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184 Chapter 17 The clinical presentation and natural history of acute deep venous thrombosis
NRO R+O
70
Percent legs affected
Venous segment
Median lysis times (days)
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700
60
50
40
30
20
10
17.4 Proportion of limbs demonstrating no abnormality (N),
reux alone (R), obstruction alone (O), and reux with obstruction (R+O) after DVT with respect to symptoms. Dark bars
indicate asymptomatic legs; light bars indicate legs with postthrombotic symptoms.
Source: (Johnson BF, Manzo RA, Bergelin RO, Strandness DE. Relationship between changes in the deep venous system and the development of
postthrombotic syndrome after an acute episode of lower limb deep vein
thrombosis: Aone- to 6- year follow-up. J Vasc Surg 1995; 21: 307–313.
Reprinted with permission.)
follow-up have not been previously thrombosed.
precise mechanism by which reux develops in initially
uninvolved segments remains unclear but may be related
to persistent proximal obstruction. There may therefore be
at least two different means by which reux develops—a
more common mechanism related to recanalization of a
thrombosed segment and a less common mechanism related
to proximal obstruction of uninvolved segments. The risk
of developing reux in segments involved by thrombus is
almost three times that in uninvolved segments.
17.5.2 Determinants of post-thrombotic
Although our understanding remains incomplete, an
appreciation of the factors involved in the development
of post-thrombotic syndrome is important in its prevention and management. Most investigators have not found
a clear relationship between the initial extent of thrombus
and ultimate outcome. However, other potential determinants of post-thrombotic manifestations include the rate
of recanalization, recurrent thrombotic events, the global
extent of reux, and the anatomic distribution of reux
and obstruction.
Rapid recanalization of venous thrombi theoretically
both relieves proximal venous obstruction and preserves
valve function. In the long-term ultrasound follow-up of
0
syndrome
109
109
The
600
500
400
300
200
100
0
CFV PFV Mid SFV
17.5 Median time from thrombosis to complete recanalization,
grouped according to ultimate reux status. Dark bars indicate
segments with reux, light bars indicate segments without reux.
Error bars denote interquartile range. Segments—common femoral vein (SFV), profunda femoris vein (PFV), mid-femoral vein
(SFM), popliteal vein (POP), posterior tibial vein (PTV), and great
saphenous vein (GSV).
Source: (Meissner MH, Manzo RA, Bergelin, RO, Markel, A, And Strandness
DE. Deep venous insufficiency: The relationship between lysis and subsequent reflux. J Vasc Surg 1993; 18: 596–608. Reprinted with permission.)
POP PTV GSV
113 patients with an acute DVT, the majority of whom were
treated with standard anticoagulation measures, the time to
complete recanalization was related to the ultimate development of reux.
78
Depending upon the venous segment
involved, complete recanalization required 2.3–7.3 times
longer in segments developing reux than in segments in
which valve function was preserved (Figure17.5). Limited
data also suggested that thrombolytic therapy has a role
in reducing the incidence of post-thrombotic syndrome
after iliofemoral DVT. Unpublished data from a multicenter registry demonstrated that among 102 patients with
iliofemoral DVT treated with catheter-directed thrombolysis, patients with complete thrombolysis were signicantly
more likely to be asymptomatic (84% without symptoms)
at 1year than were those with <50% lysis (36% without
symptoms).
110
Multiple systematic reviews and meta-analyses comparing catheter-directed thrombolysis with conventional anticoagulation have shown that although associated
with higher rates of complications, including bleeding,
catheter-directed thrombolysis is associated with signicantly improved venous patency, reduced rates of venous
reux and persistent outow obstruction, and reduced
post-thrombotic syndrome.
111,112
Several randomized
controlled trials have also evaluated the efcacy of catheter-directed thrombolysis in preventing post-thrombotic
syndrome. While the CaVenT trail demonstrated a 14.4%
absolute risk reduction in the incidence of post-thrombotic
syndrome at 2 years among patients treated with catheter-directed thrombolysis in comparison to standard anticoagulation, the ATTRACT trial found no difference in
the rate of post-thrombotic syndrome among patients with
proximal DVT treated with catheter-directed thromboly-
113,114
sis.
