Deep vein thrombosis diagnostic approach: Difference between revisions

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Latest revision as of 21:24, 16 July 2014

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

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:

First episode of suspected lower extremity DVT
Suspected recurrent lower 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.^[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

❑ 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

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?

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

↑ ^1.0 ^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.
↑ 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)
↑ 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.
↑ 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.

Template:WH Template:WS

[pmid22315267-1] 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.

[pmid10744147-2] 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)

[pmid23318311-3] 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.

[pmid21242558-4] 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.

[1]

[2]

[3]

[4]

@@ Line 1: / Line 1: @@
 __NOTOC__
-'''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.]]; '''Assistant Editor(s)-In-Chief:''' [[User:Justine Cadet|Justine Cadet]]
+{| class="infobox" style="float:right;"
+|-
+| [[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}}
 ==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==
-A number of invasive (venography) and non-invasive tests (impedance plethysmography, compression ultrasonography, D-dimer testing) are available for diagnosis. Compression ultrasonography is the noninvasive diagnosis of choice for patients with a first episode of a suspected DVT.
+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]]
-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> However, the d-dimer assays vary; for rapid quantitative immunoturbidimetric assays, a cutoff of 1.0 <g/mL is used.<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>
+** [[Deep vein thrombosis diagnostic approach#Low Pretest Probability|Low pretest probability]]
+** [[Deep vein thrombosis diagnostic approach#Moderate Pretest Probability|Moderate pretest probability]]
-Compression ultrasonography has a positive predictive value of 94 percent (95% CI: 87-98 percent). If the clinical suspicion of DVT is high even after a negative CUS, a repeat study should be done within a week. Complete lower extremity ultrasonography may eliminate the need for repeat testing, but a positive CUS demands user expertise, and requires specialized instrumentation. The algorithm below presents a possible diagnostic approach.
+** [[Deep vein thrombosis diagnostic approach#High Pretest Probability|High pretest probability]]
+** [[Deep vein thrombosis diagnostic approach#Risk Stratification Not Performed|Risk stratification not performed]]
-[[Image: DVT_diagnosis.jpg]]
+* [[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]]
-CUS stands for Compression Ultrasonography; [[D-dimer]] is the highly sensitive assay.
-Clinical judgement and local availability should be considered in patients with a moderate probability of [[DVT]]. CUS may be preferred in patients with comorbid conditions associated with elevated D-dimer levels.
-Adapted from ACCP guidelines<ref name="pmid22315267">{{cite journal |author=Bates SM, Jaeschke R, Stevens SM, ''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 |volume=141 |issue=2 Suppl |pages=e351S–418S |year=2012 |month=February |pmid=22315267 |doi=10.1378/chest.11-2299 |url=}}</ref>.
-===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.
-* The diagnostic approach may be modified based on clinical condition of the patient and [[Deep vein thrombosis specific situations|specific situations]].
 ==Complete Diagnostic Approach for First Episode of Suspected Lower Extremity DVT==
@@ Line 29: / Line 26: @@
 {{Family tree/start}}
-{{familytree | | | | | | | | | | | | | | | A01 | | | | | | | | | | | | | | | | | | | A01= The patient has a low pre-test probability for DVT}}
+{{familytree | | | | | | | | | | | | | | | A01 | | | | | | | | | | | | | | | | | | | A01= '''The patient has a low pre-test probability for DVT'''}}
 {{familytree | | | | | | | | | | | | | | | |!| | | | | | | | | | | | | | | | | | | | }}
-{{familytree | | | | | | | | | | | | | | | B01 | | | | | | | | | | | | | | | | | | | B01= Proceed with one of the following:<br>
+{{familytree | | | | | | | | | | | | | | | B01 | | | | | | | | | | | | | | | | | | | B01= '''Proceed with one of the following:'''<br>
-Highly or moderately sensitive D-dimer test (1st line)<br> Proximal US (2nd line)<br> Whole leg US (less preferred)}}
+❑ Highly or moderately sensitive [[D-dimer test]] (1st line)<br> ❑ Proximal US (2nd line)<br> ❑ Whole leg US (less preferred)}}
 {{familytree | | | | | |,|-|-|-|-|-|-|-|-|-|^|-|-|v|-|-|-|-|-|-|-|-|.| | | | | | | | }}
-{{familytree | | | | | C01 | | | | | | | | | | | C02 | | | | | | | C03 | | | | | | | C01= D-dimer (1st line)| C02= Proximal US (2nd line)| C03= Whole leg US (less preferred)}}
+{{familytree | | | | | C01 | | | | | | | | | | | C02 | | | | | | | C03 | | | | | | | C01= [[D-dimer]] (1st line)| C02= Proximal US (2nd line)| C03= Whole leg US (less preferred)}}
 {{familytree | |,|-|-|-|^|-|-|-|.| | | | | | |,|-|^|-|.| | | |,|-|-|^|-|-|.| | | | | }}
