ❑ Venography (less preferred)|E02=❑ Treat DVT|E03= DVT is excluded| E04= What is the location of the DVT?}}
{{familytree | | | | | | | | | | |!| | | | | | | | | |,|-|^|-|.| | | | | | | }}
{{familytree | | | | | | | | | | |!| | | | | | | | | F01 | | F02 | | | | | | F01= Proximal|F02= Distal}}
{{familytree | | | | | | | | | | |!| | | | | | | | | |!| | | |!| | | | | | | }}
{{familytree | | | | | | | | | | |!| | | | | | | | | F03 | | F04 | | | | | | F03= ❑ Treat DVT| F04= ❑ Perform serial US (1st line)<br>OR<br>❑ Treat DVT}}
{{familytree | | | | | | | | | | |!| | | | | | | | | | | | | | | | | | | | | }}
{{familytree | | | | | |,|-|-|-|-|^|-|-|v|-|-|-|-|-|-|-|v|-|-|-|-|-|-|-|-|.| | | }}
{{familytree | | | | | G01 | | | | | | G02 | | | | | | G03 | | | | | | | G04 | | | G01= Repeat proximal US within 1 week| G02= Highly sensitive [[D-dimer]]| G03= Whole leg US| G04=[[Venography]]}}
{{familytree | | | |,|-|^|-|.| | | |,|-|^|-|.| | | |,|-|^|-|-|.| | | |,|-|^|-|.| | }}
{{familytree | | | J01 | | J02 | | J03 | | J04 | | J05 | | | J06 | | J07 | | J08 | J01= Negative| J02= Positive| J03= Negative| J04= Positive| J05= Negative| J06= Positive| J07= Negative| J08=Positive}}
{{familytree | | | |!| | | |!| | | |!| | | |!| | | |!| | | | |!| | | |!| | | |!| | }}
{{familytree | | | K01 | | K02 | | K03 | | |!| | | K04 | | | K05 | | K06 | | K07 | K01= DVT is excluded| K02=Treat DVT| K03=DVT is excluded| K04=DVT is excluded| K05=Where is the location of the DVT?| K06=DVT is excluded| K07=Treat DVT}}
{{familytree | | | | | | | | | | | | | | | |!| | | | | | | | |!| | | | | | | }}
{{familytree | | | |,|-|-|-|-|-|-|-|v|-|-|-|^|-|-|-|.| | | | |)|-|-|-|-|.| | }}
{{familytree | | | L01 | | | | | | L02 | | | | | | L03 | | | | L04 | | L05 | L01= Repeat proximal US within 1 week| L02= Whole leg US| L03=[[Venography]] (less preferred)| L04= Proximal| L05= Distal}}
{{familytree | |,|-|^|-|.| | | |,|-|^|-|.| | | |,|-|^|-|.| | |!| | | | |!| | }}
{{familytree | M01 | | M02 | | M03 | | M04 | | M05 | | M06 | | M07 | | M08 | M01= Negative| M02= Positive| M03= Negative| M04= Positive| M05= Negative| M06= Positive| M07= ❑ Treat DVT| M08= ❑ Perform serial US (1st line)<br>OR <br>❑ Treat DVT}}
{{familytree | |!| | | |!| | | |!| | | |!| | | |!| | | |!| | | }}
{{familytree | N01 | | N02 | | N03 | | N04 | | N05 | | N06 | | N01= DVT is excluded| N02= ❑ Treat DVT| N03= DVT is excluded| N04= Where is the location of the DVT?| N05= DVT is excluded| N06= ❑ Treat DVT}}
{{familytree | | | | | | | | | | | |,|-|^|-|.| | | | }}
{{familytree | | | | | | | | | | | O01 | | O02 | | | O01= Proximal| O02= Distal}}
{{familytree | | | | | | | | | | | |!| | | |!| | | | }}
{{familytree | | | | | | | | | | | P01 | | P02 | | | P01= ❑ Treat DVT| P02= ❑ Perform serial US (1st line)<br>OR<br>❑ Treat DVT}}
{{Family tree/end}}
===Risk Stratification Not Performed===
{{Family tree/start}}
{{familytree | | | | | | | | | | | | | | | | | | | | A01 | | | | | | | | | | | A01= '''Risk stratification was not performed'''}}
{{familytree | | | | | | | | | | | | | | | | | | | | |!| | | | | | | | | | | | }}
{{familytree | | | | | | | | | | | | | | | | | | | | B01 | | | | | | | | | | | B01= '''Proceed with ONE of the following:'''<br>❑ Proximal US <br>❑ Whole leg US <br> ❑ Highly/moderately sensitive [[D-dimer]] (less preferred)}}
{{familytree | | | | | | | | | | | | | | |,|-|-|-|-|-|^|-|-|-|-|.| | | | | | | }}
{{familytree | | | | | | | | | | | | | | C01 | | | | | | | | | C02 | | | | | | C01= Proximal US| C02= Whole leg US}}
{{familytree | | | | | | | | | | | |,|-|-|^|-|-|.| | | | | |,|-|^|-|.| | | | | }}
{{familytree | | | | | | | | | | | D01 | | | | D02 | | | | D03 | | D04 | | | | D01= Negative| D02= Positive| D03= Negative| D04= Positive}}
{{familytree | | | | | | | | | | | |!| | | | | |!| | | | | |!| | | |!| | | | | }}
{{familytree | | | | | | | | | | | |!| | | | | E01 | | | | E02 | | E03 | | | | E01= ❑ Treat DVT| E02= DVT is excluded| E03= What is the location of the DVT?}}
{{familytree | | | | | | | | | | | F00 | | | | | | | | | | | | | | |!| | | | | F00= '''Proceed with ONE of the following:'''<br>❑ Highly/moderately sensitive [[D-dimer]] (most preferred) <br> ❑ Repeat proximal US within 1 week <br> ❑ Whole leg US <br> ❑ [[Venography]] (less preferred) }}
