Download PDF
Semin Respir Crit Care Med 2000; 21(6): 495-504
DOI: 10.1055/s-2000-13187
Copyright © 2000 by Thieme Medical Publishers, Inc., 333 Seventh Avenue, New York, NY 10001, USA. Tel.: +1(212) 584-4662

The Diagnostic Approach to Deep Venous Thrombosis

C. Gregory Elliott
  • Departments of Medicine and the Pulmonary Divisions of the LDS Hospital and University of Utah Health Sciences Center, Salt Lake City, Utah
Further Information

Publication History

Publication Date:
31 December 2000 (online)

    Permissions and Reprints

ABSTRACT

Accurate diagnosis of deep vein thrombosis is important because untreated deep vein thrombosis can cause death or permanent impairment and because effective treatments are available. The approach to the diagnosis of deep vein thrombosis varies because of differences in local resources and expertise. Duplex ultrasonography with venous compression is the preferred initial test for the majority of outpatients who present with symptoms and signs that suggest acute deep vein thrombosis. Clinical outcome studies have shown the safety of withholding anticoagulants when two compression ultrasonography examinations are negative over a 5- to 7-day period. Alternative strategies, for example, combining clinical scores and D-dimer with compression ultrasonography, may also prove effective. In unusual circumstances, venography or even magnetic resonance imaging may be necessary.

