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.

Could a D-dimer/fibrinogen ratio have a role in ruling-out venous thromboembolism?

2021 ◽  
pp. emermed-2020-210688
Author(s):  
Teodoro Marcianò ◽  
Stefano Franchini
Keyword(s):  
Pulmonary Embolism ◽  
Deep Vein Thrombosis ◽  
Venous Thromboembolism ◽  
Chart Review ◽  
Chest Ct ◽  
Low Risk ◽  
Vein Thrombosis ◽  
Deep Vein ◽  
Test Probability ◽  
D Dimer

BackgroundDiagnosis of venous thromboembolism (VTE) requires chest CT angiography for pulmonary embolism and venous ultrasound for deep vein thrombosis. To reduce imaging, guidelines recommend D-dimer levels to rule-out VTE in patients with a low pre-test probability. The most widely used D-dimer cut-off is 500 ng/mL. This cut-off has low specificity, meaning many patients without disease require imaging.MethodsIn this retrospective chart review, we evaluated the diagnostic performance of the D-dimer/fibrinogen ratio (DFR) for identifying thromboembolism and compared it to the performance of two different D-dimer cut-offs (500 ng/mL and 1000 ng/mL) in patients who underwent a chest CT angiography or a venous ultrasound in the ED of San Raffaele Hospital, Italy, in 2017. Patients had a retrospective Wells score calculated after chart review, identifying both high-risk and low-risk pre-test probability patients for this study and low probability patients were further stratified into low-risk of deep vein thrombosis or pulmonary embolism.ResultsEnrolled patients included 92 with suspected pulmonary embolism and 154 with suspected deep vein thrombosis; of whom 67 (27%) were diagnosed with VTE. The most accurate cut-off for DFR in terms of discriminative power was 2.65. In the whole sample and in low-risk patients, this cut-off had the same sensitivity values of the 500 ng/mL D-dimer cut-off (97% (95% CI: 89.8% to 99.2%)), while slightly lower sensitivity values were found for the 1000 ng/mL D-dimer cut-off (95.5% (95% CI: 87.6% to 98.5%)). Specificity was higher for the 2.65 DFR cut-off (55.3% (95% CI: 48.0% to 62.4%)) in the whole sample compared with both 500 ng/mL D-dimer cut-off (22.9% (95% CI: 17.4% to 29.6%)) and 1000 ng/mL D-dimer cut-off (45.8% (95% CI: 38.7% to 53.1%)). Similar results were found in all subgroups.ConclusionA DFR, with a cut-off of 2.65, may improve the specificity for VTE patients when compared with D-dimer alone in high-risk VTE emergency medicine populations. This is exploratory information only, needing evaluation in prospective, multicentre studies, prior to consideration for use in routine clinical work.

Venous Thromboembolism

2020 ◽  
Author(s):  
Samuel Z. Goldhaber
Keyword(s):  
Risk Factors ◽  
Pulmonary Embolism ◽  
Venous Thromboembolism ◽  
Venous Thrombosis ◽  
Antithrombotic Agents ◽  
Vein Thrombosis ◽  
Recurrent Venous Thrombosis ◽  
Deep Vein ◽  
D Dimer ◽  
In Pregnancy

Venous thromboembolism, which involves venous thrombosis and pulmonary embolism, is a leading cause of morbidity and mortality in hospitalized patients and is being seen with increasing frequency in outpatients. This chapter discusses the risk factors, etiology, classification, pathophysiology, natural history, prognosis, diagnosis (including venous thrombosis, recurrent venous thrombosis, and pulmonary embolism), prophylaxis, and treatment of venous thromboembolism (including the pharmacology of antithrombotic agents), as well as venous thromboembolism in pregnancy and miscellaneous thromboembolic disorders (including thrombosis of unusual sites).  This review contains 8 figures, 16 tables, and 79 references. Keywords: Venous thromboembolism, pulmonary embolism, deep vein thrombosis, embolectomy, thrombolysis, hypercoagulability, duplex ultrasonography, D-dimer, anticoagulation

scholarly journals Highly Elevated Quantitative D-Dimer Assay Values Increase the Likelihood of Venous Thromboembolism

