Deep vein thrombosis diagnostic approach
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.; Assistant Editor(s)-In-Chief: Justine Cadet
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Deep Vein Thrombosis Microchapters |
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Risk calculators and risk factors for Deep vein thrombosis diagnostic approach |
Overview
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.
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)[1] or other negative non-invasive tests may be useful in excluding DVT, without doing ultrasound. Independent studies validate the Wells 10 point rule.[2][3] However, the d-dimer assays vary; for rapid quantitative immunoturbidimetric assays, a cutoff of 1.0 <g/mL is used.[2]
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.
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[4].
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 specific 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.[4]
| 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 | |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
| 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[4]
| 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 | ||||||||||||||||
References
- ↑ 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) - ↑ 2.0 2.1 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.
- ↑ 4.0 4.1 4.2 Bates SM, Jaeschke R, Stevens SM; 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. PMID 22315267. Unknown parameter
|month=ignored (help)