Venous thromboembolism diagnosis: unresolved issues

2015 ◽  
Vol 113 (06) ◽  
pp. 1184-1192 ◽  
Author(s):  
Grégoire Le Gal ◽  
Henri Bounameaux ◽  
Marc Righini
Keyword(s):  
Pulmonary Embolism ◽  
Cost Effective ◽  
Pulmonary Angiography ◽  
Diagnostic Strategies ◽  
Diagnostic Algorithms ◽  
Vein Thrombosis ◽  
Compression Ultrasound ◽  
Effective Diagnosis ◽  
Deep Vein ◽  
Management Algorithms

SummaryRecent advances in the management of patients with suspected VTE have both improved diagnostic accuracy and made management algorithms safer, easier to use and well standardised. These diagnostic algorithms are mainly based on the assessment of clinical pretest probability, D-dimer measurement and imaging tests, mainly represented by compression ultrasound (CUS) for suspected DVT and computed tomography pulmonary angiography (CTPA) or lung ventilationperfusion scan for pulmonary embolism. These diagnostic algorithms allow a safe and cost-effective diagnosis for most patients with suspected VTE. In this review, we focus on the challenge of diagnosing VTE in special patient populations, such as elderly patients, pregnant women, or patients with a prior VTE. Some additional challenges are arising that might require adjustments to current diagnostic strategies, such as the reduced clinical suspicion threshold, resulting in a lower proportion of VTE among suspected patients; the overdiagnosis and overtreatment of VTE, especially regarding calf deep-vein thrombosis (DVT) and subsegmental pulmonary embolism (SSPE).

scholarly journals Diagnosis of acute Pulmonary Embolism

2018 ◽  
Vol 38 (01) ◽  
pp. 11-21 ◽  
Author(s):  
Helia Robert-Ebadi ◽  
Marc Righini
Keyword(s):  
Pulmonary Embolism ◽  
Cost Effective ◽  
Pulmonary Angiography ◽  
Suspected Pulmonary Embolism ◽  
Computed Tomography Pulmonary Angiography ◽  
Diagnostic Algorithms ◽  
Effective Diagnosis ◽  
Management Algorithms ◽  
Special Patient ◽  
D Dimer

SummaryDuring the last three decades, considerable advances in the management of patients with suspected pulmonary embolism (PE) have improved diagnostic accuracy and made management algorithms safer, easier to use and well standardized. These diagnostic algorithms are mainly based on the assessment of clinical pretest probability, D-Dimer measurement and imaging tests, mainly computed tomography pulmonary angiography (CTPA). These diagnostic algorithms allow a safe and cost-effective diagnosis for most patients with suspected PE.In this review, we discuss current existing evidence for PE diagnosis, the challenge of diagnosing PE in special patient populations, as well as novel imaging tests for PE diagnosis.

Diagnosis of acute pulmonary embolism and evolving imaging modalities

ESC CardioMed ◽  
2018 ◽  
pp. 2761-2766
Author(s):  
Helia Robert-Ebadi ◽  
Grégoire Le Gal ◽  
Marc Righini
Keyword(s):  
Pulmonary Embolism ◽  
Pulmonary Angiography ◽  
Thoracic Imaging ◽  
Diagnostic Strategies ◽  
Computed Tomographic ◽  
Vein Thrombosis ◽  
Clinical Probability ◽  
Venous Compression ◽  
Computed Tomographic Pulmonary Angiography ◽  
Deep Vein

Modern non-invasive diagnostic strategies for pulmonary embolism rely on the sequential use of clinical probability assessment, D-dimer measurement, and thoracic imaging tests. Planar ventilation/perfusion scintigraphy was the cornerstone test for the diagnosis of pulmonary embolism for more than two decades and has now been replaced by computed tomographic pulmonary angiography (CTPA). Diagnostic strategies using CTPA are very safe to rule out pulmonary embolism and have been well validated in large prospective management outcome studies. Venous compression ultrasonography is the cornerstone test to diagnose deep vein thrombosis but is not mandatory for the diagnosis of pulmonary embolism when using multidetector CTPA.