{{familytree | | | |,|-|-|-|-|-|-|-|+|-|-|-|v|-|-|-|.| | | | | |,|-|^|-|.| | | }}
{{familytree | | | F01 | | | | | | F02 | | F03 | | F04 | | | | F05 | | F06 | | F01= Highly/moderately sensitive [[D-dimer]] (most preferred)| F02= Repeat proximal US within 1 week| F03= Whole leg US| F04= Venography (less preferred)| F05= Proximal| F06= Distal}}
{{familytree | |,|-|^|-|.| | | |,|-|^|-|.| | | |,|-|^|-|.| | | |!| | | |!| | | }}
{{familytree | G01 | | G02 | | G03 | | G04 | | G05 | | G06 | | G07 | | G08 | | G01= Negative| G02= Positive| G03= Negative| G04= Positive| G05= Negative| G06= Positive| G07= ❑ Treat DVT| G08= ❑ Serial US (1st line)<br> OR <br> ❑ Treat DVT}}
{{familytree | |!| | | |!| | | |!| | | |!| | | |!| | | |!| | | }}
{{familytree | H01 | | H02 | | H03 | | H04 | | H05 | | H06 | | | H01= DVT is excluded| H02= ❑ Repeat proximal US within 1 week <br> OR <br> ❑ [[Venography]]| H03= DVT is excluded| H04= ❑ Treat DVT| H05= DVT is excluded| H06= ❑ Treat DVT}}
{{Family tree/end}}
==Complete Diagnostic Approach for Suspected Recurrent Lower Extremity DVT==
Shown below is the diagnostic approach to suspected recurrent [[DVT]].  The recommended initial test is either proximal ultrasound (US) or highly sensitive D-dimer tetsing rather than venography, CT venography or MR imagining.  Initial D-dimer testing is recommended over proximal US in case there is no prior ultrasound for comparison.  Note the following definitions:
* Negative US:
** Normal US, or
** Increase in residual diameter of less than 2 mman, or
** Area of prior noncompressibility with a decreased or stable residual diameter
* Nondiagnostic US:
** Ultrasound that is technically limited, or
** Area of prior noncompressibility with an increment in residual venous diameter of < 4 mm yet ≥ 2 mm, or
** Area of prior noncompressibility in the absence of a previous  measurement of the residual diameter
* Positive US:
** New noncompressible segment, or
** Area of prior noncompressibility with an increment in residual venous diameter of ≥ 4 mm<ref name="pmid22315267">{{cite journal| author=Bates SM, Jaeschke R, Stevens SM, Goodacre S, Wells PS, Stevenson MD et al.| title=Diagnosis of DVT: Antithrombotic Therapy and Prevention of Thrombosis, 9th ed: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines. | journal=Chest | year= 2012 | volume= 141 | issue= 2 Suppl | pages= e351S-418S | pmid=22315267 | doi=10.1378/chest.11-2299 | pmc=PMC3278048 | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=22315267  }} </ref>
{{Family tree/start}}
{{familytree | | | | | | | | | | | | | | | | | | | | | A01 | | | | | | | | | | | | | A01= '''The patient has recurrent DVT'''}}
{{familytree | | | | | | | | | | | | | | | | | | | | | |!| | | | | | | | | | | | | | }}
{{familytree | | | | | | | | | | | | | | | | | | | | | B01 | | | | | | | | | | | | | B01= '''Proceed with one of the following:'''<br>❑ Proximal US<br>❑ Highly sensitive D-dimer<br>❑ Venography (less preferred)<br> ❑ CT venography (less preferred)<br>❑ MR imaging (less preferred)}}
{{familytree | | | | | | | | | | | | | | | |,|-|-|-|-|-|^|-|-|-|-|-|.| | | | | | | | }}
{{familytree | | | | | | | | | | | | | | | C01 | | | | | | | | | | C02 | | | | | | | C01= Proximal US| C02= Highly sensitive D-dimer}}
{{familytree | | | | | | | | | | | |,|-|-|-|+|-|-|-|.| | | | | |,|-|^|-|.| | | | | | }}
{{familytree | | | | | | | | | | | D01 | | D02 | | D03 | | | | D04 | | D05 | | | | | D01= Negative| D02= Non diagnostic| D03= Positive| D04= Negative| D05= Positive}}
{{familytree | | | | | | | | | | | |!| | | |!| | | |!| | | | | |!| | | |!| | | | | | }}
{{familytree | | | | | | | | | | | E01 | | E02 | | E03 | | | | E04 | | E05 | | | | | E01= '''Proceed with one of the following:'''<br>❑ Highly/moderately sensitive D-dimer <br>❑ Repeat proximal US within 1 week <br> ❑ Venography (less preferred)<br> ❑ No further testing (less preferred)| E02= [[Deep vein thrombosis diagnostic approach#Diagnostic Approach for Non Diagnostic Ultrasound|Click here for the diagnostic approach in case of non diagnostic US]]| E03= ❑ Treat <br> OR <br> ❑ Venography (less preferred)| E04= DVT is excluded| E05= Proximal US}}
