Diagnosis Of Deep Vein Thrombosis - “The Case for NonInvasive Testing”

Noninvasive Testing ◽

Vein Thrombosis ◽

Non Invasive ◽

Long Term Follow Up ◽

Deep Vein ◽

High Degree

Ascending venography, although the diagnostic standard for deep vein thrombosis (DVT), has important clinical pitfalls and shortcomings. It is invasive and thus not readily repeated: its use is associated with significant discomfort in many patients and in 3-4% of patients post-veno- graphic phlebitis is induced. A high degree of technical and interpretive skill is required and in up to 20% of patients routine ascending venography fails to visualize the external and common iliac veins. In many hospitals, outpatient access is not readily available necessitating admission to hospital for elective venography. Non-invasive testing with impedance plethysmography (IPG) is gaining increasing acceptance and use because it is objective, versatile and free of morbidity. IPG is sensitive and specific for symptomatic proximal DVT, but has the potential limitation that it is insensitive to calf DVT. Because of this, two different non-invasive approaches are currently advocated: a) serial IPG’s to detect calf vein thrombi which extend proximally (advocates of this approach suggest that calf DVT rarely lead to symptomatic pulmonary emboli unless proximal extension occurs) and b) addition of leg scanning to detect calf DVT. The effectiveness of serial IPG’s is uncertain and to resolve this issue we are currently performing a randomized trial. Multiple large studies however demonstrate that because of both high sensitivity and specificity, the combined approach of IPG and leg scanning provides a replacement for venography in the majority of symptomatic patients. Furthermore, the safety of witholding anticoagulant therapy in patients negative by combined IPG and leg scanning has been confirmed by long-term follow-up. Combined IPG and leg scanning is more cost-effective than elective venography because these non-invasive tests are readily performed in the emergency room or clinic, thus preventing unnecessary admission to hospital of patients with clinically suspected DVT who are negative by testing.

Features of Thrombi and Diagnostic Accuracy of Impedance Plethysmography in Symptomatic and Asymptomatic Deep Vein Thrombosis

10.1055/s-0038-1649563 ◽

1993 ◽

Vol 70 (02) ◽

pp. 266-269 ◽

Cited By ~ 21

Author(s):

Giancarlo Agnelli ◽

Benilde Cosmi ◽

Stefano Radicchia ◽

Franca Veschi ◽

Enrico Boschetti ◽

...

Keyword(s):

Deep Vein Thrombosis ◽

Diagnostic Accuracy ◽

High Sensitivity ◽

Surveillance Programme ◽

Vein Thrombosis ◽

Asymptomatic Patients ◽

High Prevalence ◽

The Mean ◽

SummaryImpedance plethysmography (IPG) has high sensitivity and specificity in patients with symptomatic deep vein thrombosis (DVT) while it fails to detect asymptomatic DVT. The aim of this study was to determine whether the features of thrombi such as location, size and occlusiveness could explain the different accuracy of IPG in symptomatic and asymptomatic DVT patients. One-hundred and seventeen consecutive outpatients with a clinical suspicion of DVT and 246 consecutive patients undergoing hip surgery were admitted to the study. In symptomatic patients IPG was performed on the day of referral, followed by venography, while in asymptomatic patients IPG was performed as a surveillance programme, followed by bilateral venography.A venography proved DVT was observed in 37% of the symptomatic patients and 34% of the asymptomatic limbs. A significantly higher proportion of proximal DVTs was found in symptomatic patients than in asymptomatic patients (78% vs 46%; p = 0.001). The mean Marder score, taken as an index of thrombus size, was significantly higher in symptomatic patients than in asymptomatic patients (19.0 vs 9.6; p = 0.0001). A significantly higher proportion of occlusive DVTs was observed in symptomatic than in asymptomatic patients (69% vs 36%; p = 0.001).We conclude that the unsatisfactory diagnostic accuracy of IPG in asymptomatic DVT is due to the high prevalence of distal, small and non occlusive thrombi. Such thrombi are unlikely to cause a critical obstruction of the venous outflow and therefore to produce a positive IPG.

