Deep vein thrombosis diagnostic approach

Revision as of 18:48, 2 June 2014 by Rim Halaby (talk | contribs)
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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

Diagnostic Approach

A number of invasive (venography) and non-invasive tests (impedance plethysmography, compression ultrasonography, D-dimer testing) are available for diagnosis. Compression ultrasonography is the noninvasive diagnosis of choice for patients with a first episode of a suspected DVT.

In a patient population with a high prevalence of VTE, a negative D-dimer assay may be insufficient to rule out DVT as a single test, furthermore, not all D-dimer assays are validated for this. However, a D-dimer level <500 ng/mL by ELISA along with a low clinical probability (Wells score)[1] or other negative non-invasive tests may be useful in excluding DVT, without doing ultrasound. Independent studies validate the Wells 10 point rule.[2][3] However, the d-dimer assays vary; for rapid quantitative immunoturbidimetric assays, a cutoff of 1.0 <g/mL is used.[2]

Compression ultrasonography has a positive predictive value of 94 percent (95% CI: 87-98 percent). If the clinical suspicion of DVT is high even after a negative CUS, a repeat study should be done within a week. Complete lower extremity ultrasonography may eliminate the need for repeat testing, but a positive CUS demands user expertise, and requires specialized instrumentation. The algorithm below presents a possible diagnostic approach.

CUS stands for Compression Ultrasonography; D-dimer is the highly sensitive assay. Clinical judgement and local availability should be considered in patients with a moderate probability of DVT. CUS may be preferred in patients with comorbid conditions associated with elevated D-dimer levels.

Adapted from ACCP guidelines[4].

Considerations

  • Whole-leg ultrasound may be preferred in those who have severe symptoms of calf DVT or are unable to come for serial testing.
  • CT scan venography, MR venography, or MR direct thrombus imaging may be used in those patients in whom ultrasound is not practical (leg cast, excessive edema) or non-diagnostic.
  • The diagnostic approach may be modified based on clinical condition of the patient and specific situations.

Complete Diagnostic Approach for First Episode of Suspected Lower Extremity DVT

Low Pretest Probability

Shown below are the different diagnostic approaches to the diagnosis of DVT depending in case of low pre-test probability of the disease.[4]

 
 
 
 
 
 
 
 
 
 
 
 
 
 
The patient has a low pre-test probability for DVT
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Proceed with one of the following:
Highly or moderately sensitive D-dimer test (1st line)
Proximal US (2nd line)
Whole leg US (less preferred)
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
D-dimer (1st line)
 
 
 
 
 
 
 
 
 
 
Proximal US (2nd line)
 
 
 
 
 
 
Whole leg US (less preferred)
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Negative
 
 
 
 
 
Positive
 
 
 
 
Negative
 
Positive
 
Negative
 
 
 
Positive
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Proceed with either:
Proximal US (1st line)
OR
Whole leg US (less preferred)
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
What is the location of the DVT?
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
DVT is excluded
 
Proximal US (1st line)
 
 
 
 
Whole leg US (less preferred)
 
DVT is excluded
 
Treat DVT
 
DVT is excluded
 
Proximal DVT
 
Isolated distal DVT
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Negative
 
Positive
 
Negative
 
Positive
 
 
 
 
 
 
 
 
 
 
Treat DVT
 
Perform serial US (1st line)
OR
Treat DVT
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
What is the location of the DVT?
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
DVT is excluded
 
Treat DVT
 
DVT is excluded
 
Proximal DVT
 
Isolated distal DVT
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Treat DVT
 
Perform serial US (1st line)
OR
Treat DVT
 
 
 
 
 
 
 
 
 
 
 

Moderate Pretest Probability

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
The patient has a moderate pre-test probability of DVT
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Proceed with one of the following:

D-dimer test
Proximal US

Whole leg US
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Highly sensitive D-dimer test
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Proximal US
 
 
 
 
 
Whole leg US
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Negative
 
 
 
Positive
 
 
 
 
 