{{familytree | | | | | | | | | | | |!| | | | | | | | | | | | | | | | | |!| | | | | | }}
{{familytree | | | |,|-|-|-|-|-|-|-|+|-|-|-|-|-|-|-|v|-|-|-|.| | | |,|-|^|-|v|-|-|-|.| | }}
{{familytree | | | F01 | | | | | | F02 | | | | | | F03 | | F04 | | F05 | | F06 | | F07 | F01= Highly/moderately sensitive D-dimer| F02= Repeat US| F03= Venography| F04= No further testing| F05= Negative| F06= Non diagnostic| F07= Positive}}
{{familytree | |,|-|^|-|.| | | |,|-|^|-|.| | | |,|-|^|-|.| | | | | |!| | | |!| | | |!| | }}
{{familytree | G01 | | G02 | | G03 | | G04 | | G05 | | G06 | | | | G07 | | G08 | | G09 | G01= Negative| G02= Positive| G03= Negative| G04= Positive| G05= Negative| G06= Positive| G07= Repeat proximal US within 1 week<br> OR <br>Venography (less preferred)<br> OR <br> No further testing (less preferred)| G08= [[Deep vein thrombosis diagnostic approach#Diagnostic Approach for Non Diagnostic Ultrasound|Click here for the diagnostic approach in case of non diagnostic US]]| G09=Treat <br> OR <br> Venography (less preferred)}}
{{familytree | |!| | | |!| | | |!| | | |!| | | |!| | | |!| | | | | |!| | | | | | | | | | }}
{{familytree | H01 | | H02 | | H03 | | H04 | | H05 | | H06 | | | | H07 | | | | | | | | | H01= DVT is excluded| H02= ❑ Repeat proximal US within 1 week<br> OR <br>❑ Venography (less preferred)<br> OR <br> No further testing (less preferred)| H03= DVT is excluded| H04= ❑ Treat <br> OR <br> ❑ Venography (less preferred)| H05= DVT is excluded| H06= ❑ Treat DVT| H07= If proximal US is repeated, what is the result?}}
{{familytree | | | | | |!| | | | | | | | | | | | | | | | | | | |,|-|^|-|.| | | | | | | | }}
{{familytree | | | | | I01 | | | | | | | | | | | | | | | | | | I02 | | I03 | | | | | | | I01=If proximal US is repeated, what is the result?| I02= Negative | I03=Positive}}
{{familytree | | | |,|-|^|-|.| | | | | | | | | | | | | | | | | |!| | | |!| | | | | | | | }}
{{familytree | | | J01 | | J02 | | | | | | | | | | | | | | | | J03 | | J04 | | | | | | | J01= Negative| J02= Positive| J03= DVT is excluded| J04= ❑ Treat <br> OR <br> ❑ Venography (less preferred)}}
{{familytree | | | |!| | | |!| | | | | | | | | | | | | | | | | | | | | | | | | | | | }}
{{familytree | | | K01 | | K02 | | | | | | | | | | | | | | | | | | | | | | | | | | | K01= DVT is excluded| K02= ❑ Treat <br> OR <br> ❑ Venography (less preferred)}}
{{Family tree/end}}
===Diagnostic Approach for Non Diagnostic Ultrasound===
{{Family tree/start}}
{{familytree | | | | | | | | | | | | | | | | | | | | | | | A01 | | | | | | | | | | | A01= The patient has a non diagnostic proximal US}}
{{familytree | | | | | | | | | | | | | | | | | | | | | | | |!| | | | | | | | | | | | }}
{{familytree | | | | | | | | | | | | | | | | | | | | | | | B01 | | | | | | | | | | | B01= Are prior US results available?}}
{{familytree | | | | | | | | | | | | | | |,|-|-|-|-|-|-|-|-|^|-|-|-|-|-|-|-|-|.| | | }}
{{familytree | | | | | | | | | | | | | | C01 | | | | | | | | | | | | | | | | C02 | | C01= Yes| C02= No}}
{{familytree | | | | | | | | | | | | | | |!| | | | | | | | | | | | | | | | | |!| | | | | | | | | }}
{{familytree | | | | | | | | | | | | | | D01 | | | | | | | | | | | | | | | | D02 | | | | | | | | D01= Proceed with ONE of the following:<br> ❑ Venography (most preferred) <br> ❑ Repeat proximal US within 1 week <br>Highly/moderately sensitive D-dimer<br>❑ Treat DVT (less preferred)| D02= Proceed with ONE of the following:<br>❑ Venography (most preferred) <br> ❑ Highly sensitive D-dimer <br> ❑ Repeat proximal US (less preferred)}}
{{familytree | | | |,|-|-|-|-|-|-|-|v|-|-|^|-|-|-|-|v|-|-|-|.| | | |,|-|-|-|-|^|-|-|v|-|-|-|.| | }}
{{familytree | | | E01 | | | | | | E02 | | | | | | E03 | | E04 | | E05 | | | | | | E06 | | E07 | E01= Venography (most preferred)| E02= Repeat proximal US within 1 week| E03= Highly/moderately sensitive D-dimer| E04= Treat DVT (less preferred)| E05= Venography (most preferred)| E06= Highly sensitive D-dimer| E07= Repeat proximal US within 1 week (less preferred)}}