The difference in results between these two trials
may in part be attributed to the different patient populations included, as the CaVenT trial involved only those with
17.6 Clinical applications of natural history studies 185
Segment
100
Percent with reflux
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iliofemoral DVT, as opposed to the ATTRACT trial, which
included both iliofemoral and femoropopliteal vein DVT.
In fact, subgroup analysis of those with iliofemoral DVT
within the ATTRACT trial found that catheter-directed
thrombolysis was associated with reduced severity of
post-thrombotic syndrome, reduced rates of moderate-to-severe post-thrombotic syndrome, and improved
venous disease–specic quality of life at 24 months.
Recurrent thrombotic events also have a detrimental effect
on valvular competence and development of post-thrombotic syndrome. Extension of thrombus to initially uninvolved segments obviously places these segments at risk for
valvular destruction. However, rethrombosis of a partially
occluded or recanalized segment further increases the risk
of reux.
of such segments, considerably higher than the incidence
in segments without rethrombosis (Figure 17.6). Consistent with these observations, recurrent thrombotic events
have been noted in 45% of patients with post-thrombotic
symptoms in comparison to only 17% of asymptomatic
subjects.
times greater among patients with recurrent thrombosis.
Finally, the development of clinical signs and symptoms is related to the global extent of reux
anatomic distribution of reux and obstruction. Reux in
the distal deep venous segments, particularly the popliteal
and posterior tibial veins, is most signicantly associated
with post-thrombotic skin changes.
ciated supercial reux has been reported in 84%–94%
of patients with chronic skin changes and 60%–100% of
90
80
70
60
50
40
30
20
10
0
17.6 The development of reux in initially involved venous seg-
ments with and without subsequent rethrombosis. Dark bars
represent venous segments with rethrombosis in comparison to
those without rethrombosis, shown in the light bars. Segments—
common femoral vein (CFV); great saphenous vein (GSV); profunda femoris vein (PFV); proximal, mid, and distal femoral vein
(SFP, SFM, SFD); popliteal vein (PPV); and posterior tibial vein
(PTV). Numbers above bars indicate the number of segments in
which reux was observed over the number of segments in which
reux could be denitively assessed. Differences between segments with and without rethrombosis are statistically signicant
(
p < 0.005) for the SFM, SFD, and PPV segments.
*
Source: (Meissner MH, Caps MT, Bergelin RO, Manzo RA, Strandness DE.
Propagation, rethrombosis and new thrombus formation after acute DVT. J
Vasc Surg 1995; 2:v558–567. Reprinted with permission.)
115
97
Reux has been noted to develop in 36%–73%
30
The risk of post-thrombotic syndrome is six
116
and the
117–119
However, asso-
*
11/18
*
22/83
16/20
37/
106
4/11
*
8/11
9/15
8/18
10/21
26/59
1/3
0/2
CFV GSV PFV SFP SFM SFD PPV PTV
13/41
34/80
23/78
85/
112
patients with venous ulceration. Although pressure transmission through incompetent perforating veins may play a
role, direct thrombotic involvement of the supercial veins
and thrombus-independent degenerative processes also
appear important in the development of supercial venous
incompetence.
120
With respect to obstruction, the severity of post-thrombotic manifestations is most signicantly related to persistent iliofemoral and popliteal obstruction.
iliofemoral venous thrombosis appears to be particularly
important with signicantly worse post-thrombotic syndrome, as measured by the Villalta score, in comparison
to femoropopliteal or isolated calf vein thrombosis at 24
months. In contrast, femoral vein obstruction appears to be
relatively well tolerated in many patients,
121
likely secondary to axial transformation of the profunda femoris vein.
Persistent popliteal obstruction does, however, appear to
be associated with more advanced CEAP clinical classi-
116
cation.
