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{{Deep vein thrombosis}} | {{Deep vein thrombosis}} | ||
==Overview== | ==Overview== | ||
When recurrent deep vein thrombosis (DVT) is suspected, the initial test should be a [[Deep vein thrombosis ultrasound|compression ultrasound]] if a previous ultrasound is available for comparison. A highly-sensitive [[D-dimer]] is also a possible initial test. If the [[Deep vein thrombosis ultrasound|compression ultrasound]] results are abnormal but non-diagnostic (increase in residual venous diameter of < 4 but ≥ 2 mm), further testing with [[Deep vein thrombosis venography|venography]] or CT [[venography]] may be indicated. Patients suspected to have a recurrent episode of [[DVT]] may benefit from [[thrombophilia]] evaluation.<ref name="pmid22315276">{{cite journal| author=Bates SM, Greer IA, Middeldorp S, Veenstra DL, Prabulos AM, Vandvik PO et al.| title=VTE, thrombophilia, antithrombotic therapy, and pregnancy: 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= e691S-736S | pmid=22315276 | doi=10.1378/chest.11-2300 | pmc=PMC3278054 | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=22315276 }} </ref> | |||
==2012 VTE, Thrombophilia, Antithrombotic Therapy, and Pregnancy: Antithrombotic Therapy and Prevention of Thrombosis, 9th ed: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines (DO NOT EDIT)<ref name="pmid22315276">{{cite journal| author=Bates SM, Greer IA, Middeldorp S, Veenstra DL, Prabulos AM, Vandvik PO et al.| title=VTE, thrombophilia, antithrombotic therapy, and pregnancy: 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= e691S-736S | pmid=22315276 | doi=10.1378/chest.11-2300 | pmc=PMC3278054 | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=22315276 }} </ref>== | ==2012 VTE, Thrombophilia, Antithrombotic Therapy, and Pregnancy: Antithrombotic Therapy and Prevention of Thrombosis, 9th ed: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines (DO NOT EDIT)<ref name="pmid22315276">{{cite journal| author=Bates SM, Greer IA, Middeldorp S, Veenstra DL, Prabulos AM, Vandvik PO et al.| title=VTE, thrombophilia, antithrombotic therapy, and pregnancy: 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= e691S-736S | pmid=22315276 | doi=10.1378/chest.11-2300 | pmc=PMC3278054 | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=22315276 }} </ref>== | ||
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| colspan="1" style="text-align:center; background:LightGreen"|[[ACC AHA guidelines classification scheme#Classification of Recommendations|Class I]] | | colspan="1" style="text-align:center; background:LightGreen"|[[ACC AHA guidelines classification scheme#Classification of Recommendations|Class I]] | ||
|- | |- | ||
| bgcolor="LightGreen"|<nowiki>"</nowiki>'''1.''' In patients suspected of having recurrent lower extremity DVT, we recommend initial evaluation with proximal CUS or a highly sensitive D-dimer over venography, CT venography, or MRI | | bgcolor="LightGreen"|<nowiki>"</nowiki>'''1.''' In patients suspected of having recurrent lower extremity DVT, we recommend initial evaluation with proximal CUS or a highly sensitive [[D-dimer]] over [[venography]], [[CT venography]], or [[MRI]]. ''([[American College of Chest Physicians#Level of Evidence|Level of Evidence: B]])'' <nowiki>"</nowiki> | ||
|- | |- | ||
| bgcolor="LightGreen"|<nowiki>"</nowiki>'''2.''' If the highly sensitive D-dimer is positive, we recommend proximal CUS over venography, CT venography, or MRI. ''([[American College of Chest Physicians#Level of Evidence|Level of Evidence: B]])'' <nowiki>"</nowiki> | | bgcolor="LightGreen"|<nowiki>"</nowiki>'''2.''' If the highly sensitive [[D-dimer]] is positive, we recommend proximal CUS over [[venography]], [[CT venography]], or [[MRI]]. ''([[American College of Chest Physicians#Level of Evidence|Level of Evidence: B]])'' <nowiki>"</nowiki> | ||
|- | |- | ||
| bgcolor="LightGreen"|<nowiki>"</nowiki>'''3.''' We recommend that patients with suspected recurrent lower extremity DVT and a negative highly sensitive D-dimer or negative proximal CUS and negative moderately or highly sensitive D-dimer or negative serial proximal CUS undergo no further testing for suspected recurrent DVT rather than venography. ''([[American College of Chest Physicians#Level of Evidence|Level of Evidence: B]])''<nowiki>"</nowiki> | | bgcolor="LightGreen"|<nowiki>"</nowiki>'''3.''' We recommend that patients with suspected recurrent lower extremity DVT and a negative highly sensitive [[D-dimer]] or negative proximal CUS and negative moderately or highly sensitive D-dimer or negative serial proximal CUS undergo no further testing for suspected recurrent DVT rather than [[venography]]. ''([[American College of Chest Physicians#Level of Evidence|Level of Evidence: B]])''<nowiki>"</nowiki> | ||