The Diagnosis of Established Deep Vein Thrombosis

10.1055/s-0039-1687465 ◽

1979 ◽

Author(s):

R. Hull ◽

J. Hirsh

Keyword(s):

Deep Vein Thrombosis ◽

Doppler Ultrasonography ◽

Clinical Symptoms ◽

Reference Method ◽

Vein Thrombosis ◽

Non Invasive ◽

Patient Morbidity ◽

Low Sensitivity ◽

It is now generally accepted that the clinical diagnosis of deep venous thrombosis (DVT) is inaccurate both because of low sensitivity and specificity. Because more than 50% of symptomatic patients fail to show thrombi on venography, anticoagulant therapy on the basis of clinical symptoms of DVT is not acceptable. Venography has been the standard reference method for the diagnosis of DVT but is invasive and consequently associated with patient morbidity. Impedance plethysmography (IPG) and Doppler ultrasonography (Doppler) are both non-invasive and, in patients with clinically suspected DVT, are sensitive and specific tests for proximal DVT. Both tests are relatively insensitive to calf DVT. IPG has the advantage of being an objective technique whereas Doppler is subjective and its accuracy may suffer in inexperienced hands. 125I fibrinogen leg scanning (leg scanning) is an inappropriate test when used alone in patients with clinically suspected DVT as it is insensitive in the upper thigh, may be negative in 30% of patients with established DVT and may take up to 72 hours to become positive. The combination, however, of IPG and leg scanning provides an accurate approach for the detection of both proximal and calf DVT in patients with established DVT. This approach is not associated with patient morbidity and offers the clinician an alternative to venography.

COMPUTERIZED IMPEDANCE PLETHYSMOGRAPHY, A NEW PLETHYSMOGRAPHIC METHOD TO DETECT DEEP VEIN THROMBOSIS

10.1055/s-0038-1642893 ◽

1987 ◽

Author(s):

P Prandoni ◽

M Vigo ◽

M V Huisman ◽

J Jonker ◽

H R Büller ◽

...

Keyword(s):

Deep Vein Thrombosis ◽

Discriminant Analysis ◽

Single Test ◽

Vein Thrombosis ◽

Non Invasive ◽

Impedance Plethysmograph ◽

Deep Vein ◽

Center Study ◽

Sensitive Method

Since the clinical diagnosis of deep vein thrombosis (DVT) is unreliable, several invasive and non-invasive methods have been developed recently. Of these, impedance plethysmography (IPG) is a widely employed technique based on measurement of changes in blood volume produced by temporary obstruction. IPG has been shovn in large prospective studies in symptomatic patients to be a safe and effective alternative to contrast venography, if used either in combination with 1251-fibrinogen legscanning or serially as a single test. Currently available impedance plethysmographs are limited by several technical and operational problems. Therefore, a new computerized impedance plethysmograph (CIP) was developed, having the following characteristics: portability, battery operated and fully automated. A prospective two-center study in 299 consecutive outpatients was done to compare the efficacy of CIP vs. venography in patients with symptomatic DVT. Using a blind design i.e. care was taken to insure that CIP and venography were performed and interpreted independently. The results in patients without venography proven thrombosis and those with proximal vein thrombosis were subjected to a discriminant analysis producing a line of best discrimination between normal and proximal vein thrombosis. In 14 patients it was not possible to obtain an adequate CIP tracing. 12 patients were not entered because of refusal to undergo venography and 15 patients were excluded from analysis because of poor opacification of the proximal veins. On the basis of discriminant analysis 138 of the CIP results were classified as normal and 120 as abnormal. 175 patients were normal on venography and 83 had proximal thrombosis. The sensitivity of CIP for proximal vein thrombosis was thus 95% while the speci-+ ficity was 77%. It is concluded that computerized impedance plethysmography is a potentially sensitive method to detect proximal vein thrombosis in patients with clinically suspected deep vein thrombosis.

The Use Of Non-Invasive Testing And Venography For The Diagnosis Of Acute Recurrent Deep Vein Thrombosis

10.1055/s-0038-1652467 ◽

1981 ◽

Cited By ~ 1

Author(s):

R Hull ◽

C Carter ◽

P Ockelford ◽

J Hirsh ◽

A Zielinsky ◽

...

Keyword(s):

