LO21: Ability of single negative ultrasound to rule out deep vein thrombosis in pregnant women. A systematic review and meta analysis

Introduction: The accuracy of ultrasound (US) for diagnosing lower extremity deep vein thrombosis (DVT) in non-pregnant patients has been well validated. However, in pregnant women with suspected DVT and an initial negative US (with imaging of the iliac veins), serial US is recommended. We aimed to determine the ability of single negative US to exclude DVT in symptomatic pregnant women. Methods: Two authors independently reviewed the following databases: MEDLINE, PubMed and EMBase from inception until May 2017. Three authors reviewed all full text papers and data were extracted from included studies by four authors. An overlap among study populations was identified in 4 of the manuscripts, all from one multicentre Canadian study. Two authors performed data re-extraction from the hard copy research charts from this study. We assessed the risk of bias using the CLARITY group tool for prognostic studies. Results: Of 109 potentially relevant articles, 8 studies (7 prospective studies and 1 retrospective) were included. Risk of bias was low for the included populations, and low or moderate for method of measurement and for completeness of follow up. A total of 635 pregnant patients with symptoms of DVT had an initial negative US examination. Of those, 6 had positive DVT during serial US (0.94%) and 3 developed DVT during 3-month follow-up after serial ultrasound (0.47%). Using random-effects model, the pooled false negative rate of a single ultrasound was 1.27% (95% confidence interval, 0.42 to 2.56), I2= 27%. Conclusion: The false negative rate of a single ultrasound with iliac vein imaging for DVT in pregnancy is low. Our results will help inform shared decision making around planning repeat ultrasound scans in these patients.

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Accuracy of ultrasound to detect thrombosis in pregnancy: A systematic review

Revista da Associação Médica Brasileira ◽

10.1590/1806-9282.63.03.278 ◽

2017 ◽

Vol 63 (3) ◽

pp. 278-283

Author(s):

Aldemar Araujo Castro ◽

Fernando José Camello de Lima ◽

Célio Fernando de Sousa-Rodrigues ◽

Fabiano Timbó Barbosa

Keyword(s):

Deep Vein Thrombosis ◽

Diagnostic Accuracy ◽

Pregnant Women ◽

Reference Lists ◽

Grey Literature ◽

Risk Of Bias ◽

Vein Thrombosis ◽

Deep Vein ◽

Positive Results

Summary Objective: To determine the diagnostic accuracy of ultrasound to detect deep--vein thrombosis in pregnant patients. Method: We searched Pubmed, LILACS, Scopus, Google Scholar and System for Information on Grey Literature from inception to April 2016. The reference lists of the included studies were analyzed. Original articles from accuracy studies that analyzed ultrasonography to diagnose deep-vein thrombosis in pregnant women were included. Reference standard was the follow-up time. The QUADAS-2 score was used for quality assessment. Results: Titles and summaries from 2,129 articles were identified. Four studies that evaluated deep-vein thrombosis in pregnant women were included. In all, 486 participants were enrolled. High risk of bias was seen in three out of four studies included regarding flow and timing domain of QUADAS-2. Negative predictive value was 99.39%. Conclusion: Accuracy of ultrasonography to diagnose deep-vein thrombosis in pregnant women was not determined due to the absence of data yielding positive results. Further studies of low risk of bias are needed to determine the diagnostic accuracy of ultrasonography in this clinical scenario.

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P136: Evaluating the use of the YEARS clinical decision rule for diagnosing pulmonary embolism in the Emergency Department

CJEM ◽

10.1017/cem.2018.334 ◽

2018 ◽

Vol 20 (S1) ◽

pp. S105-S105 ◽

Cited By ~ 1

Author(s):

S. Sharif ◽

C. Kearon ◽

M. Eventov ◽

M. Li ◽

R. Jiang ◽

...