|- | |- | ||
| bgcolor="LightGreen"|<nowiki>"</nowiki>'''4.''' If CUS of the proximal veins is positive (new noncompressible segment in the common femoral or popliteal vein), we recommend treating for DVT and performing no further testing over performing confirmatory venography. ''([[American College of Chest Physicians#Level of Evidence|Level of Evidence: B]])''<nowiki>"</nowiki> | | bgcolor="LightGreen"|<nowiki>"</nowiki>'''4.''' If [[CUS]] of the proximal veins is positive (new noncompressible segment in the common femoral or popliteal vein), we recommend treating for DVT and performing no further testing over performing confirmatory venography. ''([[American College of Chest Physicians#Level of Evidence|Level of Evidence: B]])''<nowiki>"</nowiki> | ||
|- | |- | ||
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| colspan="1" style="text-align:center; background:LemonChiffon"| [[ACC AHA guidelines classification scheme#Classification of Recommendations|Class II]] | | colspan="1" style="text-align:center; background:LemonChiffon"| [[ACC AHA guidelines classification scheme#Classification of Recommendations|Class II]] | ||
|- | |- | ||
|bgcolor="LemonChiffon"|<nowiki>"</nowiki>'''1.''' In patients with suspected recurrent lower extremity DVT in whom initial proximal CUS is negative (normal or residual diameter increase of < 2 mm), we suggest at least one further proximal CUS (day 7 ± 1) or testing with a moderately or highly sensitive D-dimer (followed by repeat CUS [day 7 ± 1] if positive) rather than no further testing or venography. ''([[American College of Chest Physicians#Level of Evidence|Level of Evidence: B]])''<nowiki>"</nowiki> | |bgcolor="LemonChiffon"|<nowiki>"</nowiki>'''1.''' In patients with suspected recurrent lower extremity DVT in whom initial proximal [[CUS]] is negative (normal or residual diameter increase of < 2 mm), we suggest at least one further proximal CUS (day 7 ± 1) or testing with a moderately or highly sensitive D-dimer (followed by repeat CUS [day 7 ± 1] if positive) rather than no further testing or [[venography]]. ''([[American College of Chest Physicians#Level of Evidence|Level of Evidence: B]])''<nowiki>"</nowiki> | ||
|- | |- | ||
|bgcolor="LemonChiffon"|<nowiki>"</nowiki>'''2.''' If CUS of the proximal veins is positive (≥ 4-mm increase in venous diameter during compression compared with that in the same venous segment on a previous result), we recommend treating for DVT and performing no further testing over performing confirmatory venography. ''([[American College of Chest Physicians#Level of Evidence|Level of Evidence: B]])''<nowiki>"</nowiki> | |bgcolor="LemonChiffon"|<nowiki>"</nowiki>'''2.''' If CUS of the proximal veins is positive (≥ 4-mm increase in venous diameter during compression compared with that in the same venous segment on a previous result), we recommend treating for DVT and performing no further testing over performing confirmatory [[venography]]. ''([[American College of Chest Physicians#Level of Evidence|Level of Evidence: B]])''<nowiki>"</nowiki> | ||
|- | |- | ||
|} | |} | ||
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| colspan="1" style="text-align:center; background:LightGreen"|[[ACC AHA guidelines classification scheme#Classification of Recommendations|Class I]] | | colspan="1" style="text-align:center; background:LightGreen"|[[ACC AHA guidelines classification scheme#Classification of Recommendations|Class I]] | ||
|- | |- | ||
| bgcolor="LightGreen"|<nowiki>"</nowiki>'''1.''' In patients with suspected recurrent lower extremity DVT and abnormal but nondiagnostic US results (eg, an increase in residual venous diameter of < 4 but ≥ 2 mm), we recommend further testing with venography, if available | | bgcolor="LightGreen"|<nowiki>"</nowiki>'''1.''' In patients with suspected recurrent lower extremity DVT and abnormal but nondiagnostic US results (eg, an increase in residual venous diameter of < 4 but ≥ 2 mm), we recommend further testing with [[venography]], if available. ''([[American College of Chest Physicians#Level of Evidence|Level of Evidence: B]])''<nowiki>"</nowiki> | ||
