Deep vein thrombosis diagnosis specific situations

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] Ujjwal Rastogi, MBBS [3]; Kashish Goel, M.D.; Assistant Editor(s)-In-Chief: Justine Cadet

Deep Vein Thrombosis Microchapters
Home
Patient Information
Overview
Classification
Pathophysiology
Causes
Differentiating Deep vein thrombosis from other Diseases
Epidemiology and Demographics
Risk Factors
Triggers
Screening
Natural History, Complications and Prognosis
Diagnosis
Diagnostic Approach
Assessment of Clinical Probability and Risk Scores
Assessment of Probability of Subsequent VTE and Risk Scores
History and Symptoms
Physical Examination
Laboratory Findings
Ultrasound
Venography
CT
MRI
Other Imaging Findings
Treatment
Treatment Approach
Medical Therapy
IVC Filter
Invasive Therapy
Surgery
Prevention
Cost-Effectiveness of Therapy
Future or Investigational Therapies
Special Scenario
Upper extremity DVT
Recurrence
Pregnancy
Trials
Landmark Trials
Case Studies
Case #1
Deep vein thrombosis diagnosis specific situations On the Web
Most recent articles
Most cited articles
Review articles
CME Programs
Powerpoint slides
Images
Ongoing Trials at Clinical Trials.gov
US National Guidelines Clearinghouse
NICE Guidance
FDA on Deep vein thrombosis diagnosis specific situations
CDC on Deep vein thrombosis diagnosis specific situations
Deep vein thrombosis diagnosis specific situations in the news
Blogs on Deep vein thrombosis diagnosis specific situations
Directions to Hospitals Treating Deep vein thrombosis
Risk calculators and risk factors for Deep vein thrombosis diagnosis specific situations

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 the American College of Chest Physicians.

Recurrent DVT

• Patients suspected to have a recurrent episode of DVT may benefit from thrombophilia evaluation.
• Initial test in these patients should be compression ultrasound if previous ultrasound is available for comparison or highly-sensitive D-dimer.
• 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 proximal compression ultrasound.
• If initial proximal compression ultrasound is negative, serial testing with either proximal compression ultrasound at day 3 and day 7 or D-dimer at presentation should be done.
• Dopper 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) in 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 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 compression ultrasound or 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.