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The approach to diagnosis of [[DVT]] may be modified in certain situations, where the suspicion is high or there is a recurrent episode. This chapter will discuss these modifications that have been recommended to the American College of Chest Physicians.<ref name="pmid22315267">{{cite journal |author=Bates SM, Jaeschke R, Stevens SM, ''et al.'' |title=Diagnosis of DVT: Antithrombotic Therapy and Prevention of Thrombosis, 9th ed: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines |journal=Chest |volume=141 |issue=2 Suppl |pages=e351S–418S |year=2012 |month=February |pmid=22315267 |doi=10.1378/chest.11-2299 |url=}}</ref> | The approach to diagnosis of [[DVT]] may be modified in certain situations, where the suspicion is high or there is a recurrent episode. This chapter will discuss these modifications that have been recommended to the American College of Chest Physicians.<ref name="pmid22315267">{{cite journal |author=Bates SM, Jaeschke R, Stevens SM, ''et al.'' |title=Diagnosis of DVT: Antithrombotic Therapy and Prevention of Thrombosis, 9th ed: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines |journal=Chest |volume=141 |issue=2 Suppl |pages=e351S–418S |year=2012 |month=February |pmid=22315267 |doi=10.1378/chest.11-2299 |url=}}</ref> | ||
==Recurrent DVT== | == Specific Situations == | ||
=== Recurrent DVT === | |||
* Patients suspected to have a recurrent episode of [[DVT]] may benefit from [[thrombophilia]] evaluation. | * Patients suspected to have a recurrent episode of [[DVT]] may benefit from [[thrombophilia]] evaluation. | ||
* Initial test in these patients should be a [[Deep vein thrombosis ultrasound|compression ultrasound]] if a previous ultrasound is available for comparison. A highly-sensitive [[Deep vein thrombosis D-dimer|D-dimer]] is also a possible test. | * Initial test in these patients should be a [[Deep vein thrombosis ultrasound|compression ultrasound]] if a previous ultrasound is available for comparison. A highly-sensitive [[Deep vein thrombosis D-dimer|D-dimer]] is also a possible test. | ||
* If the [[Deep vein thrombosis ultrasound|compression ultrasound]] results are abnormal but nondiagnostic (increase in residual venous diameter of < 4 but ≥ 2 mm), further testing with [[Deep vein thrombosis venography|venography]] or [[Deep vein thrombosis CT venography|CT venography]] may be indicated. | * If the [[Deep vein thrombosis ultrasound|compression ultrasound]] results are abnormal but nondiagnostic (increase in residual venous diameter of < 4 but ≥ 2 mm), further testing with [[Deep vein thrombosis venography|venography]] or [[Deep vein thrombosis CT venography|CT venography]] may be indicated. | ||
==Pregnant Patients== | === Pregnant Patients === | ||
* Initial test should be a proximal [[Deep vein thrombosis ultrasound|compression ultrasound]]. | * Initial test should be a proximal [[Deep vein thrombosis ultrasound|compression ultrasound]]. | ||
* If the initial proximal [[Deep vein thrombosis ultrasound|compression ultrasound]] is negative, serial testing with either proximal [[Deep vein thrombosis ultrasound|compression ultrasound]] at day 3 and day 7 or a D-dimer at presentation should be done. | * If the initial proximal [[Deep vein thrombosis ultrasound|compression ultrasound]] is negative, serial testing with either proximal [[Deep vein thrombosis ultrasound|compression ultrasound]] at day 3 and day 7 or a D-dimer at presentation should be done. | ||
* Doppler ultrasound of the [[iliac]] vein is recommended if there are signs of isolated iliac vein thrombosis like swelling of the entire leg, with or without flank, buttock, or back pain. | * Doppler ultrasound of the [[iliac]] vein is recommended if there are signs of isolated iliac vein thrombosis like swelling of the entire leg, with or without flank, buttock, or back pain. | ||
==Upper Extremity | === Upper Extremity DVT === | ||
* Combined modality ultrasound ([[Deep vein thrombosis ultrasound|compression ultrasound]] with either Doppler to color Doppler) is the initial test of choice. | * Combined modality ultrasound ([[Deep vein thrombosis ultrasound|compression ultrasound]] with either Doppler to color Doppler) is the initial test of choice. | ||
* If the initial ultrasound is negative, but clinical suspicion stays high, further testing with [[serial ultrasound]], [[D-dimer]], or [[venography]] should be performed. | * If the initial ultrasound is negative, but clinical suspicion stays high, further testing with [[serial ultrasound]], [[D-dimer]], or [[venography]] should be performed. | ||
== | === CUS as the First Initial Test === | ||