TH Open ◽  
2019 ◽  
Vol 03 (01) ◽  
pp. e2-e9 ◽  
Author(s):  
Samuel Francis ◽  
Alexander Limkakeng ◽  
Hui Zheng ◽  
Judd Hollander ◽  
Gregory Fermann ◽  
...  
Keyword(s):  
Venous Thromboembolism ◽  
Prospective Observational Study ◽  
Secondary Analysis ◽  
Pulmonary Angiography ◽  
Ct Pulmonary Angiography ◽  
Vein Thrombosis ◽  
Ultrasound Computed Tomography ◽  
Deep Vein ◽  
Work Up ◽  
D Dimer

Objectives In patients with suspected venous thromboembolism (VTE), the D-dimer assay is commonly utilized as part of the workup. The assay is primarily used to determine whether to proceed with radiographic imaging. We compared D-dimer levels in patients suspected of having VTE. We hypothesized that higher D-dimer values predict a higher likelihood of subsequent VTE diagnosis. Methods We conducted a secondary analysis of a multinational, prospective observational study of low- to intermediate-risk adult patients presenting to the emergency department with suspicion of VTE. Demographic and clinical data were collected in a structured manner. Advanced imaging including ultrasound, computed tomography (CT) pulmonary angiography, and ventilation/perfusion scanning was obtained at the discretion of the treating physicians. Imaging was evaluated by board-certified radiologists in real time. D-dimer values' bins were evaluated using a logistic regression model. Results We evaluated 1,752 patients for suspected deep vein thrombosis (DVT), with 191 (10.4%) DVT positive. We evaluated 1,834 patients for suspected pulmonary embolism (PE), with 108 (5.9%) PE positive. Higher D-dimer values in both groups were associated with higher likelihood of subsequent VTE diagnosis, with D-dimer values > 3,999 ng/mL in both groups having the highest incidence of VTE. More than 50% of those patients were VTE positive. Conclusions Increasing D-dimer values predict increased likelihood of being found VTE positive in this patient population. Among those in the highest D-dimer category, > 3,999 ng/mL, over half of patients were VTE positive. Further research could determine additional nuance in D-dimer as a tool to work up suspected VTE.

scholarly journals Combined CT Pulmonary Angiography & Indirect CT Venography in Evaluation of Clinically Suspected Cases of Pulmonary Embolism- Our Experience in an Oncologic Setup

2013 ◽  
Vol 3 (1) ◽  
pp. 40-52
Author(s):  
Anuj Thankral ◽  
D Thakral ◽  
E Mohamed ◽  
EP Singh ◽  
H Lal
Keyword(s):  
Pulmonary Embolism ◽  
Clinical Symptoms ◽  
Imaging Modality ◽  
Pulmonary Angiography ◽  
Ct Pulmonary Angiography ◽  
Ct Venography ◽  
Vein Thrombosis ◽  
Presenting Symptoms ◽  
Pulmonary Scintigraphy ◽  
Time Required

The study was aimed at evaluating role of CT Pulmonary Angiography (CTPA) and Indirect CT venography (ICTV) in clinically suspected pulmonary embolism (PE) in oncology setup.17/31 (54.9%) patients were diagnosed with PE with or without deep vein thrombosis. DVT was diagnosed in 12(38.7%). 1 patient had DVT in absence of PE while 13/31 (41.9%) patients were diagnosed not to have PE or DVT. Clinical symptoms or pre-test probability determined by Well’s criteria and other laboratory investigations were not found predictive of PE. CTPA diagnosed PE with greater ease, shorter time required with no dependence on clinical pretest probability unlike pulmonary scintigraphy. In cases with CTPA negative for PE, CT described additional findings possibly explaining patient’s presenting symptoms unlike negative pulmonary scintigraphy. In cases where PE was excluded, CTV identified DVT (if present) in the same sitting, obviating separate venous Doppler. A single investigation with ability to deal with complete spectrum of DVT and PE makes CTPA & ICTV ‘one stop shop’ imaging modality for PE and DVT. Nepalese Journal of Radiology / Vol.3 / No.1 / Issue 4 / Jan-June, 2013 / 40-52 DOI: http://dx.doi.org/10.3126/njr.v3i1.8795

Performance of a diagnostic algorithm based on a prediction rule, D-dimer and CT-scan for pulmonary embolism in patients with previous venous thromboembolism