KEYWORD

Deep vein thrombosis - venous thromboembolism - pulmonary embolism

REFERENCES

  • 1 Hirsch J, Hoak J. Management of deep vein thrombosis and pulmonary embolism.  Circulation . 1996;  93 2212-2245
    CrossrefPubMedGoogle Scholar
  • 2 Greer I A. Thrombosis in pregnancy: maternal and fetal issues.  Lancet . 1999;  353 1258-1265
    CrossrefPubMedGoogle Scholar
  • 3 Toglia M R, Weg J G. Venous thromboembolism during pregnancy.  N Engl J Med . 1996;  335 108-114
    CrossrefPubMedGoogle Scholar
  • 4 Lensing A W, Prandoni P, Brandjes D. Detection of deep-vein thrombosis by real-time B-mode ultrasonography.  N Engl J Med . 1989;  320 342-345
    Google Scholar
  • 5 Wells P, Lensing A, Davidson B, Prins M H, Hirsch J. Accuracy of ultrasound for the diagnosis of deep venous thrombosis in asymptomatic patients after orthopedic surgery.  Ann Intern Med . 1995;  122 47-53
    PubMedGoogle Scholar
  • 6 Zwiebel W J. Sources of error in duplex venography and an algorithmic approach to the diagnosis of deep venous thrombosis.  Semin Ultrasound CT MR . 1988;  9 286-294
    PubMedGoogle Scholar
  • 7 Anand S S, Wells P S, Hunt D, Brill-Edwards P, Cook D, Ginsberg J S. Does this patient have deep vein thrombosis?.  JAMA . 1998;  279 1094-1099
    CrossrefPubMedGoogle Scholar
  • 8 Wells P S, Anderson D R, Bormanis J. Varlue of assessment of pretest probability of deep-vein thrombosis in clinical management.  Lancet . 1997;  350 1795-1798
    Google Scholar
  • 9 Wells P S, Hirsch J, Anderson D R. A simple clinical model for the diagnosis of deep-vein thrombosis combined with impedance plethysmography: potential for an improvement in the diagnostic process.  J Intern Med . 1998;  243 15-23
    CrossrefPubMedGoogle Scholar
  • 10 Wells P S, Hirsh J, Anderson D R. Accuracy of clinical assessment of deep-vein thrombosis.  Lancet . 1995;  345 1326-1330
    CrossrefPubMedGoogle Scholar
  • 11 Tapson V F, Carroll B A, Davidson B L, Elliott C G, Fedullo P R, Hales C A. The diagnostic approach to acute venous thromboembolism.  Am J Respir Crit Care Med . 1999;  160 1043-1066
    PubMedGoogle Scholar
  • 12 Rabinov K, Paulin S. Roentgen diagnosis of venous thrombosis in the leg.  Arch Surg . 1972;  104 134-144
    PubMedGoogle Scholar
  • 13 Hull R D, Hirsh J, Sackett D, Taylor D W, Carter C, Turpie A. Clinical validity of a negative venogram in patients with clinically suspected venous thrombosis.  Circulation . 1981;  64 622-625
    CrossrefPubMedGoogle Scholar
  • 14 Talbot S R. B-mode evaluation of peripheral veins.  Semin Ultrasound CT and MR . 1988;  9 259-319
    PubMedGoogle Scholar
  • 15 Bundens W P, Bergan J J, Halasz N A, Murray J, Drehobl M. The superficial femoral vein: a potentially lethal misnomer.  JAMA . 1995;  274 1296-1298
    CrossrefPubMedGoogle Scholar
  • 16 Appelman P F, DeJong T E, Lampmann L E. Deep venous thrombosis of the leg: ultrasound findings.  Radiology . 1987;  163 743-746
    PubMedGoogle Scholar
  • 17 Cronan J J, Dorfman G S, Scola F H, Schepps B. Deep venous thrombosis: US assessment using vein compression.  Radiology . 1987;  162 191-194
    PubMedGoogle Scholar
  • 18 Ginsberg J S, Caco C C, Brill-Edwards P. Venous thrombosis in patients who have undergone major hip or knee surgery: detection with compression ultrasound and impedance plethysmography.  Radiology . 1991;  181 651-654
    PubMedGoogle Scholar
  • 19 Monreal M E, Montserrat E, Salvador R, Bechini J. Real-time ultrasound for diagnosis of symptomatic venous thrombosis and for screening of patients at risk: correlation with ascending conventional venography.  Angiology . 1989;  40 527-533
    PubMedGoogle Scholar
  • 20 Pedersen O M, Aslaksen A, Vik-mo H, Bassoe A M. Compression ultrasonography in hospitalized patients with suspected deep venous thrombosis.  Arch Intern Med . 1991;  151 2217-2220
    CrossrefPubMedGoogle Scholar