Cost-effective Diagnosis of Deep Vein Thrombosis and Pulmonary Embolism

2001 ◽  
Vol 86 (07) ◽  
pp. 475-487 ◽  
Author(s):  
Henri Bounameaux ◽  
Arnaud Perrier
Keyword(s):  
Pulmonary Embolism ◽  
Venous Thromboembolism ◽  
Helical Ct ◽  
Cost Effective ◽  
Clinical Problem ◽  
Clinical Situation ◽  
Massive Pulmonary Embolism ◽  
Pulmonary Angiography ◽  
Vein Thrombosis ◽  
Effective Diagnosis

SummarySuspected acute venous thromboembolism is a frequent and challenging clinical problem. Phlebography and pulmonary angiography are costly and invasive and, hence, ill-suited for diagnosing a disease present in only 20% of patients in whom it is suspected. Novel noninvasive instruments, such as plasma D-dimer measurement, lower limb compression ultrasonography and helical CT scan are important breakthroughs in the management of patients with suspected venous thromboembolism. However, none of these instruments is ideal, and they must be combined in rational and cost-effective diagnostic algorithms including clinical assessment, which is increasingly standardized. Such strategies must be validated in management studies, in which patients without venous thromboembolism are not treated and followed up during 3 months. Suspected massive pulmonary embolism is a distinct clinical situation requiring a specific diagnostic approach, in which echocardiography plays a major role. This paper reviews the performance of clinical evaluation and diagnostic tests for venous thromboembolism, and recently validated diagnostic schemes.

scholarly journals Current challenges in diagnostic imaging of venous thromboembolism

Blood ◽  
2015 ◽  
Vol 126 (21) ◽  
pp. 2376-2382 ◽  
Author(s):  
Menno V. Huisman ◽  
Frederikus A. Klok
Keyword(s):  
Pulmonary Embolism ◽  
Deep Vein Thrombosis ◽  
Venous Thromboembolism ◽  
Clinical Decision ◽  
Pretest Probability ◽  
Current Standard ◽  
Diagnostic Algorithms ◽  
Vein Thrombosis ◽  
Compression Ultrasound ◽  
Deep Vein

Abstract Because the clinical diagnosis of deep-vein thrombosis and pulmonary embolism is nonspecific, integrated diagnostic approaches for patients with suspected venous thromboembolism have been developed over the years, involving both non-invasive bedside tools (clinical decision rules and D-dimer blood tests) for patients with low pretest probability and diagnostic techniques (compression ultrasound for deep-vein thrombosis and computed tomography pulmonary angiography for pulmonary embolism) for those with a high pretest probability. This combination has led to standardized diagnostic algorithms with proven safety for excluding venous thrombotic disease. At the same time, it has become apparent that, as a result of the natural history of venous thrombosis, there are special patient populations in which the current standard diagnostic algorithms are not sufficient. In this review, we present 3 evidence-based patient cases to underline recent developments in the imaging diagnosis of venous thromboembolism.

Diagnosis of acute pulmonary embolism and evolving imaging modalities

ESC CardioMed ◽  
2018 ◽  
pp. 2761-2766
Author(s):  
Helia Robert-Ebadi ◽  
Grégoire Le Gal ◽  
Marc Righini
Keyword(s):  
Pulmonary Embolism ◽  
Pulmonary Angiography ◽  
Thoracic Imaging ◽  
Diagnostic Strategies ◽  
Computed Tomographic ◽  
Vein Thrombosis ◽  
Clinical Probability ◽  
Venous Compression ◽  
Computed Tomographic Pulmonary Angiography ◽  
Deep Vein

Modern non-invasive diagnostic strategies for pulmonary embolism rely on the sequential use of clinical probability assessment, D-dimer measurement, and thoracic imaging tests. Planar ventilation/perfusion scintigraphy was the cornerstone test for the diagnosis of pulmonary embolism for more than two decades and has now been replaced by computed tomographic pulmonary angiography (CTPA). Diagnostic strategies using CTPA are very safe to rule out pulmonary embolism and have been well validated in large prospective management outcome studies. Venous compression ultrasonography is the cornerstone test to diagnose deep vein thrombosis but is not mandatory for the diagnosis of pulmonary embolism when using multidetector CTPA.

scholarly journals Current challenges in diagnostic imaging of venous thromboembolism

