Evolution of untreated calf deep-vein thrombosis in high risk symptomatic outpatients: The blind, prospective CALTHRO study

SummaryThe natural history of calf deep-vein thrombosis (DVT) is still uncertain and it is debated whether it warrants to be diagnosed and treated. We aimed to investigate the complication rate of untreated isolated calf DVT (ICDVT). Symptomatic outpatients were prospectively managed with serial compression ultrasonography (SCUS). Those without proximal DVT and with likely pre-test clinical probability (PCP) or altered D-dimer received immediate subsequent complete examination of calf deep veins (CCUS) by a different operator. The result of CCUS was kept blind both to the managing doctor and the patient and disclosed after three months. Primary outcome was the rate of venous thromboembolism at three months. We examined 431 subjects (196 males; median age 68.0 years) in whom five outcomes were recorded (1.2%; 95% confidence intervals [CI]: 0.4–2.7). If CCUS results had been available, outcomes would have been recorded in 3/424 patients (0.7%; 95% CI: 0.2–2.1) with two events in subjects negative at both serial and complete CUS. ICDVT was diagnosed in 65 subjects (15.3%; 95% CI: 12–19); of whom 59 remained uneventful (one was lost to follow-up). A significant higher rate of outcomes was recorded in subjects with than without ICDVT (5/64; 7.8%; 95% CI: 3–17 vs. 3/351; 0.8%; 95% CI: 0–2; p=0.003). However, after excluding two events picked at serial CUS in subjects with ICDVT, the difference became barely significant (3/64; 4.7%; 95% CI: 1–13; p=0.049). Thrombotic evolution of untreated ICDVT in high-risk subjects may be relevant. Larger studies are needed to address this issue.

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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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Warfarin-Induced Spontaneous Bilateral Breast and Extrathoracic Hematoma in an Elderly Woman

The Journal of Tehran University Heart Center ◽

10.18502/jthc.v15i2.4190 ◽

2020 ◽

Author(s):

Behnam Shakerian ◽

Negin Razavi

Keyword(s):

Deep Vein Thrombosis ◽

Lower Extremity ◽

Rare Disease ◽

Chest Wall ◽

Elderly Woman ◽

Warfarin Therapy ◽

Vein Thrombosis ◽

History Of ◽

Deep Vein

Warfarin- induced spontaneous breast hematoma is a very rare disease, with only a few cases having been reported in the literature so far. We describe an 80-year-old woman who had warfarin therapy due to deep vein thrombosis in a lower extremity. The patient was admitted with a history of swelling and red area on her bilateral breasts, chest wall, right arm, and right flank. She was treated conservatively with success. She was discharged after about 3 weeks without complications and was well at 6 months’ follow-up.

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A Negative D-dimer Excludes Recurrent Deep Vein Thrombosis: Results of a Multicentre Management Study.

Blood ◽

10.1182/blood.v110.11.698.698 ◽

2007 ◽

Vol 110 (11) ◽

pp. 698-698 ◽

Cited By ~ 9

Author(s):

Shannon Bates ◽

Clive Kearon ◽

Susan Kahn ◽

Jim A. Julian ◽

Mark A. Crowther ◽

...

Keyword(s):

Deep Vein Thrombosis ◽

High Sensitivity ◽

Vein Thrombosis ◽

Recurrent Deep Vein Thrombosis ◽

Clinically Significant ◽

Suspected Recurrence ◽

Lost To Follow Up ◽

Deep Vein ◽

D Dimer

Abstract The high frequency of residual radiologic abnormalities after initial deep vein thrombosis (DVT) makes management of patients with suspected recurrence difficult. D-dimer (DD) and serial compression ultrasonography (CUS) of the proximal veins have a high sensitivity and negative predictive value (NPV) in suspected first DVT. We hypothesized that it would be safe to withhold anticoagulation in patients with suspected recurrence who had a negative sensitive DD or negative serial CUS when DD testing was positive. In a multicentre prospective cohort study, patients underwent DD testing with an immunoturbidometric assay (MDA DD). If the DD was negative (<0.5 ug fibrinogen equivalent units [FEU]/mL), patients had no further testing. If the DD was positive, CUS was performed and, if normal, repeated after 1–3 and 7–10 days. Patients with a positive DD and abnormal CUS at presentation were managed as per their treating physician. Patients were followed for 3 months to detect venous thromboembolism (VTE) and suspected VTE were adjudicated centrally. Of the 504 patients enrolled in this study, 14 were subsequently deemed ineligible and 2 patients were lost to follow-up. The overall prevalence of confirmed recurrent DVT at presentation or during follow-up was 17%. 230 patients had a negative DD at presentation and, of the 227 evaluable patients, 4 had definite confirmed VTE (NPV of DD = 98%; 95% Confidence Interval [CI], 96–99%). Of the 135 patients with a positive DD and normal initial CUS, serial CUS was negative in 129 cases. Of these patients, 3 had definite VTE during follow-up (NPV of serial CUS in patients with positive DD = 98%; 95% CI, 93–99%). These results suggest that a negative MDA DD result excludes clinically significant recurrent DVT and that anticoagulants can also be safely withheld in patients with negative serial CUS, even if their DD is positive. This simple diagnostic approach can be used to safely manage approximately 70% of patients with suspected recurrent DVT.

