Accuracy of emergency physician–performed ultrasonography in the diagnosis of deep-vein thrombosis

Fulvio Pomero; Francesco Dentali; Valentina Borretta; Matteo Bonzini; Remo Melchio; James D. Douketis; Luigi Maria Fenoglio

doi:10.1160/TH12-07-0473

Thrombosis and Haemostasis, Inhaltsverzeichnis

Thromb Haemost 2013; 109(01): 137-145
DOI: 10.1160/TH12-07-0473

New Technologies, Diagnostic Tools and Drugs

Schattauer GmbH

Accuracy of emergency physician–performed ultrasonography in the diagnosis of deep-vein thrombosis

A systematic review and meta-analysis

Fulvio Pomero

¹Department of Clinical Medicine, ASO S. Croce e Carle, Cuneo, Italy

,

Francesco Dentali

²Department of Clinical Medicine Insubria University, Varese, Italy

,

Valentina Borretta

¹Department of Clinical Medicine, ASO S. Croce e Carle, Cuneo, Italy

,

Matteo Bonzini

³Epidemiology and Preventive Medicine Research Center, Department of Experimental Medicine, University of Insubria, Varese, Italy

,

Remo Melchio

¹Department of Clinical Medicine, ASO S. Croce e Carle, Cuneo, Italy

,

James D. Douketis

⁴Department of Medicine, McMaster University, Hamilton, Ontario, Canada

,

Luigi Maria Fenoglio

¹Department of Clinical Medicine, ASO S. Croce e Carle, Cuneo, Italy

› Institutsangaben

Abstract

Summary

Duplex ultrasound is the first-line diagnostic test for detecting lower limb deep-vein thrombosis (DVT) but it is time consuming, requires patient transport, and cannot be interpreted by most physicians. The accuracy of emergency physician–performed ultrasound (EPPU) for the diagnosis of DVT, when performed at the bedside, is unclear. We did a systematic review and meta-analysis of the literature, aiming to provide reliable data on the accuracy of EPPU in the diagnosis of DVT. The MEDLINE and EMBASE databases (up to August 2012) were systematically searched for studies evaluating the accuracy of EPPU compared to either colour-flow duplex ultrasound performed by a radiology department or vascular laboratory, or to angiography, in the diagnosis of DVT. Weighted mean sensitivity and specificity and associated 95% confidence intervals (CIs) were calculated using a bivariate random-effects regression approach. There were 16 studies included, with 2,379 patients. The pooled prevalence of DVT was 23.1% (498 in 2,379 patients), ranging from 7.4% to 47.3%. Using the bivariate approach, the weighted mean sensitivity of EPPU compared to the reference imaging test was 96.1% (95%CI 90.6–98.5%), and with a weighted mean specificity of 96.8% (95%CI:94.6–98.1%). Our findings suggest that EPPU may be useful in the management of patients with suspected DVT. Future prospective studies are warranted to confirm these findings.