{{familytree | |,|-|^|-|.| | | |,|-|^|-|.| | | |,|-|^|-|.| | | |,|-|^|-|.| | | |,|-|^|-|.| | | }}
{{familytree | F01 | | F02 | | F03 | | F04 | | F05 | | F06 | | F07 | | F08 | | F09 | | F10 | | F01= Negative| F02= Positive| F03= Negative| F04= Positive| F05= Negative| F06= Positive| F07= Negative| F08= Positive| F09= Negative| F10= Positive}}
{{familytree | |!| | | |!| | | |!| | | |!| | | |!| | | |!| | | |!| | | |!| | | |!| | | |!| | | }}
{{familytree | G01 | | G02 | | G03 | | G04 | | G05 | | G06 | | G07 | | G08 | | G09 | | G10 | | G01= DVT is excluded| G02= Treat DVT| G03= DVT is excluded| G04= Treat DVT <br> OR <br> Venography (less preferred)| G05= DVT is excluded| G06= Repeat proximal US within 1 week| G07= DVT is excluded| G08= Treat DVT| G09= DVT is excluded| G10= Venography <br> OR <br> Treat DVT (less preferred)}}
{{familytree | | | | | | | | | | | | | | | | | | | |,|-|^|-|.| | | | | | | | | | | | | | | | | }}
{{familytree | | | | | | | | | | | | | | | | | | | H01 | | H02 | | | | | | | | | | | | | | | | H01= Negative| H02= Positive}}
{{familytree | | | | | | | | | | | | | | | | | | | |!| | | |!| | | | | | | | | | | | | | | | | }}
{{familytree | | | | | | | | | | | | | | | | | | | I01 | | I02 | | | | | | | | | | | | | | | | I01= DVT is excluded| I02= Venography (less preferred)}}
{{Family tree/end}}
===Diagnostic Approach for Venography===
{{Family tree/start}}
{{familytree | | | A01 | A01= What is the result of the venography?}}
{{familytree | |,|-|^|-|.| | }}
{{familytree | B01 | | B02 | | B01= Negative| B02= Positive}}
{{familytree | |!| | | |!| | | }}
{{familytree | C01 | | C02 | | C01= DVT is excluded| C02= Treat DVT}}
{{Family tree/end}}
==Considerations==
* Whole-leg ultrasound may be preferred in those who have severe symptoms of calf DVT or are unable to come for serial testing.
* CT scan venography, MR venography, or MR direct thrombus imaging may be used in those patients in whom ultrasound is not practical (leg cast, excessive edema) or non-diagnostic.
* In a patient population with a high prevalence of [[VTE]], a negative [[D-dimer]] assay may be insufficient to rule out DVT as a single test, furthermore, not all D-dimer assays are validated for this. However, a D-dimer level <500 ng/mL by ELISA along with a low clinical probability ([[Wells score calculator for DVT|Wells score]])<ref name="pmid10744147">{{cite journal |author=Wells PS, Anderson DR, Rodger M, Ginsberg JS, Kearon C, Gent M, Turpie AG, Bormanis J, Weitz J, Chamberlain M, Bowie D, Barnes D, Hirsh J |title=Derivation of a simple clinical model to categorize patients probability of pulmonary embolism: increasing the models utility with the SimpliRED D-dimer |journal=Thromb. Haemost. |volume=83 |issue=3 |pages=416–20 |year=2000 |month=March |pmid=10744147 |doi=|url=http://www.schattauer.de/index.php?id=1268&L=1&pii=th00030416&no_cache=1 |accessdate=2012-05-01}}</ref> or other negative non-invasive tests may be useful in excluding DVT, without doing ultrasound. Independent studies validate the Wells 10 point rule.<ref name="pmid23318311">{{cite journal| author=Linkins LA, Bates SM, Lang E, Kahn SR, Douketis JD, Julian J et al.| title=Selective d-Dimer Testing for Diagnosis of a First Suspected Episode of Deep Venous Thrombosis: A Randomized Trial. | journal=Ann Intern Med | year= 2013 | volume= 158 | issue= 2 | pages= 93-100 | pmid=23318311 | doi=10.7326/0003-4819-158-2-201301150-00003 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=23318311  }} </ref><ref name="pmid21242558">{{cite journal| author=van der Velde EF, Toll DB, Ten Cate-Hoek AJ, Oudega R, Stoffers HE, Bossuyt PM et al.| title=Comparing the diagnostic performance of 2 clinical decision rules to rule out deep vein thrombosis in primary care patients. | journal=Ann Fam Med | year= 2011 | volume= 9 | issue= 1 | pages= 31-6 | pmid=21242558 | doi=10.1370/afm.1198 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=21242558  }} </ref>
* On identification of an isolated [[DVT]] in the distal calf veins, serial testing is recommended to rule out proximal extension.