2015 ◽  
Vol 113 (02) ◽  
pp. 406-413 ◽  
Author(s):  
Paul L. den Exter ◽  
Inge C. M. Mos ◽  
Menno V. Huisman ◽  
Frederikus A. Klok ◽  
Maria José Fabiá Valls ◽  
...  
Keyword(s):  
Pulmonary Embolism ◽  
Venous Thromboembolism ◽  
Random Effect ◽  
Prediction Rule ◽  
Diagnostic Algorithm ◽  
Clinical Prediction Rule ◽  
Incidence Rates ◽  
Specific Patient ◽  
History Of ◽  
D Dimer

SummaryDiagnostic management of suspected pulmonary embolism (PE) in patients with a history of venous thromboembolism (VTE) is complicateddue to persistent abnormal D-dimer levels, residual embolic obstruction and higher clinical prediction rule (CPR) scores. We aimed to evaluate the safety and efficiency of the standard diagnostic algorithm consisting of a CPR, D-dimer test and computed tomography pulmonary angiography (CTPA) in this specific patient category. We performed a systematic literature search for prospective studies evaluating a diagnostic algorithm in consecutive patients with clinically suspected PE and a history of VTE. The VTE incidence rates during three-month follow-up and the number of indicated CTPAs were pooled using random effect models. Four studies concerning 1,286 patients were included with a pooled baseline PE prevalence of 36 % (95 % confidence interval [CI] 30–42). In only 217 patients (15 %; 95 %CI 11–20) PE could be excluded without CTPA. The three-month VTE incidence rate was 0.8 % (95 %CI 0.06–2.4) in patients managed without CTPA, 1.6 % (95 %CI 0.3–4.0) in patients in whom PE was excluded by CTPA and 1.4 % (95 %CI 0.6–2.7) overall. In the pooled studies, PE was safely excluded in patients with a history of VTE based on a CPR followed by a D-dimer test and/or CTPA, although the efficiency of the algorithm is relatively low compared to patients without a history of VTE.

Comparison of clinical probability-adjusted D-dimer and age-adjusted D-dimer interpretation to exclude venous thromboembolism

2017 ◽  
Vol 117 (10) ◽  
pp. 1937-1943 ◽  
Author(s):  
Jim Julian ◽  
Lori-Ann Linkins ◽  
Shannon Bates ◽  
Clive Kearon ◽  
Sarah Takach Lapner
Keyword(s):  
Pulmonary Embolism ◽  
Deep Vein Thrombosis ◽  
Venous Thromboembolism ◽  
Diagnostic Accuracy ◽  
Blood Samples ◽  
Vein Thrombosis ◽  
Clinical Probability ◽  
Deep Vein ◽  
New Strategies ◽  
D Dimer

SummaryTwo new strategies for interpreting D-dimer results have been proposed: i) using a progressively higher D-dimer threshold with increasing age (age-adjusted strategy) and ii) using a D-dimer threshold in patients with low clinical probability that is twice the threshold used in patients with moderate clinical probability (clinical probability-adjusted strategy). Our objective was to compare the diagnostic accuracy of age-adjusted and clinical probability-adjusted D-dimer interpretation in patients with a low or moderate clinical probability of venous thromboembolism (VTE). We performed a retrospective analysis of clinical data and blood samples from two prospective studies. We compared the negative predictive value (NPV) for VTE, and the proportion of patients with a negative D-dimer result, using two D-dimer interpretation strategies: the age-adjusted strategy, which uses a progressively higher D-dimer threshold with increasing age over 50 years (age in years × 10 µg/L FEU); and the clinical probability-adjusted strategy which uses a D-dimer threshold of 1000 µg/L FEU in patients with low clinical probability and 500 µg/L FEU in patients with moderate clinical probability. A total of 1649 outpatients with low or moderate clinical probability for a first suspected deep vein thrombosis or pulmonary embolism were included. The NPV of both the clinical probability-adjusted strategy (99.7%) and the age-adjusted strategy (99.6%) were similar. However, the proportion of patients with a negative result was greater with the clinical probability-adjusted strategy (56.1% vs, 50.9%; difference 5.2%; 95% CI 3.5% to 6.8%). These findings suggest that clinical probability-adjusted D-dimer interpretation is a better way of interpreting D-dimer results compared to age-adjusted interpretation.