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Practical diagnostic management of patients with clinically suspected deep vein thrombosis by clinical probability test, compression ultrasonography, and D-dimer test

The American Journal of Medicine ◽

10.1016/s0002-9343(02)01347-5 ◽

2002 ◽

Vol 113 (8) ◽

pp. 630-635 ◽

Cited By ~ 58

Author(s):

Lidwine W Tick ◽

Evelien Ton ◽

Theo van Voorthuizen ◽

Marcel M.C Hovens ◽

Ivonne Leeuwenburgh ◽

...

Keyword(s):

Deep Vein Thrombosis ◽

Vein Thrombosis ◽

Test Compression ◽

Clinical Probability ◽

Diagnostic Management ◽

Deep Vein ◽

D Dimer ◽

Compression Ultrasonography

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Natural History of Isolated Below-Knee Vein Thrombosis in Patients with Spinal Cord Injury

Healthcare ◽

10.3390/healthcare9070861 ◽

2021 ◽

Vol 9 (7) ◽

pp. 861

Author(s):

Jang-Hyuk Cho ◽

Dong-Gyu Lee

Keyword(s):

Spinal Cord ◽

Spinal Cord Injury ◽

Deep Vein Thrombosis ◽

Natural History ◽

Vein Thrombosis ◽

Asian Patients ◽

Cord Injury ◽

History Of ◽

Deep Vein

In the general population, serial imaging is recommended over anticoagulant therapy for below-knee deep vein thrombosis (BKDVT). However, no clinical trial in Asian patients with spinal cord injury and BKDVT has been performed. Therefore, we evaluated the natural course of BKDVT in patients with acute spinal cord injury. We retrospectively analyzed inpatients with spinal cord injury with BKDVT between 2016 and 2020. All patients underwent inpatient rehabilitation treatment and duplex ultrasonographic examination of both the lower extremities at follow-up. After screening 172 patients with acute spinal cord injury for deep vein thrombosis using duplex ultrasound, 27 patients with below-the-knee deep vein thrombosis were included in this study. The mean lower-extremity motor score (median, interquartile range) was 66.0, 54.0–74.5. Sixteen patients received a non-vitamin K antagonist oral anticoagulant (NOAC) for anticoagulation. None of the patients had proximal propagation according to the follow-up duplex ultrasonography. BKDVT disappearance was not significantly different between the NOAC treatment and non-treatment groups. Asian patients with spinal cord injury have a low incidence of venous thromboembolism and favorable natural history of BKDVT. We recommend serial imaging over anticoagulant therapy for BKDVT in these patients.

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Natural history of deep vein thrombosis in children

Phlebology The Journal of Venous Disease ◽

10.1177/0268355514536154 ◽

2014 ◽

Vol 30 (6) ◽

pp. 412-417 ◽

Cited By ~ 10

Author(s):

G Spentzouris ◽

A Gasparis ◽

RJ Scriven ◽

TK Lee ◽

N Labropoulos

Keyword(s):

Deep Vein Thrombosis ◽

Signs And Symptoms ◽

Chronic Venous Disease ◽

Venous Disease ◽

Vein Thrombosis ◽

History Of ◽

Recurrent Deep Vein Thrombosis ◽

Acute Deep Vein Thrombosis ◽

Deep Vein

Objective To determine the natural history of deep vein thrombosis in children presented with a first episode in the lower extremity veins. Methods Children with objective diagnosis of acute deep vein thrombosis were followed up with ultrasound and clinical examination. Risk factors and clinical presentation were prospectively collected. The prevalence of recurrent deep vein thrombosis and the development of signs and symptoms of chronic venous disease were recorded. Results There were 27 children, 15 males and 12 females, with acute deep vein thrombosis, with a mean age of 4 years, range 0.1–16 years. The median follow-up was 23 months, range 8–62 months. The location of thrombosis involved the iliac and common femoral vein in 18 patients and the femoral and popliteal veins in 9. Only one vein was affected in 7 children, two veins in 14 and more than two veins in 6. Recurrent deep vein thrombosis occurred in two patients, while no patient had a clinically significant pulmonary embolism. Signs and symptoms of chronic venous disease were present at last follow-up in 11 patients. There were nine patients with vein collaterals, but no patient developed varicose veins. Reflux was found in 18 veins of 11 patients. Failure of recanalization was seen in 7 patients and partial recanalization in 11. Iliofemoral thrombosis ( p = 0.012) and failure to recanalize ( p = 0.036) increased significantly the risk for developing signs and symptoms. Conclusions Children with acute proximal deep vein thrombosis develop mild chronic venous disease signs and symptoms at mid-term follow-up and are closely related with iliofemoral thrombosis and failure to recanalization.