==References==
==References==
{{reflist|2}}
{{reflist|2}}


[[Category:Disease]]
[[Category:Cardiology]]
[[Category:Hematology]]
[[Category:Hematology]]
[[Category:Pulmonology]]
[[Category:Angiology]]
[[Category:Cardiology]]
[[Category:Emergency medicine]]
[[Category:Emergency medicine]]
[[Category:Mature chapter]]
[[Category:Vascular surgery]]
[[Category:Up-To-Date]]
[[Category:Cardiovascular diseases]]
[[Category:Needs overview]]


{{WH}}
{{WH}}
{{WS}}
{{WS}}

Latest revision as of 21:24, 16 July 2014



Resident
Survival
Guide

Editor(s)-In-Chief: The APEX Trial Investigators, C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-In-Chief: Cafer Zorkun, M.D., Ph.D. [2] ; Kashish Goel, M.D.; Rim Halaby, M.D. [3]; Assistant Editor(s)-In-Chief: Justine Cadet

Deep Vein Thrombosis Microchapters

Home

Patient Information

Overview

Classification

Pathophysiology

Causes

Differentiating Deep vein thrombosis from other Diseases

Epidemiology and Demographics

Risk Factors

Triggers

Screening

Natural History, Complications and Prognosis

Diagnosis

Diagnostic Approach

Assessment of Clinical Probability and Risk Scores

Assessment of Probability of Subsequent VTE and Risk Scores

History and Symptoms

Physical Examination

Laboratory Findings

Ultrasound

Venography

CT

MRI

Other Imaging Findings

Treatment

Treatment Approach

Medical Therapy

IVC Filter

Invasive Therapy

Surgery

Prevention

Cost-Effectiveness of Therapy

Future or Investigational Therapies

Special Scenario

Upper extremity DVT

Recurrence

Pregnancy

Trials

Landmark Trials

Case Studies

Case #1

Deep vein thrombosis diagnostic approach On the Web

Most recent articles

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FDA on Deep vein thrombosis diagnostic approach

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Directions to Hospitals Treating Deep vein thrombosis

Risk calculators and risk factors for Deep vein thrombosis diagnostic approach

Overview

The assessment of deep vein thrombosis (DVT) begins with the estimation of the pretest probability of DVT according to scoring systems such as the Wells score. The initial diagnostic test for a suspected DVT is either D-dimer, proximal ultrasound, or whole leg ultrasound depending on the pretest probability of the disease. Further tests might be required depending on the findings of the initial test and the pretest probability of DVT.