Hematology ◽  
2015 ◽  
Vol 2015 (1) ◽  
pp. 202-209 ◽  
Author(s):  
Menno V. Huisman ◽  
Frederikus A. Klok
Keyword(s):  
Pulmonary Embolism ◽  
Deep Vein Thrombosis ◽  
Venous Thromboembolism ◽  
Clinical Decision ◽  
Pretest Probability ◽  
Current Standard ◽  
Diagnostic Algorithms ◽  
Vein Thrombosis ◽  
Compression Ultrasound ◽  
Deep Vein

Abstract Because the clinical diagnosis of deep-vein thrombosis and pulmonary embolism is nonspecific, integrated diagnostic approaches for patients with suspected venous thromboembolism have been developed over the years, involving both non-invasive bedside tools (clinical decision rules and D-dimer blood tests) for patients with low pretest probability and diagnostic techniques (compression ultrasound for deep-vein thrombosis and computed tomography pulmonary angiography for pulmonary embolism) for those with a high pretest probability. This combination has led to standardized diagnostic algorithms with proven safety for excluding venous thrombotic disease. At the same time, it has become apparent that, as a result of the natural history of venous thrombosis, there are special patient populations in which the current standard diagnostic algorithms are not sufficient. In this review, we present 3 evidence-based patient cases to underline recent developments in the imaging diagnosis of venous thromboembolism.

Diagnostic performance of complete lower limb venous ultrasound in patients with clinically suspected acute pulmonary embolism

2004 ◽  
Vol 91 (01) ◽  
pp. 187-195 ◽  
Author(s):  
Daniel Colombier ◽  
Gérard Victor ◽  
Marie Elias ◽  
Catherine Arnaud ◽  
Henri Juchet ◽  
...  
Keyword(s):  
Pulmonary Embolism ◽  
Sensitivity And Specificity ◽  
Lower Limb ◽  
Acute Pulmonary Embolism ◽  
Pulmonary Angiography ◽  
Helical Computed Tomography ◽  
Diagnostic Strategies ◽  
Vein Thrombosis ◽  
Clinical Probability ◽  
Deep Vein

SummaryA limited ultrasound (US) confined to the popliteal and femoral veins is usually performed to detect deep vein thrombosis (DVT) in patients with clinically suspected acute pulmonary embolism (PE). Our objective was to assess the diagnostic accuracy of complete lower limb US examining both the proximal and distal veins in this setting. In this prospective study, 210 consecutive patients were included. Complete US was performed by independent operators and compared blindly with a reference strategy combining clinical probability, ventilation perfusion scan and pulmonary angiography to a three-month clinical follow-up. Simultaneously,VIDAS D-dimer (DD) assay and helical computed tomography (HCT) of the lungs were assessed independently and blindly. PE was present in 74 patients (35%). Complete US detected DVT in 91 patients (43%), proximal in 51 and distal in 40. Sensitivity and specificity with a 0.95 confidence interval were respectively 0.93 [0.85 – 0.97] and 0.84 [0.77 – 0.89]. Limited US detected DVT in only 46 patients (22%). Sensitivity and specificity were respectively 0.55 [0.44 – 0.66] and 0.96 [0.92 – 0.98]. For DD they were 0.92 [0.83 – 0.96] and 0.24 [0.17 – 0.32] and for HCT 0.84 [0.73 – 0.90] and 0.87 [0.80 – 0.92]. Complete lower limb US has higher sensitivity and capacity to exclude PE than limited US, but a slightly lower specificity. Complete US results also compared favourably with those of HCT and DD.The utility of including this method in diagnostic strategies for PE needs to be assessed in cost-effectiveness analysis and in outcome studies.

scholarly journals Advances in the Diagnosis of Venous Thromboembolism: A Literature Review

Diagnostics ◽  
2020 ◽  
Vol 10 (6) ◽  
pp. 365 ◽  
Author(s):  
Harish Patel ◽  
Haozhe Sun ◽  
Ali N. Hussain ◽  
Trupti Vakde
Keyword(s):  
Pulmonary Embolism ◽  
Venous Thromboembolism ◽  
Valsalva Maneuver ◽  
Imaging Modality ◽  
Diagnostic Algorithm ◽  
Pulmonary Angiography ◽  
Vein Thrombosis ◽  
Compression Ultrasound ◽  
Test Probability ◽  
D Dimer