|- | |- | ||
|} | |} | ||
| Line 50: | Line 50: | ||
| colspan="1" style="text-align:center; background:LemonChiffon"| [[ACC AHA guidelines classification scheme#Classification of Recommendations|Class II]] | | colspan="1" style="text-align:center; background:LemonChiffon"| [[ACC AHA guidelines classification scheme#Classification of Recommendations|Class II]] | ||
|- | |- | ||
|bgcolor="LemonChiffon"|<nowiki>"</nowiki>'''1.''' In patients with suspected recurrent lower extremity DVT and abnormal but nondiagnostic US results (eg, an increase in residual venous diameter of < 4 but ≥ 2 mm), we recommend further testing with serial proximal CUS ''([[American College of Chest Physicians#Level of Evidence|Level of Evidence: B]])'' or testing with a moderately or highly sensitive D-dimer with serial proximal CUS as above if the test is positive ''([[American College of Chest Physicians#Level of Evidence|Level of Evidence: B]])'', as opposed to other testing strategies or treatment | |bgcolor="LemonChiffon"|<nowiki>"</nowiki>'''1.''' In patients with suspected recurrent lower extremity DVT and abnormal but nondiagnostic [[US]] results (eg, an increase in residual venous diameter of < 4 but ≥ 2 mm), we recommend further testing with serial proximal [[CUS]] ''([[American College of Chest Physicians#Level of Evidence|Level of Evidence: B]])'' or testing with a moderately or highly sensitive D-dimer with serial proximal CUS as above if the test is positive ''([[American College of Chest Physicians#Level of Evidence|Level of Evidence: B]])'', as opposed to other testing strategies or treatment.<nowiki>"</nowiki> | ||
|- | |- | ||
|} | |} | ||
===Pretest Probability Assessment in Patients With Suspected Recurrent DVT=== | ===Pretest Probability Assessment in Patients With Suspected Recurrent DVT=== | ||
{|class="wikitable" | |||
|- | |||
| colspan="1" style="text-align:center; background:LightGreen"|[[ACC AHA guidelines classification scheme#Classification of Recommendations|Class I]] | |||
|- | |||
| bgcolor="LightGreen"|<nowiki>"</nowiki>'''1.''' In patients with suspected recurrent ipsilateral DVT and an abnormal US without a prior result for comparison, we recommend further testing with venography, if available. ''([[American College of Chest Physicians#Level of Evidence|Level of Evidence: B]])''<nowiki>"</nowiki> | |||
|- | |||
|} | |||
{|class="wikitable" | |||
|- | |||
| colspan="1" style="text-align:center; background:LemonChiffon"| [[ACC AHA guidelines classification scheme#Classification of Recommendations|Class II]] | |||
|- | |||
|bgcolor="LemonChiffon"|<nowiki>"</nowiki>'''1.''' In patients with suspected recurrent ipsilateral DVT and an abnormal US without a prior result for comparison, we recommend further testing with a highly sensitive D-dimer ''([[American College of Chest Physicians#Level of Evidence|Level of Evidence: B]])'' over serial proximal [[CUS]]. In patients with suspected recurrent ipsilateral DVT and an abnormal US without prior result for comparison and a negative highly sensitive [[D-dimer]], we suggest no further testing over [[venography]] ''([[American College of Chest Physicians#Level of Evidence|Level of Evidence: C]])''. In patients with suspected recurrent ipsilateral DVT and an abnormal US without prior result for comparison and a positive highly sensitive [[D-dimer]], we suggest [[venography]] if available over empirical treatment of recurrence ''([[American College of Chest Physicians#Level of Evidence|Level of Evidence: C]])''.<nowiki>"</nowiki> | |||
|- | |||
|} | |||
==References== | ==References== | ||
Latest revision as of 13:16, 17 July 2014
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Resident Survival Guide |
Editor(s)-In-Chief: The APEX Trial Investigators, C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Rim Halaby, M.D. [2]
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Risk calculators and risk factors for Deep vein thrombosis special scenario recurrence |
Overview