41
17.6 CLINICAL APPLICATIONS OF
NATURAL HISTORY STUDIES
The natural history of acute DVT has management implications that afford some opportunity to modify outcome.
Unfortunately, recent randomized clinical trials have failed
to demonstrate a clear benet for some of these interventions. Although early ambulation with concurrent compression may result in faster resolution of acute pain and
123,124
edema,
of compression stockings in the prevention of post-thrombotic sequelae is controversial. Early unblinded randomized trials suggested 30–40 mmHg compression stockings
to be associated with a 50% reduction in the risk of the
post-thrombotic syndrome,
rmed in more recent placebo controlled trials.
803 patients randomized to 30–40mm Hg graduated compression stockings or placebo stockings, there was no difference in the cumulative incidence of PTS at 6–24 months
when assessed by either Ginsberg’s criteria or the Villalta
schedule. However, low patient compliance (55.6% at
2years) and choice of PTS outcome measures have caused
the results to be questioned by some.
Based on our current understanding, recurrent venous
thrombosis is the most powerful predictor of post-thrombotic syndrome. Early ambulation, although not affecting
recanalization,
gation. More importantly, ensuring an adequate duration
and intensity of anticoagulation is critical in preventing
recurrent thrombosis. The incidence of recurrent thromboembolic events is 15 times higher among patients with
inadequate early anticoagulation,
lar-weight heparins offer some theoretical advantage over
unfractionated heparin in this regard (grade 1A).
The increased bioavailability and more predictable dose
response of these agents are associated with more rapid
inhibition of coagulation.
incidence of symptomatic recurrent thromboembolism
among those treated with low-molecular-weight and
the evidence supporting the long-term value
125,126
but this was not con-
128
may reduce the risk of thrombus propa-
82
and the low-molecu-
132
Although a difference in the
116
Persistent
127
Among
122
129–131
17
186 Chapter 17 The clinical presentation and natural history of acute deep venous thrombosis
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unfractionated heparin has not been consistently demonstrated in clinical trials,
suggested lower rates of asymptomatic extension among
patients treated with low-molecular-weight heparins.
133,134
at least some studies have
135
The predictability of the direct thrombin and Xa inhibitors may also have some role in reducing the incidence of
post-thrombotic syndrome, and prospective studies have
found that, when compared to vitamin K antagonists, the
use of direct oral anticoagulants (DOACs) is associated
with quicker and more effective recanalization, as well as
lower rates of post-thrombotic syndrome.
136,137
Some of
these differences may be the result of difculties in maintaining a consistently therapeutic level with warfarin,
given the known inuence of diet and various medications
on INR levels, with a subtherapeutic warfarin regimen
being associated with as much as a 78% increased risk of
post-thrombotic syndrome.
138
It is increasingly recognized that the risk of recurrent
thromboembolism differs among patients and that patients
with idiopathic DVT or irreversible risk factors warrant
a longer duration of treatment. It is therefore imperative that the risk of recurrent thrombosis be thoroughly
assessed prior to discontinuing anticoagulation, particularly among those with idiopathic DVT. The risk of recurrent VTE is inuenced by ongoing hypercoagulability, and
management trials suggest that there is a role for D-dimer
determination in guiding the duration of anticoagulation is
patients with unprovoked VTE.
102
With respect to recanalization, the degree and rate at
which this proceeds are important determinants of both
valve function and recurrent thrombosis. As for recurrent
thrombosis, thrombus resolution is also related to the adequacy of anticoagulation. Use of the low-molecular-weight
heparins during the maintenance phase of therapy may
have some advantages over warfarin. In comparison to
standard oral anticoagulation, 3–6 months of treatment
with low-molecular-weight heparin has been associated
with greater degrees of recanalization, variable improvements in short-term clinical outcome, and a nonsignicant
trend toward less reux.
