Clinical evaluation, with assessment of: (1) clinical pretest probability (CPTP) for VTE; (2) likelihood of important alternative diagnoses; and (3) the probable yield of D-dimer and various imaging tests, guide which tests should be performed. A systematic review and meta-analysis, D-dimer threshold increase with pretest probability unlikely for pulmonary embolism to decrease unnecessary computerized tomographic pulmonary angiography, Variable D-dimer thresholds for diagnosis of clinically suspected acute pulmonary embolism, Selective D-dimer testing for diagnosis of a first suspected episode of deep venous thrombosis: a randomized trial, Diagnostic accuracy of conventional or age adjusted D-dimer cut-off values in older patients with suspected venous thromboembolism: systematic review and meta-analysis, Potential of an age adjusted D-dimer cut-off value to improve the exclusion of pulmonary embolism in older patients: a retrospective analysis of three large cohorts, Performance of age-adjusted D-dimer cut-off to rule out pulmonary embolism, The combination of four different clinical decision rules and an age-adjusted D-dimer cut-off increases the number of patients in whom acute pulmonary embolism can safely be excluded, Age-adjusted D-dimer cutoff levels to rule out pulmonary embolism: the ADJUST-PE study, Safety and feasibility of a diagnostic algorithm combining clinical probability, D-dimer testing, and ultrasonography for suspected upper extremity deep venous thrombosis: a prospective management study, Risk of deep vein thrombosis following a single negative whole-leg compression ultrasound: a systematic review and meta-analysis, Antithrombotic therapy for VTE disease: CHEST Guideline and Expert Panel Report, Interobserver agreement on ultrasound measurements of residual vein diameter, thrombus echogenicity and Doppler venous flow in patients with previous venous thrombosis, Accuracy of diagnostic tests for clinically suspected upper extremity deep vein thrombosis: a systematic review, Whole-arm ultrasound to rule out suspected upper-extremity deep venous thrombosis in outpatients, The accuracy of MRI in diagnosis of suspected deep vein thrombosis: systematic review and meta-analysis, Diagnostic value of CT for deep vein thrombosis: results of a systematic review and meta-analysis, Magnetic resonance direct thrombus imaging differentiates acute recurrent ipsilateral deep vein thrombosis from residual thrombosis, Subsegmental pulmonary embolism diagnosed by computed tomography: incidence and clinical implications. Search for other works by this author on: Diagnosis of DVT: antithrombotic therapy and prevention of thrombosis, 9th ed: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines, Current challenges in diagnostic imaging of venous thromboembolism, Controversies in the diagnosis of venous thromboembolism, Society of Obstetricians and Gynecologists of Canada, Venous thromboembolism and antithrombotic therapy in pregnancy, ATS/STR Committee on Pulmonary Embolism in Pregnancy, An official American Thoracic Society/Society of Thoracic Radiology clinical practice guideline: evaluation of suspected pulmonary embolism in pregnancy, The role of venous ultrasonography in the diagnosis of suspected deep venous thrombosis and pulmonary embolism, Safe exclusion of pulmonary embolism using the Wells rule and qualitative D-dimer testing in primary care: prospective cohort study, Clinical decision rules for excluding pulmonary embolism: a meta-analysis, Clinical Guidelines Committee of the American College of Physicians, Evaluation of patients with suspected acute pulmonary embolism: best practice advice from the Clinical Guidelines Committee of the American College of Physicians, Diagnostic prediction models for suspected pulmonary embolism: systematic review and independent external validation in primary care, Evaluation of D-dimer in the diagnosis of suspected deep-vein thrombosis, Exclusion of deep vein thrombosis using the Wells rule in clinically important subgroups: individual patient data meta-analysis. D-dimer is formed when crosslinked fibrin is broken down by plasmin. This applies to VTE, because progressive VTE may be fatal and anticoagulant therapy is very effective. If the D-dimer results cannot be obtained with 4 hours, interim anticoagulation should be offered while awaiting the results. Diagnosis of recurrent deep vein thrombosis. Deep vein thrombosis can have the same symptoms as many other health problems. For patients with suspected PE, this includes: (1) a low CPTP; or (2) a nondiagnostic V/Q scan and negative bilateral proximal US examinations (Table 5). D-dimer tests can help management but cannot replace clinical judgment. Venous thromboembolism (VTE) is a major cause of morbidity and mortality in United States . D-dimer tests can be divided into those that are highly or only moderately sensitive for VTE. Modern diagnostic strategies for venous thromboembolism (VTE) incorporate pretest probability (PTP; prevalence) assessment. The other end of the spectrum, and a direct sequela of both upper and lower extremity DVT, is pulmonary embolism (PE), which can have significant morbidity and mortality if not recognized early and treated. Diagnosis of VTE starts with an assessment of CPTP. D-dimer is also less well evaluated in patients with suspected upper-extremity DVT. A clear