Complete compression ultrasonography of the leg veins as a single test for the diagnosis of deep vein thrombosis

SummaryNoninvasive diagnosis of deep vein thrombosis (DVT) is based on ultrasound examination of the leg veins, usually restricted to only compression of the proximal veins (CUS). Patients with negative CUS findings require a second examination or a combination with other tests, which impairs clinical efficiency. In this prospective outcome study, 1646 consecutive patients with clinically suspected DVT were examined once by a standardized protocol of complete compression ultrasound comprising all proximal and distal veins (CCUS) as the only diagnostic test. The examination was equivocal in 15 patients (1% technical failure rate). Another 366 patients (22%) were tested positive for proximal DVT, distal DVT, muscle vein thrombosis, or phlebitis. Of 1265 patients in whom CCUS findings were negative, 242 met exclusion criteria for follow-up (age <18, life expectancy <3 months, other reasons for anticoagulation, postthrombotic lesions of the leg veins, or lack of informed consent). During the 3 months of follow-up, three of 1023 patients with negative CCUS findings experienced a symptomatic venous thromboembolic event (0.3% [95% CI 0.1%-0.8%]). We conclude that the CCUS protocol has a low technical failure rate and is safe with respect to excluding DVT, thereby reducing the diagnostic workup of patients with suspected DVT to a single ultrasound examination.

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Safety of a strategy combining D-dimer testing and whole-leg ultrasonography to rule out deep vein thrombosis

Blood Advances ◽

10.1182/bloodadvances.2020002173 ◽

2020 ◽

Vol 4 (20) ◽

pp. 5002-5010

Author(s):

Synne G. Fronas ◽

Camilla T. Jørgensen ◽

Anders E. A. Dahm ◽

Hilde S. Wik ◽

Jostein Gleditsch ◽

...

Keyword(s):

Deep Vein Thrombosis ◽

Pretest Probability ◽

Vein Thrombosis ◽

Venous Thromboembolic ◽

Deep Vein ◽

D Dimer ◽

Rule Out ◽

Compression Ultrasonography ◽

High Pretest Probability

Abstract Guidelines for the diagnostic workup of deep vein thrombosis (DVT) recommend assessing the clinical pretest probability before proceeding to D-dimer testing and/or compression ultrasonography (CUS) if the patient has high pretest probability or positive D-dimer. Referring only patients with positive D-dimer for whole-leg CUS irrespective of pretest probability may simplify the workup of DVT. In this prospective management outcome study, we assessed the safety of such a strategy. We included consecutive outpatients referred to the Emergency Department at Østfold Hospital, Norway, with suspected DVT between February 2015 and November 2018. STA-Liatest D-Di Plus D-dimer was analyzed for all patients, and only patients with levels ≥0.5 µg/mL were referred for CUS. All patients with negative D-dimer or negative CUS were followed for 3 months to assess the venous thromboembolic rate. One thousand three hundred ninety-seven patients were included. Median age was 64 years (interquartile range, 52-73 years), and 770 patients (55%) were female. D-dimer was negative in 415 patients (29.7%) and positive in 982 patients (70.3%). DVT was diagnosed in 277 patients (19.8%). Six patients in whom DVT was ruled out at baseline were diagnosed with DVT within 3 months of follow-up for a thromboembolic rate of 0.5% (95% confidence interval, 0.2-1.2). A simple diagnostic approach with initial stand-alone D-dimer followed by a single whole-leg CUS in patients with positive D-dimer safely ruled out DVT. We consider this strategy to be a valuable alternative to the conventional workup of DVT in outpatients. This trial was registered at www.clinicaltrials.gov as #NCT02486445.

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Die vollständige Kompressionssonographie zur Diagnose der proximalen und distalen Venenthrombose – eine retrospektive Untersuchung

VASA ◽

10.1024/0301-1526.30.4.253 ◽

2001 ◽

Vol 30 (4) ◽

pp. 253-257 ◽

Cited By ~ 3

Author(s):

Sebastian M. Schellong ◽

T. Schwarz ◽

T. Pudollek ◽

B. Schmidt ◽

H. E. Schroeder

Keyword(s):