Keyword(s):

Emergency Department ◽

Pulmonary Embolism ◽

Deep Vein Thrombosis ◽

False Negative ◽

False Negative Rate ◽

Clinical Signs ◽

Vein Thrombosis ◽

Negative Rate ◽

Deep Vein ◽

D Dimer

Introduction: Diagnosing pulmonary embolism (PE) can be challenging because the signs and symptoms are often non-specific. Studies have shown that evidence-based algorithms are not always adhered to in the Emergency Department (ED) and are often not used correctly, which leads to unnecessary CT scanning. The YEARS diagnostic algorithm, consisting of three items (clinical signs of deep vein thrombosis, hemoptysis, and whether pulmonary embolism is the most likely diagnosis) and D-dimer, is a novel and simplified way to approach suspected acute PE. The purpose of this study was to 1) evaluate the use of the YEARS algorithm in the ED and 2) to compare the rates of testing for PE if the YEARS algorithm was used. Methods: This was a health records review of ED patients investigated for PE at two emergency departments over a two-year period (April 2013-March 2015). Inclusion criteria were ED physician ordered CT pulmonary angiogram, ventilation-perfusion scan, or D-dimer for investigation of PE. Patients under the age of 18 and those without a D-dimer test were excluded. PE was considered to be present during the emergency department visit if PE was diagnosed on CT or VQ (subsegmental level or above), or if the patient was subsequently found to have PE or deep vein thrombosis during the next 30 days. Trained researchers extracted anonymized data. The rate of CT/VQ imaging and the false negative rate was calculated. Results: There were 1,163 patients that were tested for PE and 1,083 patients were eligible for our analysis. Of the total, 317/1,083 (29.3%; 95%CI 26.6-32.1%) had CT/VQ imaging for PE, and 41/1,083 (3.8%; 95%CI 2.8-5.1%) patients were diagnosed with PE at baseline. Three patients had a missed PE, resulting in a false negative rate of 0.4% (95%CI 0.1-1.2%). If the YEARS algorithm was used, 211/1,083 (19.5%; 95%CI 17.2-22.0%) would have required imaging for PE. Of the patients who would not have required imaging according to the YEARS algorithm, 8/872 (0.9%; 95%CI 0.5-1.8%) would have had a missed PE. Conclusion: If the YEARS algorithm was used in all patients with suspected PE, fewer patients would have required imaging with a small increase in the false negative rate.

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LO55: Comparison of the age-adjusted D-dimer, clinical probability-adjusted D-dimer, and Wells rule with D-dimer for diagnosing deep vein thrombosis in the emergency department.

CJEM ◽

10.1017/cem.2020.110 ◽

2020 ◽

Vol 22 (S1) ◽

pp. S27-S27

Author(s):

S. Sharif ◽

C. Kearon ◽

M. Eventov ◽

P. Sneath ◽

M. Li ◽

...

Keyword(s):

False Negative ◽

False Negative Rate ◽

Duplex Ultrasonography ◽

Vein Thrombosis ◽

Clinical Probability ◽

Negative Rate ◽

Wells Score ◽

Wells Rule ◽

Deep Vein ◽

D Dimer

Introduction: Diagnosing deep vein thrombosis (DVT) is of critical importance because of its associated morbidity and mortality. Diagnosing DVT can be challenging in the Emergency Department (ED) due to inconsistent adherence to, and utilization of the Wells rule. Both the age-adjusted and clinical probability adjusted D-dimer have been shown to decrease ultrasound (US) utilization rates. We aimed to compare the safety and efficacy of the Wells score with D-dimer to the age-adjusted and clinical probability-adjusted D-dimer in Canadian ED patients tested for DVT. Methods: This was a health records review of ED patients investigated for DVT at two EDs over a two-year period. Inclusion criteria were ED physician ordered duplex ultrasonography or D-dimer for investigation of lower limb DVT. Patients under the age of 18 were excluded. DVT was considered to be present during the ED visit if DVT was diagnosed on duplex ultrasonography and was treated for acute DVT, or if the patient was subsequently diagnosed with pulmonary embolism (PE) or DVT during the next 30 days. Trained researchers extracted anonymized data. The Wells D-dimer, age-adjusted D-dimer, and the clinical probability-adjusted D-dimer rules were applied retrospectively. The rate of duplex ultrasonography imaging and the false negative rate was calculated for each rule. Results: Between April 1st 2013 and March 31st 2015, there were 1,198 patients tested for DVT. Of the low and moderate clinical pretest probability patients (Wells score ≤ 2), only 436 had a D-Dimer test and were eligible for our analysis. The average age of the patients was 59, 56% were female, and 4% had a malignancy. 207/436 patients (47.4%, 95%CI 42.8-52.2%) would have had US imaging for DVT if the age-adjusted D-dimer rule was used. 214/436 patients (49.1%, 95%CI 44.4-53.8%) would have had imaging for DVT if the clinical probability-adjusted D-dimer was used. If the Wells rule was used with the standard D-dimer cutoff of 500, 241/436 patients (55.2%, 95%CI 50.6-59.9%) would have had imaging for DVT. The false-negative rate for the Wells rule was 1.5% (95%CI 0.5-4.4%). The false-negative rate for the age-adjusted D-dimer rule was 1.3% (95%CI 0.4-3.8%). The false-negative rate for the clinical-probability adjusted D-Dimer was 1.8% (95%CI 0.7-4.5%). Conclusion: In comparison with the approach of the Wells score and D-dimer, both the age-adjusted and clinical probability-adjusted D-dimer diagnostic strategies could reduce the proportion of patients who require US imaging.

