0

The full content of Annals is available to subscribers

Subscribe/Learn More  >
Reviews |

Noninvasive Diagnosis of Deep Venous Thrombosis

Clive Kearon, MB, PhD; Jim A. Julian; M Math; Toni E. Newman, BA; and Jeffrey S. Ginsberg, MD
[+] Article and Author Information

for the McMaster Diagnostic Imaging Practice Guidelines Initiative. For members of the McMaster Diagnostic Imaging Practice Guidelines Initiative, Diagnosis of Deep Venous Thrombosis Working Group, see Appendix. Grant Support: Dr. Ginsberg is a Career Investigator of the Heart and Stroke Foundation of Ontario. Ms. Newman is supported by the Cancer Care Ontario Practice Guidelines Initiative. Requests for Reprints: Clive Kearon, MB, PhD, McMaster Medical Unit, Henderson General Hospital, 711 Concession Street, Hamilton, Ontario L8V 1C3, Canada. Current Author Addresses: Dr. Kearon: McMaster Medical Unit, Henderson General Hospital, 711 Concession Street, Hamilton, Ontario L8V 1C3, Canada.


Copyright ©2004 by the American College of Physicians


Ann Intern Med. 1998;128(8):663-677. doi:10.7326/0003-4819-128-8-199804150-00011
Text Size: A A A

Purpose: To review noninvasive methods for diagnosis of first and recurrent deep venous thrombosis and provide evidence-based recommendations for the diagnosis of deep venous thrombosis in symptomatic, asymptomatic, and pregnant patients.

Data Sources: Accuracy (comparison with contrast venography) and management (safety of withholding anticoagulants when results were normal) studies that evaluated tests for diagnosis of deep venous thrombosis were identified from a MEDLINE search, personal files, and bibliographies of reviews and original studies.

Study Selection: Prospective cohort studies (accuracy and management studies) and randomized comparisons (management studies) that satisfied predefined methodologic criteria were included.

Data Extraction: Sensitivity, specificity, and positive and negative predictive values were determined for accuracy studies. Rates of venous thromboembolism during long-term follow-up of patients with normal results were determined for management studies.

Data Synthesis: Data from individual studies were combined under a random-effects model. The accuracy of noninvasive tests was compared, with emphasis on within-study comparisons. Recommendations for diagnosis of deep venous thrombosis were developed by a multidisciplinary group and graded according to the strength of the supporting evidence.

Venous ultrasonography is the most accurate noninvasive test for the diagnosis of a first symptomatic proximal deep venous thrombosis.However, neither ultrasonography nor impedance plethysmography is accurate in asymptomatic postoperative patients. Venous ultrasonography is less accurate for symptomatic isolated distal (calf) deep venous thrombosis than for proximal deep venous thrombosis, and the clinical utility of venous ultrasonography of the distal veins is uncertain. Withholding anticoagulant therapy in symptomatic patients with suspected deep venous thrombosis who have normal results on serial venous ultrasonography or impedance plethysmography is safe. Diagnosis of recurrent deep venous thrombosis requires evidence of new thrombus formation, such as a new noncompressible venous segment detected by venous ultrasonography, conversion of a normal result on impedance plethysmography to abnormal, or presence of an intraluminal filling defect on venography. Suspected deep venous thrombosis in pregnant patients can usually be managed with serial venous ultrasonography or impedance plethysmography. In symptomatic patients with a suspected first episode of deep venous thrombosis, clinical assessment and d-dimer testing are complementary to testing with venous ultrasonography and impedance plethysmography.

Conclusions: Patients with suspected deep venous thrombosis can usually be managed with noninvasive testing. However, if the results of this testing are nondiagnostic or are discordant with the clinical assessment, venography should be considered.

Figures

Grahic Jump Location
Figure 1.
Accuracy of impedance plethysmography and venous ultrasonography for diagnosis of a first episode of deep venous thrombosis in symptomatic and asymptomatic patients.Table 1Table 2

Weighted means and 95% CIs were derived from the studies shown in and . All = all instances of deep venous thrombosis; proximal = proximal deep venous thrombosis; distal = isolated distal deep venous thrombosis; symptomatic = symptomatic patients; asymptomatic = asymptomatic postoperative patients at high risk for deep venous thrombosis; PV = predictive value.

Grahic Jump Location
Grahic Jump Location
Figure 2.
Approaches to diagnosing a first symptomatic deep venous thrombosis (DVT) with venous ultrasonography (VU) or impedance plethysmography (IPG).

* = Follow-up venous ultrasonography after 7 days is recommended in all pregnant patients. If clinical suspicion of iliac deep venous thrombosis is high (for example, if the entire leg is swollen or if the patient has back pain), venography or impedance plethysmography should be done. † = In pregnant patients, if symptoms and signs of deep venous thrombosis are confined to below the knee or if intraluminal filling defects are found on limited venography (with abdominal shielding), radiologic examination of the iliac veins is not necessary.

Grahic Jump Location
Grahic Jump Location
Figure 3.
Approach to the diagnosis of recurrent deep venous thrombosis (DVT).

* = If clinical suspicion for deep venous thrombosis is high, venography should be considered. ILFD = intraluminal filling defect; IPG = impedance plethysmography; VU = venous ultrasonography.

Grahic Jump Location

Tables

References

Letters

NOTE:
Citing articles are presented as examples only. In non-demo SCM6 implementation, integration with CrossRef’s "Cited By" API will populate this tab (http://www.crossref.org/citedby.html).

Comments

Submit a Comment
Submit a Comment

Summary for Patients

Clinical Slide Sets

Terms of Use

The In the Clinic® slide sets are owned and copyrighted by the American College of Physicians (ACP). All text, graphics, trademarks, and other intellectual property incorporated into the slide sets remain the sole and exclusive property of the ACP. The slide sets may be used only by the person who downloads or purchases them and only for the purpose of presenting them during not-for-profit educational activities. Users may incorporate the entire slide set or selected individual slides into their own teaching presentations but may not alter the content of the slides in any way or remove the ACP copyright notice. Users may make print copies for use as hand-outs for the audience the user is personally addressing but may not otherwise reproduce or distribute the slides by any means or media, including but not limited to sending them as e-mail attachments, posting them on Internet or Intranet sites, publishing them in meeting proceedings, or making them available for sale or distribution in any unauthorized form, without the express written permission of the ACP. Unauthorized use of the In the Clinic slide sets will constitute copyright infringement.

Toolkit

Buy Now

to gain full access to the content and tools.

Want to Subscribe?

Learn more about subscription options

Advertisement
Related Articles
Related Point of Care
Topic Collections
PubMed Articles

Buy Now

to gain full access to the content and tools.

Want to Subscribe?

Learn more about subscription options

Forgot your password?
Enter your username and email address. We'll send you a reminder to the email address on record.
(Required)
(Required)