Deep Vein Thrombosis ◽

Outcome Study ◽

Repeated Testing ◽

Clinical Safety ◽

Vein Thrombosis ◽

Clinical Probability ◽

Compression Ultrasound ◽

Low Incidence ◽

Deep Vein

Background: Compression ultrasound is considered the preferred test for the diagnosis of deep vein thrombosis of the leg (DVT). Since sensitivity for distal thrombosis is low additional tests are required. We developed a protocol of complete compression ultrasound of all venous segments of the leg (CCUS). A retrospective outcome study was performed to get an estimate of the rate of indeterminate results necessitating repeated testing as well as for the clinical safety of CCUS in a cohort of consecutive, unselected patients. Patients and methods: Case records of all patients referred for clinical suspicion of deep vein thrombosis within a three months period were reviewed. Patients with negative CCUS were followed directly or via the general practitioner in order to know whether an episode of venous thromboembolism had been documented since the initial CCUS. Results: 132 inpatients and 154 outpatients were identified. Clinical probability was high in 50 patients, medium in 142, and low in 94. The first CCUS was negative in 209 cases. Five patients (1,8%) had repeated CCUS within the next 7 days because of incomplete visualisation of the distal veins and turned out to be negative as well. Of all 214 patients with negative CCUS a clinical follow-up information was obtained after 168 ± 25 days. Five patients had died, none due to pulmonary embolism. In two patients deep vein thrombosis had been documented (0,9% [95% CI: 0,1–3,3%]) 148 and 172 days after CCUS, respectively. Conclusion: CCUS for diagnosis of DVT needs to be repeated in very few cases only. Clinical safety seems to fall into the same range as with combined algorithms and should be tested in a prospective design. Patients with medium and high probability showed a very low incidence of DVT within three months following CCUS; therefore, they may be included in a prospective outcome study.

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Asymptomatic Deep Vein Thrombosis is Associated with an Increased Risk of Death: Insights from the APEX Trial

Thrombosis and Haemostasis ◽

10.1055/s-0038-1675606 ◽

2018 ◽

Vol 118 (12) ◽

pp. 2046-2052 ◽

Cited By ~ 11

Author(s):

Arzu Kalayci ◽

C. Gibson ◽

Gerald Chi ◽

Megan Yee ◽

Serge Korjian ◽

...

Keyword(s):

Deep Vein Thrombosis ◽

Cardiovascular Diseases ◽

Linear Trend ◽

Vein Thrombosis ◽

Risk Of Death ◽

Increased Risk ◽

Compression Ultrasound ◽

All Cause Mortality ◽

Deep Vein

Aim Asymptomatic deep vein thrombosis (DVT) diagnosed with compression ultrasound (CUS) is a common endpoint in trials assessing the efficacy of anticoagulants to prevent venous thromboembolism (VTE), but the relationship of asymptomatic thrombus to mortality remains uncertain. Methods In the APEX trial (ClinicalTrials.gov: NCT01583218), 7,513 acutely ill hospitalized medical patients were randomly assigned to extended-duration betrixaban (35–42 days) or enoxaparin (10 ± 4 days). Asymptomatic DVT was assessed once with CUS between day 32 and 47, and mortality was assessed through 77 days. Results A total of 309 asymptomatic DVTs were detected through CUS. Of these, 133 (4.27%) subjects were in the betrixaban group, and 176 (5.55%) subjects were in the enoxaparin group (relative risk = 0.77, 95% confidence interval [CI] = 0.62–0.97, p = 0.025, number needed to treat = 79). With respect to all-cause mortality due to cardiovascular diseases, non-cardiovascular diseases and unknown causes, the number of the deaths was 5 (1.67%), 4 (1.34%) and 1 (0.33%) in the asymptomatic DVT group and 25 (0.42%), 33 (0.56%) and 11 (0.19%) in the no DVT group, respectively. Subjects with an asymptomatic DVT had an almost threefold increase in the risk of all-cause mortality compared with subjects without DVT (hazard ratio = 2.87, 95% CI = 1.48–5.57, p = 0.001). A positive linear trend was observed between greater thrombus burden and mortality during the follow-up (p = 0.019). Conclusion Asymptomatic DVT was associated with approximately threefold increased risk of short-term all-cause mortality in patients hospitalized with an acute medical illness within the prior 77 days. A positive linear trend was observed between greater thrombus burden and mortality during the follow-up.

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Safety of Excluding Suspected Deep Vein Thrombosis with a Single Whole-Leg Compression Ultrasound: Systematic Review and Meta-Analysis.

Blood ◽

10.1182/blood.v114.22.243.243 ◽

2009 ◽

Vol 114 (22) ◽

pp. 243-243 ◽

Cited By ~ 1

Author(s):

Stacy A Johnson ◽

Scott M Stevens ◽

Scott C Woller ◽

Erica Lake ◽

Marco Donadini ◽

...