131,139
The potential role of the
direct thrombin and Xa inhibitors in reducing post-thrombotic manifestations awaits clinical trials, though as
discussed earlier, initial studies suggest improved and
quicker recanalization with DOACs, with lower rates of
subsequent post-thrombotic syndrome.
therapy does appear to have a role in promoting rapid and
136,137
Thrombolytic
complete recanalization in at least some patients, specically good-risk patients with acute iliofemoral DVT of less
than 14 days’ duration. Finally, early application of compression hosiery may also have a role in promoting early
recanalization. In a small, randomized trial comparing
immediate versus delayed use of compression stockings,
complete recanalization at 90 days was achieved in 82%
of occluded segments in the early compression group in
comparison to 60% of those in the delayed group.
discussed earlier, the value of long-term compression stockings in preventing PTS remains controversial. Early small
trials with good compliance have suggested a signicant
reduction in PTS, while more recent randomized trials,
with relatively poor compliance, have suggested no benet.
Although the most recent Chest guidelines
141
suggest that
compression stockings not be routinely used to prevent
PTS (weak recommendations, low certainty of evidence),
the guidelines of the European Society for Vascular Surgery
suggest that compression stockings should be considered
in patients with proximal DVT to reduce the risk of PTS
(IIa, A).
142
Additionally, recent data from a large randomized trial suggest that there may be a role for individualized application of compression stocking after a proximal
143
DV T.
Sixty-six percent of patients were able to discontinue stockings between 6 and 12 months after DVT if their
Villalta score remained low on consecutive visits, with no
difference in the incidence of PTS at 2years between those
randomized to an individualized versus a standard 2-year
duration of compression.
As most late deaths associated with DVT are due to
cardiac and malignant disease, few interventions are likely
to reduce mortality. Notably, the routine use of vena cava
lters has not been shown to decrease either immediate or long-term mortality.
144,145
However, several studies
have now suggested a survival advantage among cancer
patients with early or limited disease treated with low-molecular-weight heparins.
146
No similar advantage has been
noted for patients with advanced metastatic disease.
140
As
Guidelines 17.0 of the American Venous Forum on the clinical presentation and natural history of acute deep venous
thrombosis
No. Guideline Strength of
17.1 Based on differences in natural history, we recommend that lower extremity DVT be
precisely characterized as involving the iliofemoral veins, the femoropopliteal veins, or
isolated to the calf veins rather than being simply designated as involving the proximal
or distal veins.
17.2 We recommend formal determination of the pretest probability of DVT using a validated
scoring system in all patients presenting with signs and symptoms of acute DVT.
17.3 We recommend that the risk of recurrent VTE be thoroughly assessed prior to discontinuing anticoagulation, particularly among those with idiopathic DVT.
recommendation
1
(strong)
1
(strong)
1
(strong)
Grade of
evidence
A
(high)
A
(high)
B
(moderate)
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CHAPTER
18
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Diagnostic algorithms for acute deep
venous thrombosis and pulmonary embolism
Joann M. Lohr
18.1 INTRODUCTION
Venous thromboembolism (VTE) encompasses a spectrum
of disease, beginning with deep venous thrombosis (DVT)
and commonly resulting in pulmonary embolism (PE) or
post-thrombotic syndrome. Given the numerous diagnostic studies now available, the task of accurately and
cost-effectively ruling out VTE can at times be daunting.
The intent of this chapter is to provide a brief overview
of the widely available diagnostic studies, as well as an
algorithm, seen in Figure18.1, to assist in the workup of
patients with suspected VTE.
18.1.1 Signs and symptoms
The classic “textbook” patient is rarely encountered in
medicine, and this is especially true with regard to the presentation of patients with possible DVT. The “textbook”
patient is one who presents with pain, pitting edema, and
blanching (phlegmasia alba dolens) or a painful blue leg
(phlegmasia cerulean dolens). Much of the time, presenting complaints are vague and can be attributable to a host
of other etiologies. Up to 70% of patients presenting with
complaints compatible with DVT will not have the disease,
and up to 50% of patients with DVT will not have any
symptoms.