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Increased Warfarin Requirements during Concurrent Dicloxacillin Therapy

Journal of Pharmacy Technology ◽

10.1177/875512251202800504 ◽

2012 ◽

Vol 28 (5) ◽

pp. 197-200 ◽

Cited By ~ 1

Author(s):

Kelsey N Kohman ◽

Rebecca L Dunn ◽

Winter J Smith

Keyword(s):

Warfarin Dose ◽

International Normalized Ratio ◽

Heparin Therapy ◽

Probability Scale ◽

Vein Thrombosis ◽

Therapeutic Anticoagulation ◽

History Of ◽

Lost To Follow Up ◽

Deep Vein

Objective: To report on a patient who required increased dosages of warfarin to achieve therapeutic anticoagulation while taking dicloxacillin. Case Summary: A 60-year-old woman was hospitalized for an infected lymphocele and cellulitis. Based on microbiology results, dicloxacillin 500 mg by mouth 4 times daily was initiated to complete 14 days of treatment. Concurrently, a deep vein thrombosis was diagnosed by computed tomography angiography. Enoxaparin 100 mg subcutaneously twice daily and warfarin 5 mg by mouth daily were initiated with an international normalized ratio (INR) goal of 2–3. The patient had a history of a supratherapeutic INR while on warfarin 5 mg daily. Throughout the 20-day hospitalization, her warfarin dose was steadily increased in an attempt to achieve a therapeutic INR. Required doses ranged from 7.5 to 15 mg daily. Two days after discontinuation of dicloxacillin and with administration of a 15-mg warfarin boost, the INR was therapeutic at 2.3. Enoxaparin was discontinued and the patient was discharged on warfarin 7.5 mg daily. Upon clinic follow-up 5 days after discharge, the INR was supratherapeutic at 3.3 and the warfarin dose was decreased. The patient was then lost to follow-up. Discussion: This interaction between warfarin and dicloxacillin has been described in the literature; however, the mechanism responsible remains unknown. In all cases reported, increased warfarin requirements appeared after several days of dicloxacillin therapy and slowly disappeared after dicloxacillin discontinuation. This case differs from previously reported cases because it demonstrates warfarin resistance associated with dicloxacillin and a subsequent new initiation of warfarin therapy. The Naranjo probability scale and the Horn Drug Interaction Probability Scale both rate this interaction as probable. Conclusions: Patients taking dicloxacillin who are initiated on warfarin may require a longer duration of concurrent low-molecular-weight heparin therapy, as well as higher doses of warfarin, and may take longer to achieve a therapeutic INR.

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Is Colour Doppler Ultrasound a Sensitive Screening Method in Diagnosing Deep Vein Thrombosis after Hip Surgery ?

Thrombosis and Haemostasis ◽

10.1055/s-0038-1650252 ◽

1996 ◽

Vol 75 (02) ◽

pp. 242-245 ◽

Cited By ~ 20

Author(s):

Marie Magnusson ◽

Bengt I Eriksson ◽

Peter Kãlebo ◽

Ramon Sivertsson

Keyword(s):

Deep Vein Thrombosis ◽

High Risk ◽

Doppler Ultrasound ◽

Predictive Value ◽

Screening Method ◽

Colour Doppler ◽

Vein Thrombosis ◽

Colour Doppler Ultrasound ◽

Asymptomatic Patients ◽

Deep Vein

SummaryPatients undergoing orthopedic surgery are at high risk of developing deep vein thrombosis. One hundred and thirty-eight consecutive patients undergoing total hip replacement or hip fracture surgery were included in this study. They were surveilled with colour Doppler ultrasound (CDU) and bilateral ascending contrast phlebography. The prevalence of proximal and distal DVT in this study was 5.8% and 20.3% respectively.CDU has a satisfactory sensitivity in patients with symptomatic deep vein thrombosis, especially in the proximal region. These results could not be confirmed in the present study of asymptomatic patients. The sensitivity was 62.5% (95% confidence interval: C.I. 24-91%) and the specificity 99.6% (C.I. 98-100%) for proximal DVT; 53.6% (C.I. 34-73%) and 98% (C.I. 96-99%) respectively for distal thrombi. The overall sensitivity was 58.1% (C.I. 39-75%) and the specificity 98% (C.I. 96-99%). The positive predictive value was 83.3% (C.I. 36-99%) and 75% (C.I. 51-91%) for proximal and distal DVT respectively. The negative predictive value was 98.9% (C.I. 98-100%) and 94.9% (C.I. 92-98%) for proximal and distal DVT respectively. The results of this study showed that even with a highly specialised and experienced investigator the sensitivity of CDU was too low to make it suitable for screening purposes in a high risk surgical population.

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