Diagnostic Approach

This page contains algorithms that depicts the diagnostic approach to DVT in the following situations:

Complete Diagnostic Approach for First Episode of Suspected Lower Extremity DVT

Low Pretest Probability

Shown below are the different diagnostic approaches to the diagnosis of DVT depending in case of low pre-test probability of the disease.[1]

 
 
 
 
 
 
 
 
 
 
 
 
 
 
The patient has a low pre-test probability for DVT
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Proceed with one of the following:
❑ Highly or moderately sensitive D-dimer test (1st line)
❑ Proximal US (2nd line)
❑ Whole leg US (less preferred)
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
D-dimer (1st line)
 
 
 
 
 
 
 
 
 
 
Proximal US (2nd line)
 
 
 
 
 
 
Whole leg US (less preferred)
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Negative
 
 
 
 
 
Positive
 
 
 
 
Negative
 
Positive
 
Negative
 
 
 
Positive
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Proceed with either:
❑ Proximal US (1st line)
OR
❑ Whole leg US (less preferred)
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
What is the location of the DVT?
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
DVT is excluded
 
❑ Proximal US (1st line)
 
 
 
 
❑ Whole leg US (less preferred)
 
DVT is excluded
 
❑ Treat DVT
 
DVT is excluded
 
Proximal DVT
 
Isolated distal DVT
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Negative
 
Positive
 
Negative
 
Positive
 
 
 
 
 
 
 
 
 
 
Treat DVT
 
Perform serial US (1st line)
OR
Treat DVT
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
What is the location of the DVT?
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
DVT is excluded
 
Treat DVT
 
DVT is excluded
 
Proximal DVT
 
Isolated distal DVT
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
❑ Treat DVT
 
❑ Perform serial US (1st line)
OR
❑ Treat DVT
 
 
 
 
 
 
 
 
 
 
 

Moderate Pretest Probability

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
The patient has a moderate pre-test probability of DVT
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Proceed with one of the following:

❑ D-dimer test
❑ Proximal US

❑ Whole leg US
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Highly sensitive D-dimer test
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Proximal US
 
 
 
 
 
Whole leg US
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Negative
 
 
 
Positive
 
 
 
 
 
 
 
 
 
 
 
 
Negative
 
 
 
 
Positive
 
Negative
 
Positive
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Proceed with either:
❑ Proximal US
OR
❑ Whole leg US
 
 
 
 
 
 
 
 
 
 
 
 
❑ Repeat proximal US
OR
❑ Moderately/highly sensitive D-dimer
 
 
 
 
❑ Treat DVT
 
DVT is excluded
 
Where is the location of the DVT?
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
DVT is excluded
 
Proximal US
 
 
 
Whole leg US
 
 
 
 
 
❑ Repeat proximal US within 1 week
 
 
 
Moderately/highly sensitive D-dimer
 
 
 
 
 
 
 
Proximal DVT
 
Isolated distal DVT
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Negative
 
Positive
 
Negative
 
Positive
 
Negative
 
Positive
 
Negative
 
Positive
 
 
 
Treat DVT
 
Perform serial US (1st line)
OR
Treat DVT
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
❑ Repeat proximal US within 1 week
 
Treat DVT
 
DVT is excluded
 
What is the location of the DVT?
 
DVT is excluded
 
Treat DVT
 
DVT is excluded
 
❑ Repeat proximal US within 1 week
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Negative
 
Positive
 
 
 
Proximal DVT
 
Isolated distal DVT
 
 
 
 
 
 
 
 
 
Negative
 
Positive
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
DVT is excluded
 
❑ Treat DVT
 
 
 
❑ Treat DVT
 
❑ Perform serial US (1st line)
OR
❑ Treat DVT
 
 
 
 
 
 
 
 
 
❑ Treat DVT
 
❑ Perform serial US (1st line)
OR
❑ Treat DVT

High Pretest Probability

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
The patient has a high pre-test probability for DVT
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Proceed with either:
❑ Proximal US
OR
❑ Whole leg US
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Proximal US
 
 
 
 
 
Whole leg US
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Negative
 
Positive
 
Negative
 
Positive
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Proceed with ONE of the following:
❑ Repeat proximal US
❑ Highly sensitive D-dimer
❑ Whole leg US
❑ Venography (less preferred)
 
❑ Treat DVT
 
DVT is excluded
 
What is the location of the DVT?
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Proximal
 
Distal
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
❑ Treat DVT
 
❑ Perform serial US (1st line)
OR
❑ Treat DVT
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Repeat proximal US within 1 week
 
 
 
 
 
Highly sensitive D-dimer
 
 
 
 
 
Whole leg US
 
 
 
 
 
 
Venography
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Negative
 
Positive
 
Negative
 
Positive
 
Negative
 
 
Positive
 
Negative
 
Positive
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
DVT is excluded
 
Treat DVT
 
DVT is excluded
 
 
 
 
 
 
DVT is excluded
 
 
Where is the location of the DVT?
 