Deep Vein Thrombosis ◽

Anticoagulant Therapy ◽

Clinical Utility ◽

First Episode ◽

Invasive Approach ◽

Vein Thrombosis ◽

Non Invasive ◽

Impedance plethysmography (IPG) combined with leg scanning is highly sensitive and specific for deep vein thrombosis (DVT) in patients with their first episode of clinically suspected DVT. This approach has not been evaluated in patients with suspected recurrent DVT. In this group of patients venography alone is of limited value in excluding acute DVT in the presence of previous DVT but is useful if constant intraluminal filling defects (ILFD) suggesting acute DVT are present. We have evaluated the clinical utility of IPG plus leg scanning and venography in 132 patients with clinically suspected acute recurrent DVT. If the IPG on referral was negative the patient was leg scanned daily for 72 hours and if both were negative, anticoagulant therapy was witheld. The validity and safety of this approach was tested by 3 months follow-up. If IPG was positive, venography was performed to distinguish ILFD’s from chronic DVT. If ILFD’s were detected, anticoagulant therapy was commenced. If no ILFD’s were detected the patient was leg scanned for 72 hours and if negative treatment was witheld. The clinical utility of this non-invasive approach is demonstrated by the results of this study. Of 132 patients, 82 (62%) were negative by both non-invasive tests and none died, developed pulmonary embolism or recurrent DVT during follow-up. The remaining 50 patients were positive by noninvasive testing; in 31 patients ILFD’s were detected and in 16 venography was indeterminate showing collaterals, absent segments, recanalization or inadequate visualization. The leg scan was positive in 10 of the latter 16 patients. Thus the diagnosis of recurrent acute DVT was established by the presence of ILFD’s or a positive leg scan. In 6 patients with a positive IPG, negative leg scan and indeterminate venogram the diagnosis remained uncertain. In conclusion this combined non-invasive and invasive approach provided definitive management in 126 of 132 patients (95%).

The Use of the D-Dimer Test in Combination with Non-Invasive Testing Versus Serial Non-Invasive Testing Alone for the Diagnosis of Deep-Vein Thrombosis

10.1055/s-0038-1648483 ◽

1992 ◽

Vol 67 (05) ◽

pp. 510-513 ◽

Cited By ~ 30

Author(s):

Harriët Heijboer ◽

Jeffrey S Ginsberg ◽

Harry R Büller ◽

Anthonie W A Lensing ◽

Louisa P Colly ◽

...

Keyword(s):

Deep Vein Thrombosis ◽

Combined Approach ◽

Vein Thrombosis ◽

Non Invasive ◽

Diagnostic Approaches ◽

Deep Vein ◽

Real Time Ultrasonography ◽

D Dimer

SummaryWe studied the usefulness of the determination of plasma D-dimer levels (using an ELISA) in combination with non-invasive testing with impedance plethysmography (IPG) or real-time ultrasonography (US) for the diagnosis of deep-vein thrombosis (DVT), in outpatients with clinically suspected DVT This combined approach was compared to serial non-invasive testing alone in these patients. The sensitivity of a positive D-dimer test (>300 μg/1) for the presence of DVT was 100% (70/70 patients; 95% C. I.: 95-100%), whereas the specificity was 29% (69/ 239 patients; 95% C. I.: 23-34%). The proportion of patients in which a definitive decision about the presence or absence of DVT could be made on the day of referral, was calculated for both approaches. When applying the combined approach, in 42% of all referred patients the diagnosis of DVT could either be established or refuted on entry, as opposed to only 19% of patients using serial non-invasive testing alone.Also, the costs per DVT diagnosed were calculated for the two diagnostic approaches. For the diagnosis of DVT the costs using serial IPG were comparable to the costs using the combination of IPG and the D-dimer test. The same conclusion holds for the comparison of serial US with the combination of US and D-dimer testing.We conclude that for the diagnosis of DVT in symptomatic outpatients the combination of non-invasive testing with the D-dimer test might be preferred over serial non-invasive testing alone, although the safety of such an approach remains to be established in future management studies.

Feasibility Study of Catheter-directed Thrombolysis with Recombinant Staphylokinase in Deep Venous Thrombosis

10.1055/s-0037-1614936 ◽

1998 ◽

Vol 79 (03) ◽

pp. 517-519 ◽

Cited By ~ 13

Author(s):

Stephane Heymans ◽

Raymond Verhaeghe ◽

Luc Stockx ◽

Désiré Collen

Keyword(s):

Deep Vein Thrombosis ◽

Continuous Infusion ◽

High Speed ◽

Minor Bleeding ◽

Vein Thrombosis ◽

Catheter Directed Thrombolysis ◽

Long Term Follow Up ◽

Valve Function ◽

Rotating Impeller ◽

SummaryThe feasibility of catheter-directed thrombolysis with recombinant staphylokinase was evaluated in six selected patients with deep vein thrombosis. The patients underwent intrathrombus infusion of recombinant staphylokinase (2 mg bolus followed by a continuous infusion of 1 mg/h). Heparin was given via the catheter as a bolus (5000 U) and as a continuous infusion (1000 U/h). Complete lyis was obtained in five patients and partial lysis in one patient. Complications consisted of minor bleeding in four subjects. Symptomatic reocclusion occurred in one. Debulking of the thrombus mass by a high speed rotating impeller (n = 1) and stenting (n = 3) were used as additional interventions. An underlying anatomical abnormality was present in two patients. Long term follow up revealed normal patency in all patients and normal valve function in four patients. Symptomatic venous insufficiency with valve dysfunction was present in the two with a second thrombotic episode.Thus catheter-directed infusion of recombinant staphylokinase in patients with deep vein thrombosis appears feasible and may be associated with a high frequency of thrombolysis. Larger studies to define the clinical benefit of this treatment appear to be warranted.