 {{familytree | D01 | | | | | | D02 | | | | | D03 | | D04 | | D05 | | | | D06 | | | | D01= Negative| D02= Positive| D03= Negative| D04= Positive| D05= Negative| D06= Positive}}
 {{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 | |!| | | | | | | 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 | |!| | | |,|-|-|-|^|-|-|.| | | |!| | | |!| | | |!| | | |,|-|^|-|.| | | }}
-{{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 | 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 | | | |,|-|^|-|.| | | |,|^|-|-|.| | | | | | | | | | | | |!| | | |!|}}
 {{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}}
@@ Line 48: / Line 45: @@
 {{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}}
+{{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 | | | | | | | | | | | | | | | | A01 | | | | | | | | | | | | | | | | | A01= '''The patient has a moderate pre-test probability of DVT'''}}
 {{familytree | | | | | | | | | | | | | | | | |!| | | | | | | | | | | | | | | | | | }}
-{{familytree | | | | | | | | | | | | | | | | B01 | | | | | | | | | | | | | | | | | B01=Proceed with one of the following:<br>
+{{familytree | | | | | | | | | | | | | | | | B01 | | | | | | | | | | | | | | | | | B01='''Proceed with one of the following:'''<br>
-D-dimer test<br>
+❑ D-dimer test<br>
-Proximal US<br>
+❑ Proximal US<br>
-Whole leg US}}
+❑ Whole leg US}}
 {{familytree | | | | |,|-|-|-|-|-|-|-|-|-|-|-|^|-|-|-|-|-|-|-|-|-|v|-|-|-|-|-|-|-|.| | }}
-{{familytree | | | | C01 | | | | | | | | | | | | | | | | | | | | C02 | | | | | | C03 | | | | |C01= Highly sensitive D-dimer test| C02= Proximal US| C03= Whole leg US}}
+{{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 | |!| | | | | 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 | 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 | 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 | 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}}
 ===High Pretest Probability===
 {{Family tree/start}}
-{{familytree | | | | | | | | | | | | | | | | A01 | | | | | | | | A01= The patient has a high pre-test probability for DVT}}
+{{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 | | | | | | | | | | | | | | | | 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}}
@@ Line 87: / Line 84: @@
 {{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 | | | | | | | | | | 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 | | | | | | | | | | |!| | | | | | | | | 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 | | | | | 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}}
@@ Line 101: / Line 98: @@
 {{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 | | | 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 | 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 | 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}}
+{{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 | | | | | | | | | | | | | | | | | | | | 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 | | | | | | | | | | | | | | | | | | | | 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}}
@@ Line 122: / Line 119: @@
 {{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 | | | | | | | | | | | |!| | | | | 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 | | | | | | | | | | | 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 | | | 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 | 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}}
+{{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}}
@@ Line 147: / Line 144: @@
 {{Family tree/start}}
-{{familytree | | | | | | | | | | | | | | | | | | | | | A01 | | | | | | | | | | | | | A01= The patient has recurrent DVT}}
+{{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 | | | | | | | | | | | | | | | | | | | | | 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}}
@@ Line 155: / Line 152: @@
 {{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= [[Pulmonary embolism resident survival guide#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 | | | | | | | | | | | 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= [[Pulmonary embolism resident survival guide#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 | 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 | 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 | | | 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)}}
+{{familytree | | | K01 | | K02 | | | | | | | | | | | | | | | | | | | | | | | | | | | K01= DVT is excluded| K02= ❑ Treat <br> OR <br> ❑ Venography (less preferred)}}
 {{Family tree/end}}
@@ Line 179: / Line 176: @@
 {{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 | | | | | | | | | | | | | | 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)}}
@@ Line 200: / Line 197: @@
 {{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==
 {{reflist|2}}

Deep vein thrombosis diagnostic approach: Difference between revisions

Latest revision as of 21:24, 16 July 2014

Overview

Diagnostic Approach

Complete Diagnostic Approach for First Episode of Suspected Lower Extremity DVT

Low Pretest Probability

Moderate Pretest Probability

High Pretest Probability

Risk Stratification Not Performed

Complete Diagnostic Approach for Suspected Recurrent Lower Extremity DVT

Diagnostic Approach for Non Diagnostic Ultrasound

Diagnostic Approach for Venography

Considerations

References

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