Keyword(s):

Deep Vein Thrombosis ◽

Lower Extremity ◽

Conflicts Of Interest ◽

Data Extraction ◽

Meta Analysis ◽

Diagnostic Efficiency ◽

Vein Thrombosis ◽

Compression Ultrasound ◽

Deep Vein

Abstract Abstract 243 Background: In patients with suspected lower extremity deep vein thrombosis (DVT), compression ultrasonography (CUS) is typically used as the initial test to confirm or exclude DVT. Patients with a negative CUS and either a moderate-to-high probability and/or a positive D-dimer usually require repeat CUS testing after 5–7 days to exclude proximal propagation of distal DVT, reducing diagnostic efficiency. Whole-leg compression ultrasound may safely exclude proximal and distal DVT in a single evaluation. Purpose: To assess the safety of withholding anticoagulation in patients presenting with suspected lower extremity DVT following a single negative whole-leg CUS. Methods: MEDLINE, EMBASE, CINAHL, LILACS, Cochrane, Health Technology Assessments databases were searched from January 1970 to April 2009 without language restrictions. This search was supplemented by reviewing Google, Google Scholar, clinicaltrials.gov, meeting abstracts, conference proceedings, reference lists, and by contacting content experts. Study Selection and Data Extraction: Randomized controlled trials and prospective cohort studies of patients with suspected DVT with a negative whole-leg CUS, not treated with anticoagulation, and followed at least 90 days for occurrence of venous thromboembolism (VTE). Studies required objective confirmation of VTE events during follow-up. Two authors independently reviewed articles and extracted data. Results: Six studies were included totaling 4,229 patients with negative whole-leg CUS exams and not receiving anticoagulation. VTE or suspected VTE-related death occurred within the follow-up period in 24 (0.6%) patients. Of these 24 events, 9 (37.5%) were distal DVT, 7 (29.2%) were proximal DVT, 6 (25.0%) were non-fatal pulmonary embolism, and 2 (8.3%) were deaths, possibly related to VTE. Combined VTE event rate at 3 months was 0.46% (95% CI 0.22, 0.70). Limitations: Pretest probability assessment was not available for all analyzed patients. Conclusions: Withholding anticoagulation in patients with suspected DVT based on a single whole-leg CUS is associated with a low risk of VTE (0.46%) during 3 months of follow-up. This strategy represents a safe and efficient alternative to serial CUS testing in patients with suspected DVT. Disclosures: No relevant conflicts of interest to declare.

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Incidence of venous thrombosis following peripheral arterial interventions. A prospective study

VASA ◽

10.1024/0301-1526.37.4.359 ◽

2008 ◽

Vol 37 (4) ◽

pp. 359-363

Author(s):

Schwarz ◽

Rastan ◽

Sixt ◽

Schwarzwälder ◽

Neumann ◽

...

Keyword(s):

Deep Vein Thrombosis ◽

Arterial Intervention ◽

Closure Device ◽

Compression Bandage ◽

Vein Thrombosis ◽

Compression Bandages ◽

Compression Ultrasound ◽

Peripheral Arterial ◽

Deep Vein

Background: The objective of the study was to investigate the incidence of deep vein thrombosis (DVT) at the puncture site following peripheral interventions and to assess if there is a difference between using a vascular closure by means of vascular closure systems or compression bandages. Patients and methods: We prospectively included 474 consecutive patients after peripheral arterial interventions. The day after peripheral arterial intervention we performed venous compression ultrasound to exclude DVT in the area of the groin. We recorded management of arterial closure and subsequent antithrombotic treatment of the patient. Four weeks after intervention follow-up was performed by phone to exclude clinical DVT, pulmonary embolism (PE), and death. Results: We included 474 consecutive patients (mean age 69 y; 298 male / 176 female). All patients were under oral antiplatelet therapy. Vascular closure was achieved in 296 patients (62.44%) by Femostop™ followed by compression bandage and in 178 (37.56 %) by using a vascular closure device alone. Sonography revealed no DVT the day after intervention, no clinical PE occurred. Four weeks follow-up showed no DVT, but there was one patient in the compression bandage group who had PE without proven deep vein thrombosis. Two patients died from other reasons than PE. Conclusions: The immediate and mid-term risk of DVT after peripheral arterial interventions is extremely low and is not increased if compression bandages are used for vascular closure.

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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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Recurrence of Upper Extremity Deep Vein Thrombosis Secondary to COVID-19

Viruses ◽

10.3390/v13050878 ◽

2021 ◽

Vol 13 (5) ◽

pp. 878

Author(s):

Yesha H. Parekh ◽

Nicole J. Altomare ◽

Erin P. McDonnell ◽

Martin J. Blaser ◽

Payal D. Parikh

Keyword(s):

Deep Vein Thrombosis ◽

Lower Extremity ◽

Upper Extremity ◽

Thromboembolic Events ◽

Vein Thrombosis ◽

Venous Thromboembolic Events ◽

Venous Thromboembolic ◽

Deep Vein

Infection with SARS-CoV-2 leading to COVID-19 induces hyperinflammatory and hypercoagulable states, resulting in arterial and venous thromboembolic events. Deep vein thrombosis (DVT) has been well reported in COVID-19 patients. While most DVTs occur in a lower extremity, involvement of the upper extremity is uncommon. In this report, we describe the first reported patient with an upper extremity DVT recurrence secondary to COVID-19 infection.

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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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