intraluminal filling defect on CTPA >3 months after a previous PE is likely to reflect acute recurrent PE. Inability to fully compress (ie, obliterate) the vein lumen with pressure from the US probe is the primary criterion for DVT. If, despite further testing, the probability of VTE remains between these thresholds, the options are to: (1) withhold treatment while performing serial US of the proximal leg veins (eg, over 2 weeks) and only treat if (new) proximal DVT develops (usually the preferred option)6Â ; or (2) treat despite having a nondiagnostic posttest probability for VTE. Second generation assays provide results within an hour, and point of care tests produce results within 10-15 minutes. For these reasons, a high level of certainty is required before patients are judged to have VTE. Recently, it has been proposed that the specificity of D-dimer testing can be increased without unduly compromising negative predictive by using D-dimer <1000 Î¼g/L to exclude VTE in patients with a low CPTP because they have a low prevalence of disease, while continuing to use D-dimer <500 Î¼g/L in patients with moderate CPTP.21-23Â This âCPTP-adjustedâ approach to D-dimer interpretation has been prospectively validated in patients with suspected DVT.23Â It has also been proposed that using a D-dimer threshold of <500 Î¼g/L to exclude VTE in patients 50 years or younger, and a threshold equal to 10Ã the patientâs age (eg, <750 Î¼g/L at 75 years) in those over 50 years, will increase the specificity of D-dimer testing without compromising sensitivity.19,24-27Â This âage-adjustedâ approach to D-dimer interpretation has been prospectively validated in patients with suspected PE.28Â. If the posttest probability of VTE lies between the ruling-out and ruling-in thresholds (ie, 3% to 84%), the patient requires further testing. Failing this, a substantial increase in the compressed diameter (ie, â¥4 mm) of the popliteal or common femoral vein or convincing extension within the femoral vein of the thigh (â¥10 cm) can be considered diagnostic.1-3,6,32Â Qualitative findings on US, such as thrombus echogenicity, thrombus irregularity, and changes in venous flow, may help, but cannot be depended upon to distinguish new thrombus from old. The overall incidence of venous thromboembolism (VTE) --including both deep vein thrombosis (DVT) and pulmonary embolism (PE) — is one case per 1000 patient years. J Thromb Haemost. If that occurs, repeat evaluation for VTE is required, often with more extensive testing than on the first occasion. Evidence review: A systematic search was conducted in EMBASE Classic, EMBASE, Ovid MEDLINE, and other nonindexed citations using broad terms for … Raised D-dimer levels are seen in a number of conditions other than VTE, including postoperatively, or with infection, cancer, inflammation, or trauma; 11–13 therefore a raised D-dimer level alone is not predictive of VTE. Ventilation-perfusion scanning is associated with less radiation exposure than CTPA and is preferred in younger patients, particularly during pregnancy. Venous US can serve 2 purposes in patients with suspected PE. Avoidance of radiation is particularly important in young women (eg, <40 years of age, particularly during pregnancy) due to the risk of breast cancer; V/Q scanning is often preferred in these patients. Subsequent testing is guided by these evaluations and test availability (Table 6). Presence of JAK2 V617F Minor Criteria 1. Combinations of test results that rule-in and rule-out DVT or PE are summarized in Tables 3-5. DVT Modified Wells Criteria Probability of VTE increases from 3 to 75 % as wells score increases. Accurate diagnosis of VTE is important due to the morbidity and mortality associated with missed diagnoses and the potential side effects, patient inconvenience, and resource implications of anticoagulant treatment given for VTE. It is noninvasive and relatively easy to perform.1,6Â Proximal venous US examines the common femoral vein, femoral vein (previously called the superficial femoral vein), popliteal vein, and the calf vein trifurcation (ie, proximal junction of deep calf veins). Because the signs and symptoms of deep venous thrombosis and pulmonary embolism are common but non-specific, they often present a diagnostic challenge. A normal perfusion scan excludes PE but is obtained in only â¼25% of patients. D-dimer tests vary in terms of the measurement method and the D-dimer level that is used to categorize a test as positive or negative. Anticoagulant therapy causes bleeding and many patients find it burdensome. C.K. Both underdiagnosis and overdiagnosis are associated with substantial morbidity and mortality. 