DVT is excluded
 
Treat DVT
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Repeat proximal US within 1 week
 
 
 
 
 
Whole leg US
 
 
 
 
 
Venography (less preferred)
 
 
 
Proximal
 
Distal
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Negative
 
Positive
 
Negative
 
Positive
 
Negative
 
Positive
 
❑ Treat DVT
 
❑ Perform serial US (1st line)
OR
❑ Treat DVT
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
DVT is excluded
 
❑ Treat DVT
 
DVT is excluded
 
Where is the location of the DVT?
 
DVT is excluded
 
❑ Treat DVT
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Proximal
 
Distal
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
❑ Treat DVT
 
❑ Perform serial US (1st line)
OR
❑ Treat DVT
 
 

Risk Stratification Not Performed

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Risk stratification was not performed
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Proceed with ONE of the following:
❑ Proximal US
❑ Whole leg US
❑ Highly/moderately sensitive D-dimer (less preferred)
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Proximal US
 
 
 
 
 
 
 
 
Whole leg US
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Negative
 
 
 
Positive
 
 
 
Negative
 
Positive
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
❑ Treat DVT
 
 
 
DVT is excluded
 
What is the location of the DVT?
 
 
 
 
 
 
 
 
 
 
 
 
 
Proceed with ONE of the following:
❑ Highly/moderately sensitive D-dimer (most preferred)
❑ Repeat proximal US within 1 week
❑ Whole leg US
Venography (less preferred)
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Highly/moderately sensitive D-dimer (most preferred)
 
 
 
 
 
Repeat proximal US within 1 week
 
Whole leg US
 
Venography (less preferred)
 
 
 
Proximal
 
Distal
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Negative
 
Positive
 
Negative
 
Positive
 
Negative
 
Positive
 
❑ Treat DVT
 
❑ Serial US (1st line)
OR
❑ Treat DVT
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
DVT is excluded
 
❑ Repeat proximal US within 1 week
OR
Venography
 
DVT is excluded
 
❑ Treat DVT
 
DVT is excluded
 
❑ Treat DVT
 
 

Complete Diagnostic Approach for Suspected Recurrent Lower Extremity DVT

Shown below is the diagnostic approach to suspected recurrent DVT. The recommended initial test is either proximal ultrasound (US) or highly sensitive D-dimer tetsing rather than venography, CT venography or MR imagining. Initial D-dimer testing is recommended over proximal US in case there is no prior ultrasound for comparison. Note the following definitions:

  • Negative US:
    • Normal US, or
    • Increase in residual diameter of less than 2 mman, or
    • Area of prior noncompressibility with a decreased or stable residual diameter
  • Nondiagnostic US:
    • Ultrasound that is technically limited, or
    • Area of prior noncompressibility with an increment in residual venous diameter of < 4 mm yet ≥ 2 mm, or
    • Area of prior noncompressibility in the absence of a previous measurement of the residual diameter
  • Positive US:
    • New noncompressible segment, or
    • Area of prior noncompressibility with an increment in residual venous diameter of ≥ 4 mm[1]
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
The patient has recurrent DVT
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Proceed with one of the following:
❑ Proximal US
❑ Highly sensitive D-dimer
❑ Venography (less preferred)
❑ CT venography (less preferred)
❑ MR imaging (less preferred)
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Proximal US
 
 
 
 
 
 
 
 
 
Highly sensitive D-dimer
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Negative
 
Non diagnostic
 
Positive
 
 
 
Negative
 
Positive
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Proceed with one of the following:
❑ Highly/moderately sensitive D-dimer
❑ Repeat proximal US within 1 week
❑ Venography (less preferred)
❑ No further testing (less preferred)
 
Click here for the diagnostic approach in case of non diagnostic US
 
❑ Treat
OR
❑ Venography (less preferred)
 
 
 
DVT is excluded
 
Proximal US
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Highly/moderately sensitive D-dimer
 
 
 
 
 
Repeat US
 
 
 
 
 
Venography
 
No further testing
 
Negative
 
Non diagnostic
 
Positive
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Negative
 
Positive
 
Negative
 
Positive
 
Negative
 
Positive
 
 
 
Repeat proximal US within 1 week
OR
Venography (less preferred)
OR
No further testing (less preferred)
 
Click here for the diagnostic approach in case of non diagnostic US
 
Treat
OR
Venography (less preferred)
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
DVT is excluded
 