  • 21 Borris L C, Christiansen H M, Lassen M R. Comparison of real time B-mode ultrasonography and bilateral ascending phlebography for detection of postoperative deep vein thrombosis following elective hip surgery.  Thromb Haemost . 1989;  61 363
    PubMedGoogle Scholar
  • 22 Borris L C, Christiansen H M, Lassen M R. Real-time B-mode ultrasonography in the diagnosis of postoperative deep-vein thrombosis in non-symptomatic high-risk patients.  Eur J Vasc Surg . 1990;  4 473
    PubMedGoogle Scholar
  • 23 Barnes C L, Nelson C L, Nix M L, McGowan T C, Lavender R C, Barnes R W. Duplex scanning versus venography as a screening examination in total hip arthroplasty patients.  Clin Orthop . 1990;  271 180-189
    PubMedGoogle Scholar
  • 24 Cronan J J, Froehlich J A, Dorfman G S. Image-directed Doppler ultrasound: a screening technique for patients at high risk to develop deep vein thrombosis.  J Clin Ultrasound . 1991;  19 133
    PubMedGoogle Scholar
  • 25 Agnelli G, Volpato R, Radicchia S. Detection of asymptomatic deep vein thrombosis by real-time B-mode compression ultrasound in hip surgery patients.  Thromb Haemost . 1992;  68 257
    PubMedGoogle Scholar
  • 26 Woolson S T, PoHorf G. Venous ultrasonography in the detection of proximal vein thrombosis after total knee arthroplasty.  Clin Orthop . 1991;  273 131-135
    PubMedGoogle Scholar
  • 27 Jongbloets L MM, Lensing A WA, Koopman M MW, Buller H R, ten Cate W J. Limitations of real-time compression ultrasound for the detection of asymptomatic deep-vein thrombosis in postoperative patients.  Lancet . 1994;  343 1142-1144
    CrossrefPubMedGoogle Scholar
  • 28 Lensing A W, Doris C I, McGrath F P. A comparison of compression ultrasound with color Doppler ultrasound for the diagnosis of symptomless postoperative deep-vein thrombosis.  Arch Intern Med . 1997;  157 765-768
    CrossrefPubMedGoogle Scholar
  • 29 Elliott C G, Suchyta M, Rose S C, Talbot S, Ford C, Raskob G. Duplex ultrasonography for the detection of deep vein thrombi after total hip or knee arthroplasty.  Angiology . 1993;  44 26-33
    PubMedGoogle Scholar
  • 30 Tremaine M D, Choroszy C J, Gordon G H, Menking S A. Diagnosis of deep vein thrombosis by compression ultrasound in knee arthroplasty patients.  J Arthroplasty . 1992;  7 187
    CrossrefPubMedGoogle Scholar
  • 31 Rose S C, Zwiebel W J, Murdock L E. Insensitivity of color Doppler flow imaging for detection of actue calf deep venous thrombosis in asymptomatic postoperative patients.  J Vasc Intervent Radiol . 1993;  4 111-117
    CrossrefPubMedGoogle Scholar
  • 32 Davidson B L, Elliott C G, Lensing A W. A comparison of compression ultrasound with color Doppler ultrasound for the diagnosis of symptomless postoperative deep vein thrombosis.  Ann Intern Med . 1992;  157 765-768
    PubMedGoogle Scholar
  • 33 Mattos J A, Londrey G L, Leutz D W. Color flow duplex scanning for the surveillance and diagnosis of acute deep venous thrombosis.  J Vasc Surg . 1992;  15 366-376
    PubMedGoogle Scholar
  • 34 Habscheid W, Hohmann M, Wilhelm T, Epping J. Real-time ultrasound in the diagnosis of acute deep venous thrombosis of the lower extremity.  Angiology . 1990;  41 599-608
    PubMedGoogle Scholar
  • 35 Rose S C, Zwiebel W J, Nelson B D, Priest D L. Symptomatic lower extremity deep venous thrombosis: accuracy, limitations, and role of color duplex flow imaging in diagnosis.  Radiology . 1990;  175 639-644
    PubMedGoogle Scholar
  • 36 Heijboer H, Buller H R, Lensing A, Turpie A, Colly L P, ten Cate W J. A comparison of real-time compression ultrasonography with impedance plethysmography for the diagnosis of deep-vein thrombosis in symptomatic outpatients.  N Engl J Med . 1993;  329 1365-1369
    Google Scholar
  • 37 Birdwell B G, Raskob G E, Whitsett T L. The clinical validity of normal compression ultrasonography in outpatients suspected of deep venous thrombosis.  Ann Intern Med . 1998;  128 1-7
    CrossrefPubMedGoogle Scholar