It is recommended that the [[Deep vein thrombosis pretest probabiltiy|pretest probability]] should be computed in each patient to assess the need for further testing. However, in certain clinical scenarios (like moderate probability), the clinician may decide to proceed with [[Deep vein thrombosis ultrasound|compression ultrasound]] as the first test. | It is recommended that the [[Deep vein thrombosis pretest probabiltiy|pretest probability]] should be computed in each patient to assess the need for further testing. However, in certain clinical scenarios (like moderate probability), the clinician may decide to proceed with [[Deep vein thrombosis ultrasound|compression ultrasound]] as the first test. | ||
* If positive, then treatment should be started. | * If positive, then treatment should be started. | ||
* If negative, repeat the [[Deep vein thrombosis ultrasound|compression ultrasound]]. If not, D-dimer testing should be done in 1 week. | * If negative, repeat the [[Deep vein thrombosis ultrasound|compression ultrasound]]. If not, D-dimer testing should be done in 1 week. | ||
==Positive D-dimer only== | === Positive D-dimer only === | ||
* If the initial D-dimer is positive, but [[Deep vein thrombosis ultrasound|compression ultrasound]] is negative, a repeat [[Deep vein thrombosis ultrasound|compression ultrasound]] should be performed in 1 week. | * If the initial D-dimer is positive, but [[Deep vein thrombosis ultrasound|compression ultrasound]] is negative, a repeat [[Deep vein thrombosis ultrasound|compression ultrasound]] should be performed in 1 week. | ||
==Isolated | === Isolated Distal DVT === | ||
* On identification of an isolated [[DVT]] in the distal calf veins, serial testing is recommended to rule out proximal extension. | * On identification of an isolated [[DVT]] in the distal calf veins, serial testing is recommended to rule out proximal extension. | ||
Revision as of 21:44, 28 January 2013
Editor(s)-In-Chief: The APEX Trial Investigators, C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-In-Chief: Cafer Zorkun, M.D., Ph.D. [2] ; Kashish Goel, M.D.; Assistant Editor(s)-In-Chief: Justine Cadet
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Overview
The approach to diagnosis of DVT may be modified in certain situations, where the suspicion is high or there is a recurrent episode. This chapter will discuss these modifications that have been recommended to the American College of Chest Physicians.[1]
Specific Situations
Recurrent DVT
- Patients suspected to have a recurrent episode of DVT may benefit from thrombophilia evaluation.
- Initial test in these patients should be a compression ultrasound if a previous ultrasound is available for comparison. A highly-sensitive D-dimer is also a possible test.
- If the compression ultrasound results are abnormal but nondiagnostic (increase in residual venous diameter of < 4 but ≥ 2 mm), further testing with venography or CT venography may be indicated.
Pregnant Patients
- Initial test should be a proximal compression ultrasound.
- If the initial proximal compression ultrasound is negative, serial testing with either proximal compression ultrasound at day 3 and day 7 or a D-dimer at presentation should be done.
- Doppler ultrasound of the iliac vein is recommended if there are signs of isolated iliac vein thrombosis like swelling of the entire leg, with or without flank, buttock, or back pain.
Upper Extremity DVT
- Combined modality ultrasound (compression ultrasound with either Doppler to color Doppler) is the initial test of choice.
- If the initial ultrasound is negative, but clinical suspicion stays high, further testing with serial ultrasound, D-dimer, or venography should be performed.
CUS as the First Initial Test
It is recommended that the pretest probability should be computed in each patient to assess the need for further testing. However, in certain clinical scenarios (like moderate probability), the clinician may decide to proceed with compression ultrasound as the first test.
- If positive, then treatment should be started.
- If negative, repeat the compression ultrasound. If not, D-dimer testing should be done in 1 week.
Positive D-dimer only
- If the initial D-dimer is positive, but compression ultrasound is negative, a repeat compression ultrasound should be performed in 1 week.
Isolated Distal DVT
- On identification of an isolated DVT in the distal calf veins, serial testing is recommended to rule out proximal extension.
References
- ↑ Bates SM, Jaeschke R, Stevens SM; et al. (2012). "Diagnosis of DVT: Antithrombotic Therapy and Prevention of Thrombosis, 9th ed: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines". Chest. 141 (2 Suppl): e351S–418S. doi:10.1378/chest.11-2299. PMID 22315267. Unknown parameter
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