❑ Repeat proximal US within 1 week
OR
❑ Venography (less preferred)
OR
No further testing (less preferred)
 
DVT is excluded
 
❑ Treat
OR
❑ Venography (less preferred)
 
DVT is excluded
 
❑ Treat DVT
 
 
 
If proximal US is repeated, what is the result?
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
If proximal US is repeated, what is the result?
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Negative
 
Positive
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Negative
 
Positive
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
DVT is excluded
 
❑ Treat
OR
❑ Venography (less preferred)
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
DVT is excluded
 
❑ Treat
OR
❑ Venography (less preferred)
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 

Diagnostic Approach for Non Diagnostic Ultrasound

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
The patient has a non diagnostic proximal US
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Are prior US results available?
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Yes
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
No
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Proceed with ONE of the following:
❑ Venography (most preferred)
❑ Repeat proximal US within 1 week
Highly/moderately sensitive D-dimer
❑ Treat DVT (less preferred)
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Proceed with ONE of the following:
❑ Venography (most preferred)
❑ Highly sensitive D-dimer
❑ Repeat proximal US (less preferred)
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Venography (most preferred)
 
 
 
 
 
Repeat proximal US within 1 week
 
 
 
 
 
Highly/moderately sensitive D-dimer
 
Treat DVT (less preferred)
 
Venography (most preferred)
 
 
 
 
 
Highly sensitive D-dimer
 
Repeat proximal US within 1 week (less preferred)
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Negative
 
Positive
 
Negative
 
Positive
 
Negative
 
Positive
 
Negative
 
Positive
 
Negative
 
Positive
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
DVT is excluded
 
Treat DVT
 
DVT is excluded
 
Treat DVT
OR
Venography (less preferred)
 
DVT is excluded
 
Repeat proximal US within 1 week
 
DVT is excluded
 
Treat DVT
 
DVT is excluded
 
Venography
OR
Treat DVT (less preferred)
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Negative
 
Positive
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
DVT is excluded
 
Venography (less preferred)
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 

Diagnostic Approach for Venography

 
 
What is the result of the venography?
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Negative
 
Positive
 
 
 
 
 
 
 
 
 
 
 
 
DVT is excluded
 
Treat DVT
 

Considerations

  • Whole-leg ultrasound may be preferred in those who have severe symptoms of calf DVT or are unable to come for serial testing.
  • CT scan venography, MR venography, or MR direct thrombus imaging may be used in those patients in whom ultrasound is not practical (leg cast, excessive edema) or non-diagnostic.
  • In a patient population with a high prevalence of VTE, a negative D-dimer assay may be insufficient to rule out DVT as a single test, furthermore, not all D-dimer assays are validated for this. However, a D-dimer level <500 ng/mL by ELISA along with a low clinical probability (Wells score)[2] or other negative non-invasive tests may be useful in excluding DVT, without doing ultrasound. Independent studies validate the Wells 10 point rule.[3][4]
  • On identification of an isolated DVT in the distal calf veins, serial testing is recommended to rule out proximal extension.

References

  1. 1.0 1.1 Bates SM, Jaeschke R, Stevens SM, Goodacre S, Wells PS, Stevenson MD; et al. (2012). "Diagnosis of DVT: Antithrombotic Therapy and Prevention of Thrombosis, 9th ed: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines". Chest. 141 (2 Suppl): e351S–418S. doi:10.1378/chest.11-2299. PMC 3278048. PMID 22315267.
  2. Wells PS, Anderson DR, Rodger M, Ginsberg JS, Kearon C, Gent M, Turpie AG, Bormanis J, Weitz J, Chamberlain M, Bowie D, Barnes D, Hirsh J (2000). "Derivation of a simple clinical model to categorize patients probability of pulmonary embolism: increasing the models utility with the SimpliRED D-dimer". Thromb. Haemost. 83 (3): 416–20. PMID 10744147. Retrieved 2012-05-01. Unknown parameter |month= ignored (help)
  3. Linkins LA, Bates SM, Lang E, Kahn SR, Douketis JD, Julian J; et al. (2013). "Selective d-Dimer Testing for Diagnosis of a First Suspected Episode of Deep Venous Thrombosis: A Randomized Trial". Ann Intern Med. 158 (2): 93–100. doi:10.7326/0003-4819-158-2-201301150-00003. PMID 23318311.
  4. van der Velde EF, Toll DB, Ten Cate-Hoek AJ, Oudega R, Stoffers HE, Bossuyt PM; et al. (2011). "Comparing the diagnostic performance of 2 clinical decision rules to rule out deep vein thrombosis in primary care patients". Ann Fam Med. 9 (1): 31–6. doi:10.1370/afm.1198. PMID 21242558.

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