  • 38 Cogo A, Lensing A W, Koopman M M. Compression ultrasonography for diagnostic management of patients with clinically suspected deep vein thrombosis: prospective cohort study.  Br Med J . 1998;  316 17-24
    Google Scholar
  • 39 Bernardi E, Prandoni P, Lensing A, Agnelli G, Guazzaloca G, Scannapicco G. D-dimer testing as an adjunct to ultrasonography in patients with clinically suspected deep vein thrombosis: prospective cohort study: the multi-centre Italian D-dimer Ultrasound Investigators Group.  BMJ . 1998;  317 1037-1040
    CrossrefPubMedGoogle Scholar
  • 40 Anderson J F, Wheeler H B. Non invasive detection of deep vein thrombosis using impedence plethysmography.  J Vasc Technol . 1988;  12 93-97
    PubMedGoogle Scholar
  • 41 Anderson F A, Cordullo P A, Wheeler H B. Problems commonly encountered in IPG testing and their solution.  Bruit . 1980;  4 21-24
    PubMedGoogle Scholar
  • 42 Taylor D W, Hull R, Sackett D, Hirsh J. Simplification of the sequential impedance plethysmography technique without loss of accuracy.  Thromb Res . 1980;  17 561-565
    CrossrefPubMedGoogle Scholar
  • 43 Hull R, van Aken G W, Hirsch J. Impedance plethysmography using the occlusive cuff technique in the diagnosis of venous thrombosis.  Circulation . 1976;  53 696-700
    CrossrefPubMedGoogle Scholar
  • 44 Hull R, Hirsh J, Sackett D L. Combined use of leg scanning and impedance plethysmography in suspected venous thrombosis: an alternative to venography.  N Engl J Med . 1977;  296 1497-1500
    CrossrefPubMedGoogle Scholar
  • 45 Hull R, Taylor D W, Hirsh J. Impedance plethysmography: the relationship between venous filling and sensitivity and specificity for proximal vein thrombosis.  Circulation . 1978;  58 898-902
    PubMedGoogle Scholar
  • 46 Hull R, Hirsh J, Sackett D L. Replacement of venography in suspected venous thrombosis by impedance plethysmography and I-fibrinogen leg scanning: a less invasive approach.  Ann Intern Med . 1981;  94 12-15
    CrossrefPubMedGoogle Scholar
  • 47 Prandoni P, Lensing A WA, Huisman M V. A new computerized impedance plethysmograph: accuracy in the detection of proximal deep-vein thrombosis in symptomatic outpatients.  Thromb Haemost . 1991;  65 229-232
    PubMedGoogle Scholar
  • 48 Wells P S, Hirsh J, Anderson D R. Comparison of the accuracy of impedance plethysmography and compression ultrasonography in outpatients with clinical suspected deep vein thrombosis.  Thromb Haemost . 1995;  77 1423-1427
    PubMedGoogle Scholar
  • 49 Agnelli G, Cosmi B, Ranucci V. Impedance plethysmography in the diagnosis of asymptomatic deep vein thrombosis in hip surgery: a venography-controlled study.  Arch Intern Med . 1991;  151 2167-2171
    CrossrefPubMedGoogle Scholar
  • 50 Paiement G, Wessinger S, Waltman A, Harris W H. Surveillance of deep-vein thrombosis in asymptomatic total hip replacement patients: impedance plethysmography and fibrinogen scanning versus roentgenographic phlebography.  Am J Surg . 1988;  155 400-404
    PubMedGoogle Scholar
  • 51 Cruickshank M K, Levine M N, Hirsh J. An evaluation of impedance plethysmography and 125I-fibrinogen scanning in patients following hip surgery.  Thromb Haemost . 1989;  62 830-834
    PubMedGoogle Scholar
  • 52 Spritzer C E, Sostman H D, Wilkes D C, Coleman R E. Deep venous thrombosis: experience with gradient-echo MR imaging in 66 patients.  Radiology . 1990;  177 235-241
    CrossrefPubMedGoogle Scholar
  • 53 Carpenter J, Holland G A, Baum R A. Magnetic resonance venography for the detection of deep venous thrombosis: comparison with contrast venography and duplex Doppler ultrasonography.  J Vasc Surg . 1993;  18 734-741
    CrossrefPubMedGoogle Scholar
  • 54 Evans A J, Sostman H D, Knelson M H. Detection of DVT: prospective comparison of MRI with contrast venography.  AM J Roentgenol . 1993;  161 131-139
    Google Scholar