In a study of patients presenting to their primary care
physicians with symptoms of DVT, a multivariate regression analysis of 17 predictors led to the establishment of
nine independent predictors of DVT.
identifying these independent risk factors, the authors
noted that the predictive value of the variables was low. In
fact, the patients who were categorized as low risk based
on these variables had a 15% prevalence of DVT. Aprevalence rate of 35% was found for the patients labeled as
being at moderate risk, and the prevalence in the high-risk
group was 100%, but consisted of only a few patients.
In the primary care setting, patient history and physical
examination are insufcient to rule in or out the presence
of DVT.
vider to maintain a high clinical suspicion of DVT and to
order the appropriate conrming studies.
1,2
It is therefore the responsibility of the care pro-
1
Interestingly, despite
18.1.2 Clinical decision/scale
With technological advances in medicine, the emphasis
on proper diagnosis appears to have shifted from the clinician’s skills of observation and examination to the clinician’s ability to order the correct diagnostic study. As
mentioned earlier, the classically taught methods of diagnosis may indeed be lacking in both sensitivity and specicity when compared to the diagnostic modalities available
1,2
today.
In 1997, Wells etal. developed a clinical model for predicting pretest probability of DVT based upon nine variables that can be seen in Table 18.1.
these variables, symptomatic patients were stratied into
high (>3), moderate (1–2), and low (0 or less) probability
groups with overall prevalence rates of VTE of 75%, 17%,
and 3%, respectively. A subsequent comparison of the
Wells score and empirical assessment demonstrated poor
agreement between the two.
at categorizing low-risk patients, and empirical assessment
was better at identifying high-risk patients. Other studies
comparing clinical intuition to validated scoring systems
have been published, with similar results of poor correla-
5
Close to 40% of patients evaluated were underes-
tion.
timated by physicians in one study, whereas the patients
were overestimated by physicians in a different study.
Although the Wells scoring system is the most widely
used, its validity has been questioned. Oudega etal. studied patients with suspected DVT based upon the presence
of a painful, swollen leg for less than 30 days.
to the previous study by Wells etal., Oudega et al.’s results
demonstrated that, based on the Wells pretest probability
score, 15% of the patients in the lowest-risk group were
diagnosed with DVT using compression ultrasound (US).
However, a more recent meta-analysis of 14 studies by
Wells et al. supports their earlier ndings, with pooled
prevalence rates of DVT in the low-, moderate-, and highrisk groups of 5%, 17%, and 53%, respectively.
No study suggested that clinical probability scoring
alone was adequate to rule DVT in or out, as the utility of
the scoring system comes from combining a low/moderate-probability score with an additional study to rule out
the presence of DVT. There is a large degree of variability
4
The Wells score was better
3
By implementing
4,5
2
Contrary
6
3
DOI: 10.1201/9781003328971-21
191191
192 Chapter 18 Diagnostic algorithms for acute deep venous thrombosis and pulmonary embolism
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Suspected acute DVT
Calculate pretest clinical probability
Low/moderate probability
D-Dimer
Negative
No treatment
Negative Positive
No treatment Treatment
Positive/indeterminate
Venous US
Negative Positive
No treatment Treatment
Indeterminate
MRI/CV
Negative Indeterminate
Serial US
(5–7 days)
No treatment No treatmentTreatment
High probability
Venous US
Positive
Treatment MRI/CV
NegativePositiveNegative
Positive
Treatment
18.1 Algorithm for the diagnosis of deep venous thrombosis. CV: cardiovascular; DVT: deep venous thrombosis; MRI: magnetic
resonance imaging; US: ultrasound.