Keywords

Ultrasound - deep-vein thrombosis - emergency physician

Volltext

Referenzen

References
1 Calder KK, Herbert M, Henderson SO. The mortality of untreated pulmonary embolism in emergency department patients. Ann Emerg Med 2005; 45: 302-310. DOI:10.1016/j.annemergmed.2004.10.001.
2 Wells PS, Hirsh J, Anderson DR. et al. Accuracy of clinical assessment of deep-vein thrombosis. Lancet 1995; 345: 1326-1330. DOI:10.1016/S0140-6736(95)92535-X.
3 Gaitini D. Current approaches and controversial issues in the diagnosis of deep venous thrombosis via duplex Doppler ultrasound. J Clin Ultrasound 2006; 34: 289-297. DOI:10.1002/jcu.20236.
4 Andrews Jr EJ, Fleischer AC. Sonography for deep venous thrombosis: current and future applications. Ultrasound Q 2005; 21: 213-225. DOI:10.1097/01.ruq.0000187024.54319.19.
5 Burnside PR, Brown MD, Kline A. Systematic Review of Emergency Physician-Performed Ultrasonography for Lower-Extremity Deep Vein Thrombosis. Acad Emerg Med 2008; 15: 493-498. DOI:10.1111/j.1553-2712.2008.00101.x.
6 Leeflang MM, Deeks JJ, Gatsonis C. et al. Cochrane Diagnostic Test Accuracy Working Group. Systematic reviews of diagnostic test accuracy. Ann Intern Med 2008; 149: 889-897.
7 McGinn T, Wyer PC, Newman TB. et al. Evidence- Based Medicine Teaching Tips Working Group. Tips for learners of evidence-based medicine: 3. Measures of observer variability (kappa statistic). CMAJ 2004; 171: 1369-1373. DOI:10.1503/cmaj.1031981.
8 Whiting PF, Rutjes AW, Westwood ME. et al. QUADAS-2 Group . QUADAS-2: A Revised Tool for the Quality Assessment of Diagnostic Accuracy Studies. Ann Intern Med 2011; 155: 529-536.
9 Bland JM, Kerry SM. Statistics notes. Weighted comparison of means. Br Med J 1998; 316: 129. DOI:10.1136/bmj.316.7125.129.
10 Higgins JP, Thompson SG, Deeks JJ. et al. Measuring inconsistency in meta-analyses. Br Med J 2003; 327: 557-560. DOI:10.1136/bmj.327.7414.557.
11 Reitsma GB, Glas AS, Rutjes AWS. et al. Bivariate analysis of sensitivity and specificity produces informative summary measures in diagnostic reviews. J Clin Epidemiol 2005; 58: 982-990. DOI:10.1016/j.jclinepi.2005.02.022.
12 Jolly BT, Massarin E, Pigman EC. Color Doppler ultrasonography by emergency physicians for the diagnosis of acute deep venous thrombosis. Acad Emerg Med 1997; 04: 129-132. DOI:10.1111/j.1553-2712.1997.tb03719.x.
13 Wakai A, Frazee B, Snoey E. Emergency Department compression ultrasound to diagnose proximal deep vein thrombosis. J Emerg Med 2001; 21: 444-445. DOI:10.1016/S0736-4679(01)00414-0.
14 Jang TB, Polites G, Docherty M. et al. Resident Performed Compression Ultrasound for the Evaluation of Proximal Lower Extremity Deep Vein Thrombosis: Fast, Accurate, and Timely. Acad Emerg Med 2003; 10 Supplement SAEM Annual Meeting Abstracts 427. DOI:10.1197/aemj.10.5.427-a.
15 Shiver SA, Lyon M, Blaivas M. et al. A Prospective Comparison of Emergency Physician-Performed Limited Venous Ultrasound and CT Venography of the Lower Extremity for Deep Venous Thrombosis. Ann Emerg Med 2007; 50: 87. DOI:10.1016/j.annemergmed.2007.06.263.
16 Kline J, O’Malley P, Tayal V. et al. Emergency Clinician-Performed Compression Ultrasonography to Diagnosi and Esclude deep Vein Thrombosis of the Lower Extremity. Acad Emerg Med 2008; 15 Supplement SAEM Annual Meeting Abstracts 219.
17 Theodoro DL, Blaivas M, Duggal S. et al. Emergency Physician-performed Lower-extremity Doppler Results in Significant Time Saving. Acad Emerg Med 2002; 09 Supplement SAEM Annual Meeting Abstracts 541. DOI:10.1197/aemj.9.5.541-a.
18 Frazee BW, Snoey ER, Levitt MA. et al. Negative Emergency Department Compression Ultrasound Reliably Excludes Proximal Deep Vein Thrombosis. Acad Emerg Med 1998; 05 Supplement SAEM Annual Meeting Abstracts 406.
19 Jacoby JL, Cesta M, Axelband J. et al. Can Emergency Medicine Residents Detect Acute DVT with a limited Two-site Ultrasound Examination?. Acad Emerg Med 2004; 11 Supplement SAEM Annual Meeting Abstracts 585 DOI:10.1197/j.aem.2004.02.327
20 Thomas T, Rosembaum TG, Boniface K. et al. Deep Vein Thrombosis in the Emergency Department (DVT-ED). Acad Emerg Med 2003; 10 Supplement SAEM Annual Meeting Abstracts 486. DOI:10.1197/aemj.10.5.486-a.
21 Mulcare MR, Borda T, Hana Yi D. et al. Inter-rater Reliability of Emergency Physician Ultrasonography For Diagnosing Lower Extremity Deep Venous and Great Saphenous vein Thromboses Compared To Ultrasonographic Studies Performed By Radiology. Acad Emerg Med 2012; 19 Supplement SAEM Annual Meeting Abstracts 59-60.
22 Chance JF, Abbitt PL, Tegtmeyer CJ. et al. Real-time ultrasound for the detection of deep venous thrombosis. Ann Intern Med 1991; 115: 87.
23 Frazee BW, Snoey ER, Levitt A. Emergency Department compression ultrasound to diagnose proximal deep vein thrombosis. J Emerg Med 2001; 20: 107-112. DOI:10.1016/S0736-4679(00)00302-4.
24 Theodoro D, Blaivas M, Duggal S. et al. Real-time B-mode ultrasound in the ED saves time in the diagnosis of deep vein thrombosis (DVT). Am J Emerg Med 2004; 22: 197-200. DOI:10.1016/j.ajem.2004.02.007.