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Critical Evaluation of Impedance Phlebography for the Diagnosis of Deep Vein Thrombosis

Thrombosis and Haemostasis ◽

10.1055/s-0038-1649161 ◽

1974 ◽

Vol 31 (02) ◽

pp. 273-278

Author(s):

Kenneth K Wu ◽

John C Hoak ◽

Robert W Barnes ◽

Stuart L Frankel

Keyword(s):

Deep Vein Thrombosis ◽

False Positive ◽

False Negative ◽

Critical Evaluation ◽

Original Method ◽

Vein Thrombosis ◽

Negative Results ◽

False Negative Results ◽

Deep Vein ◽

Positive Results

SummaryIn order to evaluate its daily variability and reliability, impedance phlebography was performed daily or on alternate days on 61 patients with deep vein thrombosis, of whom 47 also had 125I-fibrinogen uptake tests and 22 had radiographic venography. The results showed that impedance phlebography was highly variable and poorly reliable. False positive results were noted in 8 limbs (18%) and false negative results in 3 limbs (7%). Despite its being simple, rapid and noninvasive, its clinical usefulness is doubtful when performed according to the original method.

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Prospective 12-Year Follow-up Study of Clinical and Hemodynamic Sequelae After Deep Vein Thrombosis in Low-Risk Patients (Zürich Study)

Circulation ◽

10.1161/01.cir.93.1.74 ◽

1996 ◽

Vol 93 (1) ◽

pp. 74-79 ◽

Cited By ~ 106

Author(s):

Ulrich K. Franzeck ◽

Ilse Schalch ◽

Kurt A. Jäger ◽

Ernst Schneider ◽

Jörg Grimm ◽

...

Keyword(s):

Deep Vein Thrombosis ◽

Low Risk ◽

Vein Thrombosis ◽

Follow Up Study ◽

Risk Patients ◽

Deep Vein

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Post-thrombotic syndrome after deep vein thrombosis: The role of follow-up Doppler ultrasound

Medicina Clínica (English Edition) ◽

10.1016/j.medcle.2020.01.024 ◽

2021 ◽

Vol 156 (5) ◽

pp. 251-252

Author(s):

Francisco Galeano-Valle ◽

Jorge del-Toro-Cervera ◽

Pablo Demelo-Rodríguez

Keyword(s):

Deep Vein Thrombosis ◽

Doppler Ultrasound ◽

Vein Thrombosis ◽

Post Thrombotic Syndrome ◽

Deep Vein

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Predictors of long-term post-thrombotic syndrome following high proximal deep vein thrombosis: a cross-sectional study

Thrombosis Journal ◽

10.1186/s12959-020-00253-8 ◽

2021 ◽

Vol 19 (1) ◽

Author(s):

Marit Engeseth ◽

Tone Enden ◽

Per Morten Sandset ◽

Hilde Skuterud Wik

Keyword(s):