When recurrent deep vein thrombosis (DVT) is suspected, the initial test should be a compression ultrasound if a previous ultrasound is available for comparison. A highly-sensitive D-dimer is also a possible initial test. If the compression ultrasound results are abnormal but non-diagnostic (increase in residual venous diameter of < 4 but ≥ 2 mm), further testing with venography or CT venography may be indicated. Patients suspected to have a recurrent episode of DVT may benefit from thrombophilia evaluation.[1]
2012 VTE, Thrombophilia, Antithrombotic Therapy, and Pregnancy: Antithrombotic Therapy and Prevention of Thrombosis, 9th ed: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines (DO NOT EDIT)[1]
Venography in Patients With Suspected Recurrent DVT
| Class I |
| "1. In patients suspected of having recurrent lower extremity DVT, we recommend initial evaluation with proximal CUS or a highly sensitive D-dimer over venography, CT venography, or MRI. (Level of Evidence: B) " |
| "2. If the highly sensitive D-dimer is positive, we recommend proximal CUS over venography, CT venography, or MRI. (Level of Evidence: B) " |
| "3. We recommend that patients with suspected recurrent lower extremity DVT and a negative highly sensitive D-dimer or negative proximal CUS and negative moderately or highly sensitive D-dimer or negative serial proximal CUS undergo no further testing for suspected recurrent DVT rather than venography. (Level of Evidence: B)" |
| "4. If CUS of the proximal veins is positive (new noncompressible segment in the common femoral or popliteal vein), we recommend treating for DVT and performing no further testing over performing confirmatory venography. (Level of Evidence: B)" |
| Class II |
| "1. In patients with suspected recurrent lower extremity DVT in whom initial proximal CUS is negative (normal or residual diameter increase of < 2 mm), we suggest at least one further proximal CUS (day 7 ± 1) or testing with a moderately or highly sensitive D-dimer (followed by repeat CUS [day 7 ± 1] if positive) rather than no further testing or venography. (Level of Evidence: B)" |
| "2. If CUS of the proximal veins is positive (≥ 4-mm increase in venous diameter during compression compared with that in the same venous segment on a previous result), we recommend treating for DVT and performing no further testing over performing confirmatory venography. (Level of Evidence: B)" |
Compression Ultrasonography in Patients With Suspected Recurrent DVT
| Class I |
| "1. In patients with suspected recurrent lower extremity DVT and abnormal but nondiagnostic US results (eg, an increase in residual venous diameter of < 4 but ≥ 2 mm), we recommend further testing with venography, if available. (Level of Evidence: B)" |
| Class II |
| "1. In patients with suspected recurrent lower extremity DVT and abnormal but nondiagnostic US results (eg, an increase in residual venous diameter of < 4 but ≥ 2 mm), we recommend further testing with serial proximal CUS (Level of Evidence: B) or testing with a moderately or highly sensitive D-dimer with serial proximal CUS as above if the test is positive (Level of Evidence: B), as opposed to other testing strategies or treatment." |
Pretest Probability Assessment in Patients With Suspected Recurrent DVT
| Class I |
| "1. In patients with suspected recurrent ipsilateral DVT and an abnormal US without a prior result for comparison, we recommend further testing with venography, if available. (Level of Evidence: B)" |
| Class II |
| "1. In patients with suspected recurrent ipsilateral DVT and an abnormal US without a prior result for comparison, we recommend further testing with a highly sensitive D-dimer (Level of Evidence: B) over serial proximal CUS. In patients with suspected recurrent ipsilateral DVT and an abnormal US without prior result for comparison and a negative highly sensitive D-dimer, we suggest no further testing over venography (Level of Evidence: C). In patients with suspected recurrent ipsilateral DVT and an abnormal US without prior result for comparison and a positive highly sensitive D-dimer, we suggest venography if available over empirical treatment of recurrence (Level of Evidence: C)." |
References
- ↑ 1.0 1.1 Bates SM, Greer IA, Middeldorp S, Veenstra DL, Prabulos AM, Vandvik PO; et al. (2012). "VTE, thrombophilia, antithrombotic therapy, and pregnancy: Antithrombotic Therapy and Prevention of Thrombosis, 9th ed: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines". Chest. 141 (2 Suppl): e691S–736S. doi:10.1378/chest.11-2300. PMC 3278054. PMID 22315276.