The incidence of venous thromboembolism (VTE), including lower extremity deep vein thrombosis (DVT) and pulmonary embolism (PE) is increasing. The increase in suspicion for VTE has lowered the threshold for performing imaging studies to confirm diagnosis of VTE. However, only 20% of suspected cases have a confirmed diagnosis of VTE. Development of pulmonary embolism rule-out criteria (PERC) and update in pre-test probability have changed the paradigm of ruling-out patient with low index of suspicion. The D-dimer test in conjunction to the pre-test probability has been utilized in VTE diagnosis. The age appropriate D-dimer cutoff and inclusion of YEARS algorithm (signs of the DVT, hemoptysis and whether PE is the likely diagnosis) for the D-dimer cutoff have been recent updates in the evaluation of suspected PE. Multi-detector computed tomography pulmonary angiography (CTPA) and compression ultrasound (CUS) are the preferred imaging modality to diagnose PE and DVT respectively. The VTE diagnostic algorithm do differ in pregnant individuals. The prerequisite of avoiding excessive radiation has recruited planar ventilation-perfusion (V/Q) scan as preferred in pregnant patients to evaluate for PE. The modification of CUS protocol with addition of the Valsalva maneuver should be performed while evaluating DVT in pregnant individual.

scholarly journals A comparative analysis of the diagnostic performances of four clinical probability models to rule out pulmonary embolism

2021 ◽  
Vol 10 (Supplement_1) ◽  
Author(s):  
BV Silva ◽  
C Mendonca ◽  
P Silverio Antonio ◽  
A Ferreira ◽  
N Cunha ◽  
...  
Keyword(s):  
Pulmonary Embolism ◽  
Pulmonary Angiography ◽  
Probability Models ◽  
Vein Thrombosis ◽  
Funding Sources ◽  
Clinical Probability ◽  
Low Probability ◽  
Deep Vein ◽  
Rule Out ◽  
Funding Acknowledgements

Abstract Funding Acknowledgements Type of funding sources: None. Background  Ruling out pulmonary embolism (PE) through a combination of clinical assessment and Ddimer is crucial to avoid excessive computed tomography pulmonary angiography (CTPA), and different algorithms should be considered as an alternative to the fixed cutoff to achieve that goal. Purpose  To compare diagnostic performance of 4 algorithms to rule out PE: fixed Ddimer cutoff, age-adjusted, YEARS and PEGeD. Methods  Retrospective study of consecutive outpatients who presented to the emergency department and underwent CTPA for PE suspicion from April 2019 to May 2020. In fixed and age-adjusted cut-off, high probability patients are directly selected for CTPA. Low to moderate probability patients perform CTPA if Ddimer ≥500µg/L in fixed cutoff, and in age-adjusted cutoff if Ddimer ≥500µg/L in patients who are ≤ 50 years of age, and if Ddimer level was more than 10 times the patient’s age in patients older than 50 years. YEARS includes 3 items (signs of deep vein thrombosis, haemoptysis and whether PE is the most likely diagnosis): patients without any YEARS items and Ddimer ≥1000ng/mL or with ≥1 items and Ddimer 500ng/mL perform CTPA. In the PEGeD, patients with high clinical probability or with intermediate and Ddimers >500µg/L or low probability and Ddimer >1000 µg/L are selected for CTPA. Results We enrolled 571 patients and PE was confirmed by CTPA in 172. Compared with a fixed Ddimer cutoff, age-adjusted was associated with a significant increase of specificity (p < 0.001), correctly avoiding 38 CTPAs, without losing sensitivity. YEARS and PEGED resulted in a increase in specificity, compared to the fixed cutoff, but with an impairment of sensitivity (p < 0.001). PEGeD had the worst sensitivity (13 more false negatives (FN) than the fixed cutoff). Despite the lack of difference between PEGed and YEARS strategies regarding sensitivity, PEGED had a significantly higher specificity (p < 0.001) and allowed to correctly avoid a higher number of CTPA (95 vs 85), compared to the fixed cutoff. Conclusion  Compared to fixed d-dimer cutoff, all algorithms were associated with an increased specificity. Age-adjusted cutoff was the only that is not associated with a significant decrease in sensitivity when compared to fixed cutoff, allowing to safely reduce the need to perform CTPA. Sen(%)Spec(%)Correctly avoid CTPAs(n)FN(n)Fixed cutoff251017Age-adjusted933513912YEARS894718619PEGED884919620

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