Venous Thromboembolism

2020 ◽  
Author(s):  
Samuel Z. Goldhaber
Keyword(s):  
Risk Factors ◽  
Pulmonary Embolism ◽  
Venous Thromboembolism ◽  
Venous Thrombosis ◽  
Antithrombotic Agents ◽  
Vein Thrombosis ◽  
Recurrent Venous Thrombosis ◽  
Deep Vein ◽  
D Dimer ◽  
In Pregnancy

Venous thromboembolism, which involves venous thrombosis and pulmonary embolism, is a leading cause of morbidity and mortality in hospitalized patients and is being seen with increasing frequency in outpatients. This chapter discusses the risk factors, etiology, classification, pathophysiology, natural history, prognosis, diagnosis (including venous thrombosis, recurrent venous thrombosis, and pulmonary embolism), prophylaxis, and treatment of venous thromboembolism (including the pharmacology of antithrombotic agents), as well as venous thromboembolism in pregnancy and miscellaneous thromboembolic disorders (including thrombosis of unusual sites).  This review contains 8 figures, 16 tables, and 79 references. Keywords: Venous thromboembolism, pulmonary embolism, deep vein thrombosis, embolectomy, thrombolysis, hypercoagulability, duplex ultrasonography, D-dimer, anticoagulation

Venous Thromboembolism

2020 ◽  
Author(s):  
Samuel Z. Goldhaber
Keyword(s):  
Risk Factors ◽  
Pulmonary Embolism ◽  
Venous Thromboembolism ◽  
Venous Thrombosis ◽  
Antithrombotic Agents ◽  
Vein Thrombosis ◽  
Recurrent Venous Thrombosis ◽  
Deep Vein ◽  
D Dimer ◽  
In Pregnancy

Venous thromboembolism, which involves venous thrombosis and pulmonary embolism, is a leading cause of morbidity and mortality in hospitalized patients and is being seen with increasing frequency in outpatients. This chapter discusses the risk factors, etiology, classification, pathophysiology, natural history, prognosis, diagnosis (including venous thrombosis, recurrent venous thrombosis, and pulmonary embolism), prophylaxis, and treatment of venous thromboembolism (including the pharmacology of antithrombotic agents), as well as venous thromboembolism in pregnancy and miscellaneous thromboembolic disorders (including thrombosis of unusual sites).  This review contains 8 figures, 16 tables, and 79 references. Keywords: Venous thromboembolism, pulmonary embolism, deep vein thrombosis, embolectomy, thrombolysis, hypercoagulability, duplex ultrasonography, D-dimer, anticoagulation

The value of 64-detector row computed tomography for the exclusion of pulmonary embolism

2011 ◽  
Vol 105 (05) ◽  
pp. 901-907 ◽  
Author(s):  
Giorgio de Conti ◽  
Isabella Minotto ◽  
Lucia Filippi ◽  
Marta Mongiat ◽  
Daniele de Faveri ◽  
...  
Keyword(s):  
Computed Tomography ◽  
Pulmonary Embolism ◽  
Clinical Decision ◽  
First Episode ◽  
Diagnostic Strategy ◽  
Clinical Disorder ◽  
Vein Thrombosis ◽  
Test Probability ◽  
D Dimer

SummaryRecently, a diagnostic strategy using a clinical decision rule, D-dimer testing and spiral computed tomography (CT) was found to be effective in the evaluation of patients with clinically suspected pulmonary embolism (PE). However, the rate of venous thromboembolic complications in the three-month follow-up of patients with negative CT was still substantial and included fatal events. It was the objective to evaluate the safety of withholding anticoagulants after a normal 64-detector row CT (64-DCT) scan from a cohort of patients with suspected PE. A total of 545 consecutive patients with clinically suspected first episode of PE and either likely pre-test probability of PE (using the simplified Wells score) or unlikely pre-test probability in combination with a positive D-dimer underwent a 64-DCT. 64-DCT scanning was inconclusive in nine patients (1.6%), confirmed the presence of PE in 169 (31%), and ruled out the diagnosis in the remaining 367. During the three-month follow-up of the 367 patients one developed symptomatic distal deep-vein thrombosis (0.27%; 95%CI, 0.0 to 1.51%) and none developed PE (0 %; 95%CI, 0 to 1.0%). We conclude that 64-DCT scanning has the potential to safely exclude the presence of PE virtually in all patients presenting with clinical suspicion of this clinical disorder.

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.

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