Deep Vein Thrombosis ◽

Proximal Deep Vein Thrombosis ◽

Cross Sectional ◽

Clinical Criteria ◽

Vein Thrombosis ◽

Post Thrombotic Syndrome ◽

Younger Age ◽

Deep Vein

Abstract Background Post-thrombotic syndrome (PTS) is a frequent chronic complication of proximal deep vein thrombosis (DVT) of the lower limb, but predictors of PTS are not well established. We aimed to examine predictors of PTS in patients with long-term PTS following proximal DVT. Methods During 2006–09, 209 patients with a first time acute upper femoral or iliofemoral DVT were randomized to receive either additional catheter-directed thrombolysis or conventional therapy alone. In 2017, the 170 still-living participants were invited to participate in a cross-sectional follow-up study. In the absence of a gold standard diagnostic test, PTS was defined in line with clinical practice by four mandatory, predefined clinical criteria: 1. An objectively verified DVT; 2. Chronic complaints (> 1 month) in the DVT leg; 3. Complaints appeared after the DVT; and 4. An alternative diagnosis was unlikely. Possible predictors of PTS were identified with multivariate logistic regression. Results Eighty-eight patients (52%) were included 8–10 years following the index DVT, and 44 patients (50%) were diagnosed with PTS by the predefined clinical criteria. Younger age and higher baseline Villalta score were found to be independent predictors of PTS, i.e., OR 0.96 (95% CI, 0.93–0.99), and 1.23 (95% CI, 1.02–1.49), respectively. Lack of iliofemoral patency at six months follow-up was significant in the bivariate analysis, but did not prove to be significant after the multivariate adjustments. Conclusions In long-term follow up after high proximal DVT, younger age and higher Villalta score at DVT diagnosis were independent predictors of PTS.

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Diagnostic Accuracy of a New d-Dimer Assay (Sclavo Auto d-Dimer) for Exclusion of Deep Vein Thrombosis in Symptomatic Outpatients

Clinical and Applied Thrombosis/Hemostasis ◽

10.1177/1076029616649436 ◽

2016 ◽

Vol 23 (3) ◽

pp. 221-228 ◽

Cited By ~ 1

Author(s):

Cristina Legnani ◽

Michela Cini ◽

Mirella Frascaro ◽

Giuseppina Rodorigo ◽

Michelangelo Sartori ◽

...

Keyword(s):

Deep Vein Thrombosis ◽

Imaging Techniques ◽

False Negative ◽

High Specificity ◽

Predictive Values ◽

Cutoff Value ◽

Vein Thrombosis ◽

Number Of Patients ◽

Deep Vein ◽

D Dimer

In patients presenting non-high clinical pretest probability (PTP), a negative d-dimer can exclude venous thromboembolism without imaging tests. However, each d-dimer assay should be validated in prospective studies. We evaluated an automated d-dimer immunoassay using the Sclavo Auto d-dimer (Sclavo Diagnostics Int, Sovicille, Italy) provided by Dasit Diagnostica (Cornaredo, Milan, Italy). Three hundred two consecutive outpatients suspected of leg deep vein thrombosis (DVT) with non-high PTP were included. The Sclavo Auto d-dimer assay was evaluated on 2 analyzers (Sysmex CA-7000 and Sysmex CS-2100; Sysmex Corporation, Kobe, Japan, provided by Dasit). The cutoff value (200 ng/mL) was established a priori. Prevalence of DVT was 11.9%. Since no false-negative patients were detected, the sensitivity and negative predictive values (NPVs) were 100% (sensitivity = CA-7000: 100% [95% confidence interval, CI: 93.3-100], CS-2100: 100% [95% CI: 93.3-100]; NPV = CA-7000: 100% [95% CI: 97.9-100], CS-2100: 100% [95% CI: 98.0-100]). Specificity was 65.4% (95% CI: 59.4-71.1) and 69.2% (95% CI: 63.3-74.7) for CA-7000 and CS-2100, respectively. Specificity increased when a higher cutoff value (234 ng/mL) was used for patients aged ≥60 years without compromising the safety. Assay reproducibility was satisfactory at concentrations near the cutoff value (total coefficient of variations <10%). In conclusion, the Sclavo Auto d-dimer assay was accurate when used for DVT diagnostic workup in outpatients with non-high PTP. Based on its high sensitivity and NPV, it can be used as a stand-alone test in outpatients with non-high PTP. Given its high specificity, the number of patients in whom further imaging techniques can be avoided increased, improving the yield of the test.

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