  • 55 Dupas B D, El Kouri D, Curtet C. Angiomagnetic resonance imaging of iliofemorocaval venous thrombosis.  Lancet . 1995;  346 17-19
    Google Scholar
  • 56 Laissy J P, Cinqualbre A, Loshkajian A. Assessment of deep venous duplex Doppler sonography.  Am J Roentgenol . 1996;  167 971-975
    PubMedGoogle Scholar
  • 57 Vukov L F, Berquist T H, King B F. MRI for calf deep venous thrombosis.  Ann Emerg Med . 1991;  20 497-499
    PubMedGoogle Scholar
  • 58 Aschwanden M, Labs K H, Jeanneret C, Gehrig A, Jaeger K A. The value of rapid D-dimer testing combined with structured clinical evaluation for the diagnosis of deep vein thrombosis.  J Vasc Surg . 1999;  30 929-935
    PubMedGoogle Scholar
  • 59 Lennox A F, Delis K T, Serunkuma S, Zaska Z A, Daskalopoulou S E, Nicolaides A N. Combination of a clinical risk assessment score and rapid whole blood D-dimer testing in the diagnosis of deep vein thrombosis in symptomatic patients.  J Vasc Surg . 1999;  30 794-804
    PubMedGoogle Scholar
  • 60 Moser K M, LeMoine J R. Is embolic risk conditioned by location of deep venous thrombosis?.  Ann Intern Med . 1981;  94 439-444
    PubMedGoogle Scholar
  • 61 Lagerstedt C I, Olsson C, Fagher B O, Oquist B W, Albrechtsson U. Need for long-term anticoagulant treatment in symptomatic calf-vein thrombosis.  Lancet . 1985;  2 515-518
    PubMedGoogle Scholar
  • 62 Birdwell B G, Raskob G E, Whitsett T L. Predictive value of compression ultrasonography for deep vein thrombosis in symptomatic outpatients.  Arch Intern Med . 2000;  160 309-313
    CrossrefPubMedGoogle Scholar
  • 63 Knudson G J, Wiedmeyer D A, Erickson S J. Color Doppler sonographic imaging in the assessment of upper-extremity deep venous thrombosis.  Am J Roentgenol . 1990;  154 399-403
    PubMedGoogle Scholar
  • 64 Baxter G M, Kincain W, Jeffrey R F. Comparison of colour Doppler ultrasound with venography in the diagnosis of axillary and subclavian thrombosis.  Br J Radiol . 1991;  64 777-781
    PubMedGoogle Scholar
  • 65 Bergqvist A, Bergqvist D, Hallbook T. Deep vein thrombosis during pregnancy: a prospective study.  Acta Obstet Gynecol Scand . 1983;  62 443-448
    PubMedGoogle Scholar
  • 66 Hull R D, Raskob G E, Carter C J. Serial impedance plethysmography in pregnant patients with clinically suspected deep-vein thrombosis. Clinical validity of negative findings.  Ann Intern Med . 1990;  112 663-667
    PubMedGoogle Scholar
  • 67 Ginsberg J S, Hirsh J, Rainbow A J, Coates G. Risks to the fetus of radiologic procedures used in the diagnosis of maternal venous thromboembolic disease.  Thromb Haemost . 1989;  61 189-196
    PubMedGoogle Scholar
  • 68 Hull R D, Carter C J, Jay R M. The diagnosis of acute recurrent deep vein thrombosis: a diagnostic challenge.  Circulation . 1983;  67 901-906
    PubMedGoogle Scholar
  • 69 Anderson D R, Gross M, Robinson K S. Ultrasonographic screening for deep vein thrombosis following arthroplasty fails to reduce post hospital thromboembolic complications: the post arthroplasty screening study (PASS).  Chest . 1998;  114 119S-122S
    PubMedGoogle Scholar
  • 70 Hull R D, Raskob G, Coates G, Panju A A, Gill G J. A new noninvasive management strategy for patients with suspected pulmonary embolism.  Arch Intern Med . 1989;  149 2549-2555
    CrossrefPubMedGoogle Scholar
  • 71 Hull R D, Raskob G, Ginsberg J S. A noninvasive strategy for the treatment of patients with suspected pulmonary embolism.  Arch Intern Med . 1994;  154 289-297
    CrossrefPubMedGoogle Scholar
  • 72 Turkstra F, Kuijer P MM, van Beek J R E, Brandjes D PM, ten Cate W J, Buller H R. Diagnostic utility of ultrasonography of leg veins in patients suspected of having pulmonary embolism.  Ann Intern Med . 1997;  126 775-781
    CrossrefPubMedGoogle Scholar
  • 73 Wells P S, Ginsberg J S, Anderson D R. Use of a clinical model for safe management of patients with suspected pulmonary embolism.  Ann Intern Med . 1998;  129 997-1005
    Google Scholar
      >