TABLE 18.1 Clinical model for predicting the pretest clinical probability of deep venous thrombosis
Clinical characteristic Score
Active cancer (patient receiving treatment for cancer within the previous 6 months or currently receiving palliative treatment) 1
Paralysis, paresis, or recent plaster immobilization of the lower extremities 1
Recently bedridden for 3 days or more or major surgery within the previous 12 weeks requiring general or regional anesthesia 1
Localized tenderness along the distribution of the deep venous system 1
Entire leg swollen 1
Calf swelling at least 3cm larger than that on the asymptomatic side (measured 10cm below the tibial tuberosity) 1
Pitting edema conned to the symptomatic leg 1
Collateral supercial veins (nonvaricose) 1
Previously documented deep venous thrombosis 1
Alternative diagnosis at least as likely as deep venous thrombosis −2
A score of 2 or higher indicates that the probability of deep venous thrombosis is likely; a score of less than 2 indicates that the
probability of deep venous thrombosis is unlikely. In patients with symptoms in both legs, the more symptomatic leg is used.
a
Source: From Wells PS etal. N Engl J Med 2003;349(13):1227–35. With permission.
Abbreviations: High-probability: score 3 or greater. Moderate probability: score 1 or 2. Low probability: score 0 or less.
with regard to clinical assessment, rendering its usefulness
suspect at best. The goal of diagnostic testing is to “rule in”
(greater than 85% post-test probability of DVT) or “rule
out” DVT (less than 2% post-test probability of venous
thromboembolism [VTE] in the next 3 months) with an
acceptable level of certainty, thereby justifying instituting
or withholding anticoagulant therapy, respectively.
18.1.3 Contrast venography
Contrast venography (CV), as detailed in Chapter14, has,
by default, long been hailed as the gold standard for the
detection of symptomatic DVT. As of late, its current role
in the diagnosis of DVT has been largely relegated to one of
historical interest. The study is limited in its practicality by
both the availability of highly sensitive, noninvasive studies and its own disadvantages, including risk of phlebitis,
intravenous contrast load with associated risk of nephrotoxicity and allergic reactions, increased cost, and need for
adequate intravenous access.
Of the available methods for performing CV, two techniques have emerged as being dominant. The rst technique, described by Rabinov–Paulin, involves spot lms,
whereas the second technique involves long-leg lms.
Lensing et al. compared the two techniques and documented an inadequacy rate for interpretation of 20% for
18.1 Introduction 193
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the Rabinov–Paulin technique versus an inadequacy rate
of 2% for the long-leg lms (P < 0.001).
7
There was also
a much higher level of interobserver disagreement using
the Rabinov–Paulin technique (21%) versus the long-leg
technique (4%). If CV is to be performed, the long-leg technique is preferable.
Given CV’s role as the gold standard for the detection
of symptomatic DVT, subsequent studies have been compared to CV in order to establish their suitability. Terao
etal. compared CV to US in the same group of patients and
noted a sensitivity and specicity of 95.5% and 91.4%,
respectively, for CV and a sensitivity and specicity of
78.3% and 96.5%, respectively, for US.
8
US sensitivity was
inferior to CV, especially in the calf, detecting only 73.6%
of the DVTs noted on CV. An additional smaller study by
Ozbudak etal. reported that 11.8% of the patients were
discovered to have DVT by CV, which US did not demon-
9
de Valois etal. echoed this opinion in a study that
strate.
compared CV to duplex sonography and strain gauge
plethysmography.
10
The authors admitted that duplex
sonography was promising, but concluded that CV should
be used as a “golden backup” in case of doubt.
In recent years, newer imaging modalities and technologies have emerged that may rival CV with regard to
sensitivity and specicity. Additionally, the newer methods
seek to address, in some part, the shortcomings or inconveniences of CV. Arole for CV may still exist when noninvasive studies are unavailable, nondiagnostic, or in the
presence of a clinical condition that is known to produce
false results (e.g., D-dimer levels postoperatively or during
pregnancy, compression of the iliac veins by the uterus in
pregnant women, or recent postpartum women on a magnetic resonance venography [MRV] study). Rarely is CV a
rst-line study.