Confirmation of the Failure of Computerized Impedance Plethysmography in the Diagnostic Management of Patients with Clinically Suspected Deep-Vein Thrombosis

10.1055/s-0038-1646500 ◽

1991 ◽

Vol 66 (06) ◽

pp. 744-744

Author(s):

Anthonie W A Lensing ◽

Harry R Büller ◽

Jan Wouter ten Cate ◽

Paolo Prandoni

Keyword(s):

Deep Vein Thrombosis ◽

Vein Thrombosis ◽

Diagnostic Management ◽

D-Dimers, Thrombin Antithrombin III Complexes and Prothrombin Fragments 1 + 2: Diagnostic value in Clinically Suspected Deep Vein Thrombosis

10.1055/s-0038-1647449 ◽

1991 ◽

Vol 65 (01) ◽

pp. 028-032 ◽

Cited By ~ 105

Author(s):

B Boneu ◽

G Bes ◽

H Pelzer ◽

P Sié ◽

H Boccalon

Keyword(s):

Deep Vein Thrombosis ◽

Antithrombin Iii ◽

High Sensitivity ◽

Diagnostic Value ◽

Predictive Values ◽

Vein Thrombosis ◽

High Negative Predictive Value ◽

Deep Vein ◽

D Dimer ◽

Mercury Strain Gauge

SummaryThis study was performed to determine the accuracy of D-Dimer fibrin derivatives, thrombin-antithrombin III (TAT) complexes and prothrombin fragments 1 + 2 (F 1 + 2) determinations for the diagnosis of deep vein thrombosis (DVT). One hundred and sixteen consecutive patients referred to the angiology unit of our hospital for a clinically suspected DVT were investigated. They were submitted to mercury strain gauge plethysmography and to ultrasonic duplex scanning examination; in cases of inconclusive results or of proximal DVT (n = 35), an ascending phlebography was performed. After these investigations were completed, the diagnosis of DVT was confirmed in 34 and excluded in 82. One half of the patients were already under anticoagulant therapy at the time of investigation. The 3 biological markers were assayed using commercially available ELISA techniques and the D-Dimer was also assayed with a fast latex method. The normal distribution of these markers was established in 40 healthy blood donors. The most accurate assay for the diagnosis of DVT was the D-Dimer ELISA which had both a high sensitivity (94%) and a high negative predictive value (95%). The D-Dirner latex, TAT complexes and F 1 + 2 were far less sensitive and provided negative predictive values which ranged between 78 and 85%. In spite of positive and significant correlations between the levels of ihe 3 markers, their association did not improve their overall accuracy for detecting D\/L Therefore, with the exception of the D-Dimer ELISA, these markers were of little value for the diagnosis of DVT in this specific population.

Diagnosis of Deep Vein Thrombosis by Combination of Doppler Ultrasound Flow Examination and Strain Gauge Plethysmography

10.1055/s-0038-1657149 ◽

1982 ◽

Vol 47 (02) ◽

pp. 141-144 ◽

Cited By ~ 7

Author(s):

H Bounameaux ◽

B Krähenbühl ◽

S Vukanovic

Keyword(s):

Deep Vein Thrombosis ◽

Negative Predictive Value ◽

Doppler Ultrasound ◽

Strain Gauge ◽

Predictive Value ◽

Lower Limbs ◽

Vein Thrombosis ◽

Non Invasive ◽

Strain Gauge Plethysmography ◽

SummaryDoppler ultrasound flow examination, strain gauge plethysmography and contrast venography were performed in 160 lower limbs of 80 in-patients. Deep vein thrombosis (DVT) was suspected in 87 limbs. Using measurement of venous stop-flow pressure, the Doppler method had an overall sensitivity of 83%. By combined use of Doppler and Plethysmography, sensitivity was increased to 96%. Specificity was 62% and 51%, respectively. With a positive and a negative predictive value of 80% and 73%, respectively, the combination of both non-invasive methods cannot reliably replace venography in the diagnosis of DTV, although all (40/40) thromboses proximal to or involving the popliteal segment were detected by either Doppler and Plethysmography or both.After exclusion of 14 patients (18%) suffering from conditions known to alter the results of these non-invasive methods, the positive predictive value of abnormal findings in both Doppler and Plethysmography was increased to 94% for suspected limbs, whilst negative predictive value of both negative Doppler and Plethysmography was 90%, allowing the avoidance of venography in these patients.