25 Jang T, Docherty M, Aubin C. et al. Resident-performed Compression Ultrasonography for the Detection of Proximal Deep Vein Thrombosis: Fast and Accurate. Acad Emerg Med 2004; 11: 319-322.
26 Kline JA, O’Malley PM, Tayal VS. et al. Emergency Clinician-Performed Compression Ultrasonography for Deep Venous Thrombosis of the Lower Extremity. Ann Emerg Med 2008; 52: 437-445. DOI:10.1016/j.annemergmed.2008.05.023.
27 Magazzini S, Vanni S, Toccafondi S. et al. Duplex Ultrasound in the Emergency Department for the Diagnostic Management of Clinically Suspected Deep Vein Thrombosis. Acad Emerg Med 2007; 14: 216-220. DOI:10.1111/j.1553-2712.2007.tb01776.x.
28 Crisp JG, Lovato LM, Jang TB. Compression ultrasonography of the lower extremity with portable vascular ultrasonography can accurately detect deep venous thrombosis in the emergency department. Ann Emerg Med 2010; 56: 601-610. DOI:10.1016/j.annemergmed.2010.07.010.
29 Shiver SA, Lyon M, Blaivas M. et al. Prospective comparison of emergency physician-performed venous ultrasound and CT venography for deep venous thrombosis. Am J Emerg Med 2010; 28: 354-358. DOI:10.1016/j.ajem.2009.01.009.
30 Farahmand S, Farnia M, Shahriaran S. et al. The accuracy of limited B-mode compression technique in diagnosing deep venous thrombosis in lower extremities. Am J Emerg Med 2011; 29: 687-690. DOI:10.1016/j.ajem.2010.11.028.
31 Jacoby J, Cesta M, Axelband J. et al. Can emergency medicine residents detect acute deep venous thrombosis with a limited, two-site ultrasound examination?. J Emerg Med 2007; 32: 197-200. DOI:10.1016/j.jemermed.2006.06.008.
32 Blaivas M, Lambert MJ, Harwood RA. et al. Lower-extremity Doppler for deep venous thrombosis - Can emergency physicians be accurate and fast?. Acad Emerg Med 2000; 07: 120-126. DOI:10.1111/j.1553-2712.2000.tb00512.x.
33 Turnbull TL, Dymowski JJ, Zalut TE. A prospective study of hand-held Doppler ultrasonography by emergency physicians in the evaluation of suspected deep-vein thrombosis. Ann Emerg Med 1990; 19: 691-695. DOI:10.1016/S0196-0644(05)82481-3.
34 Fojtik PJ, Handly N, Costantino TG. Accuracy of Emergency Medicine Performed Compression Ultrasound for the Evaluation of Deep Venous Thrombosis. Acad Emerg Med 2003; 10 Supplement SAEM Annual Meeting Abstracts 426. DOI:10.1197/aemj.10.5.426-a.
35 Rice C, Faragher J, Byyny R. et al. Emergency Physician Compression ultrasonography for the detection of lower Extremity Deep Vein Thrombosis. Acad Emerg Med 2009; 16 Supplement SAEM Annual Meeting Abstracts 139.
36 Dean AJ, Davies S. Accuracy of Resident-performed Limited Compression Ultrasonography for the Diagnosis of Lower-extremity Deep Vein Thrombosis. Acad Emerg Med 2004; 11 Supplement SAEM Annual Meeting Abstracts 584. DOI:10.1197/j.aem.2004.02.328.
37 Poley R, Newbigging J, Sivilotti MLA. Introducing Bedside Limited Compression Ultrasound by Emergency Physicians into the Diagnostic Algorithm for Patients with Suspected DVT: A Prospective Cohort Trial. Acad Emerg Med 2012; 19 Supplement SAEM Annual Meeting Abstracts 60-61.
38 de Valois JC, van Schaik CC, Verzijlbergen F. et al. Contrast venography. Eur J Radiol 1990; 11: 131-137. DOI:10.1016/0720-048X(90)90162-5.
39 Imberti D, Ageno W, Dentali F. et al. Management of primary care patients with suspected deep vein thrombosis: use of a therapeutic dose of low-molecular-weight heparin to avoid urgent ultrasonographic evaluation. J Thromb Haemost 2006; 04: 1037-1041. DOI:10.1111/j.1538-7836.2006.01940.x.
40 Bates SM, Jaeschke R, Stevens SM. et al. American College of Chest Physicians . Diagnosis of DVT: Antithrombotic Therapy and Prevention of Thrombosis, 9th ed: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines. Chest 2012; 141 (Suppl. 02) e351S-418S. DOI:10.1378/chest.11-2299.
41 Wells PS, Anderson DR, Rodger M. et al. Evaluation of D-dimer in the diagnosis of suspected deep vein thrombosis. N Engl J Med 2003; 349: 1227-1235. DOI:10.1056/NEJMoa023153.
42 Lagerstedt CI, Olsson CG, Fagher BO. et al. Need for long-term anticoagulant treatment in symptomatic calf-vein thrombosis. Lancet 1985; 02: 515-518. DOI:10.1016/S0140-6736(85)90459-3.
43 Kearon C, Akl EA, Comerota AJ. et al. American College of Chest Physicians . Antithrombotic therapy for VTE disease: Antithrombotic Therapy and Prevention of Thrombosis, 9th ed: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines. Chest 2012; 141 (Suppl. 02) e419S-94S. DOI:10.1378/chest.11-2301.
44 Tayal V, Blaivas M, Mandavia D. Emergency Ultrasound Guidelines - 2008. Ann Emerg Med 2009; 53: 550-570. DOI:10.1016/j.annemergmed.2008.12.013.
45 Deeks JJ, Macaskill P, Irwig L. The performance of tests of publication bias and other sample size effects in systematic reviews of diagnostic test accuracy was assessed. J Clin Epidemiol 2005; 58: 882-893. DOI:10.1016/j.jclinepi.2005.01.016.

Zusatzmaterial

Zusatzmaterial