18.1.4 Impedance plethysmography
Impedance plethysmography (IPG), as discussed in Chapter13, is based upon the physiological principle that the
impedance between two points on the skin of an extremity will decrease as the volume of blood contained in the
extremity increases. The technique examines the rate at
which venous outow occurs, thereby determining the
presence or absence of venous outow obstruction. The
presence of DVT in the major vessels of the lower extremity, including the popliteal vein and proximally, should
reduce the rate of venous outow and subsequently affect
the tracing. In the instance of non-ow-limiting thrombi,
the study will be negative.
Contemporary studies examining IPG are increasingly difcult to nd, as the clinical role of IPG continues
to decrease. In a study by Anderson etal., testing outpatients with suspected DVT resulted in 15% of patients with
abnormal IPG ndings and an additional 22% of patients
with normal IPG ndings but high clinical suspicion of
11
For proximal DVT, IPG had a positive predictive
DV T.
value of only 65% and a sensitivity of 66% when compared to CV or compression US (CUS). This low sensitivity
is supported by another study, in which the sensitivity of
IPG for proximal DVT was 65% and the specicity was
12
IPG detected only 23% of the DVTs that involved
93%.
the popliteal but not the supercial femoral vein. In the
inpatient setting, when IPG was compared to CV, IPG
was noted to have 96% sensitivity and 83% specicity for
proximal DVT.
13
Kearon and Hirsh performed a literature review to identify the reasons for the large discrepancy in the sensitivity
and specicity of IPG.
14
Several biases were found, including repeated IPG before CV and the inclusion of patients
with known abnormal IPGs. Additionally, the conversion
rate from a negative to a positive study for IPG is higher
than for US. This difference may result from IPG missing smaller proximal DVTs, which propagate or become
ow-limiting.
Given the inconsistent sensitivity and specicity demonstrated by IPG, especially in the outpatient setting, as well
as the inability of IPG to detect DVT distal to the popliteal vein, there is little to recommend the use of IPG as a
rst-line study. Even in the setting of a negative IPG study,
adjunctive studies are recommended for patients with high
clinical suspicion of DVT.
14
Alternative imaging studies of
higher sensitivity, specicity, and convenience are readily
available at most institutions.
18.1.5 Duplex ultrasound (DUS)
DUS, as detailed in Chapter 11, has almost completely
replaced CV as the diagnostic test of choice for the detection
of DVT. Its benets over CV include lack of radiation, portability, noninvasiveness, and cost-effectiveness. In addition,
US can distinguish nonvascular pathologies such as inguinal
adenopathy, Baker cysts, abscesses, and hematomas. DUS
combines compression using real-time B-mode US with Doppler venous ow detection. The main concern is whether or
not US is comparable to CV in its diagnostic ability.
In a meta-analysis, Goodacre etal. compared US to CV.
The overall sensitivity for proximal DVT was 94.2% and
63.5% for distal DVT. Specicity was 93.5%.
bined color Doppler technique was noted to have a higher
sensitivity, whereas CUS had optimal specicity. Asimilar
study of CUS and CV measured a sensitivity of 97% with
a specicity of 87% for CUS.
13
The role of repeat US examinations in a patient with
documented DVT was examined by Ascher et al.
were retrospectively analyzed after an initial diagnosis of
lower extremity DVT. Proximal extension of DVT was
noted in 19% despite adequate heparin and warfarin therapy. In addition, those with proximal extension were noted
to have an increased prevalence of PE (P < 0.05). Given the
results of this study, repeat DUS may help to distinguish
those high-risk patients who may benet from placement
of an inferior vena cava lter.
Debate continues regarding the role of repeat/serial US
in the diagnosis of DVT. The sensitivity of CUS is high for
proximal DVT and lower for nonoccluding and isolated
calf vein thrombosis. As a result, the missed thrombus may
propagate and produce PE. After a single normal US examination with no additional testing, a VTE rate of 2.5% is
17,18
noted.
With the addition of repeat US 7–14 days after
an initial negative examination, the rate of thromboembolic complications is reduced to approximately 1% over
3 months of follow-up.
19
Based on similar studies, the
general consensus has been to repeat US examinations
when persistent clinical concern remains despite a negative
15
The com-
16
Patients
18
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