5 Assessment of pulmonary embolism severity and the risk of early death. Antiphospholipid syndrome is thought to be associated with a high risk for both recurrent venous thromboembolism and arterial thrombosis.67 The presence of persistently elevated antiphospholipid antibodies with a first venous thromboembolism is an acceptable indication for indefinite duration of anticoagulation.16 67 A diagnosis of antiphospholipid syndrome is made on the … A non-specific increase in D-dimer concentration is seen in many situations, precluding its use for diagnosing venous thromboembolism (VTE). CPTP is higher if: (1) symptoms and signs are typical for DVT or PE; (2) there are risk factors for VTE; (3) VTE is thought to be the most likely diagnosis; and (4) symptoms and signs are more severe. doi: https://doi.org/10.1182/asheducation-2016.1.397. The purpose of this article was to review the validity and utility of the suggested ultrasound diagnostic criteria for DVT recurrence, and to review how CUS compares to other diagnostic imaging methods. Copyright ©2020 by American Society of Hematology, What posttest probability ârules-inâ or ârules-outâ DVT or PE, Clinical pretest probability (CPTP) for DVT and PE, Venography for leg and upper-extremity DVT, CT and magnetic resonance imaging (MRI) venography for DVT, Sequence of testing for DVT and PE, and results that are diagnostic, https://doi.org/10.1182/asheducation-2016.1.397, deep venous thrombosis of upper extremity, Active cancer (treatment ongoing or within previous 6 mo or palliative)Â, Paralysis, paresis, or recent plaster immobilization of the lower extremitiesÂ, Recently bedridden >3 d or major surgery within 4 wksÂ, Localized tenderness along the distribution of the deep venous systemÂ, Calf swelling 3 cm greater than on asymptomatic side (measured 10 cm below tibial tuberosity)Â, Pitting edema confined to the symptomatic legÂ, Alternative diagnosis as likely or greater than that of DVTÂ, Alternative diagnosis is less likely than PEÂ, Immobilization or surgery in previous 4-wk periodÂ, Malignancy or treatment of it in previous 6-mo periodÂ, âNoncompressibility of proximal veins (calf vein trifurcation included)Â, âNoncompressibility of distal veins, when findings are extensiveÂ, âIntraluminal defect (unequivocal) with associated absence of flow in the iliac veins or inferior vena cava, when compressibility cannot be assessedÂ, âIntraluminal filling defect in proximal or distal deep veinsÂ, âNegative very sensitive test (eg, D-dimer <500 Î¼g/L) AND low or moderate CPTPÂ, âNegative moderately sensitive test (including D-dimer <1000 Î¼g/L) AND low CPTPÂ, âFully compressible proximal veins AND low CPTPÂ, âFully compressible proximal veins AND moderately or very sensitive D-dimer testÂ, âFully compressible proximal and distal veins (whole-leg US)Â, âFully compressible proximal veins AND normal repeat proximal US after 7 dÂ, âAll deep veins seen and no intraluminal filling defectsÂ, âA new, noncompressible proximal vein segmentÂ, âA 4-mm increase in diameter of the common femoral or popliteal vein compared with a previous testÂ, âA unequivocal extension of thrombosis (eg, additional 10 cm) within the femoral veinÂ, âIntraluminal filling defect in proximal or distal deep veins (new, or >3 mo after last event)Â, ââ¤1 mm increase in diameter of the common femoral, and femoral and popliteal veins compared with a previous test AND remains unchanged on repeat testing after 2 d and 7 dÂ, âNoncompressibility of the axillary, brachial veins, or jugular veinÂ, âIntraluminal defect (unequivocal) with associated absence of flow in the subclavian veinÂ, âIntraluminal filling defect within brachial vein to superior vena cavaÂ, âNo DVT within brachial to subclavian veins AND not suspected of having a more central DVTÂ, âNo DVT on US AND normal repeat US after 7 dÂ, âNegative very sensitive test (eg, D-dimer <500 Î¼g/L) AND low or unlikely CPTPÂ, âNo intraluminal filling defect within brachial vein to superior vena cavaÂ, âIntraluminal filling defect in a lobar or main pulmonary arteryÂ, âIntraluminal filling defect in a segmental pulmonary artery AND moderate or high CPTPÂ, âHigh-probability scan AND moderate or high CPTPÂ, Positive diagnostic test for DVT (with a nondiagnostic V/Q scan or CTPA, or scan not done)Â, Perfusion scan (usually part of V/Q scan)Â, âNegative moderately sensitive test AND low CPTPÂ, âIn patients over 50 y, D-dimer level <10 times the patient's age AND a low or moderate CPTPÂ, Nondiagnostic V/Q scan or CTPA AND normal proximal venous US AND one of:Â, âNegative moderately or very sensitive D-dimer testÂ, âNormal repeat proximal US after 7 d and 14 dÂ, May identify a suspected alternative to PE (eg, progressive malignancy; aortic dissection)Â, May identify a suspected alternative to DVT (eg, ruptured Baker cyst; hematoma)Â, Favors whole-leg US over serial proximal USÂ, D-dimer will be high even if no DVT or PE (eg, postoperative; inpatient; sepsis)Â, Younger, particularly if females and pregnantÂ, Lung disease or abnormal chest radiographÂ. It does not address the diagnosis of DVT in usual sites, or superficial vein thrombosis. But about half the time, this blood clot in a deep vein, often in your leg, causes no symptoms. Elevated RBC mass > 25% above mean normal predicted value or hemoglobin > 18.5 gm/dL (male) or 16.5 gm/dL (female) 2. Some VTE diagnostic tests can identify an alternative diagnosis (eg, CT pulmonary angiography [CTPA] or leg US), whereas others do not (eg, D-dimer testing or perfusion scanning). It is acceptable for diagnostic testing not to detect VTE that are very unlikely to progress and, therefore, the patient would not benefit from anticoagulant therapy. D-dimer has been less well evaluated in patients who are suspected of having recurrent VTE.1,3,19,20Â Specificity is lower than in patients with a first suspected VTE, presumably because of a higher prevalence of comorbid conditions that increase D-dimer. It is the standard imaging test to diagnose DVT. 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