 
 
 
 
 
 
 
Negative
 
 
 
 
Positive
 
Negative
 
Positive
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Proceed with either:
Proximal US
OR
Whole leg US
 
 
 
 
 
 
 
 
 
 
 
 
Repeat proximal US
OR
Moderately/highly sensitive D-dimer
 
 
 
 
Treat DVT
 
DVT is excluded
 
Where is the location of the DVT?
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
DVT is excluded
 
Proximal US
 
 
 
Whole leg US
 
 
 
 
 
Repeat proximal US within 1 week
 
 
 
Moderately/highly sensitive D-dimer
 
 
 
 
 
 
 
Proximal DVT
 
Isolated distal DVT
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Negative
 
Positive
 
Negative
 
Positive
 
Negative
 
Positive
 
Negative
 
Positive
 
 
 
Treat DVT
 
Perform serial US (1st line)
OR
Treat DVT
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Repeat proximal US within 1 week
 
Treat DVT
 
DVT is excluded
 
What is the location of the DVT?
 
DVT is excluded
 
Treat DVT
 
DVT is excluded
 
Repeat proximal US within 1 week
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Negative
 
Positive
 
 
 
Proximal DVT
 
Isolated distal DVT
 
 
 
 
 
 
 
 
 
Negative
 
Positive
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
DVT is excluded
 
Treat DVT
 
 
 
Treat DVT
 
Perform serial US (1st line)
OR
Treat DVT
 
 
 
 
 
 
 
 
 
Treat DVT
 
Perform serial US (1st line)
OR
Treat DVT

High Pretest Probability

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
The patient has a high pre-test probability for DVT
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Proceed with either:
Proximal US
OR
Whole leg US
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Proximal US
 
 
 
 
 
Whole leg US
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Negative
 
Positive
 
Negative
 
Positive
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Proceed with ONE of the following:
Repeat proximal US
Highly sensitive D-dimer
Whole leg US
Venography (less preferred)
 
Treat DVT
 
DVT is excluded
 
What is the location of the DVT?
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Proximal
 
Distal
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Treat DVT
 
Perform serial US (1st line)
OR
Treat DVT
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Repeat proximal US within 1 week
 
 
 
 
 
Highly sensitive D-dimer
 
 
 
 
 
Whole leg US
 
 
 
 
 
 
Venography
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Negative
 
Positive
 
Negative
 
Positive
 
Negative
 
 
Positive
 
Negative
 
Positive
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
DVT is excluded
 
Treat DVT
 
DVT is excluded
 
 
 
 
 
 
DVT is excluded
 
 
Where is the location of the DVT?
 
DVT is excluded
 
Treat DVT
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Repeat proximal US within 1 week
 
 
 
 
 
Whole leg US
 
 
 
 
 
Venography (less preferred)
 
 
 
Proximal
 
Distal
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Negative
 
Positive
 
Negative
 
Positive
 
Negative
 
Positive
 
Treat DVT
 
Perform serial US (1st line)
OR
Treat DVT
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
DVT is excluded
 
Treat DVT
 
DVT is excluded
 
Where is the location of the DVT?
 
DVT is excluded
 
Treat DVT
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Proximal
 
Distal
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Treat DVT
 
Perform serial US (1st line)
OR
Treat DVT
 
 

Risk Stratification Not Performed

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Risk stratification was not performed
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Proceed with ONE of the following:
Proximal US
Whole leg US
Highly/moderately sensitive D-dimer (less preferred)
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Proximal US
 
 
 
 
 
 
 
 
Whole leg US
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Negative
 
 
 
Positive
 
 
 
Negative
 
Positive
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Treat DVT
 
 
 
DVT is excluded
 
What is the location of the DVT?
 
 
 
 
 
 
 
 
 
 
 
 
 
Proceed with ONE of the following:
Highly/moderately sensitive D-dimer (most preferred)
Repeat proximal US within 1 week
Whole leg US
Venography (less preferred)
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Highly/moderately sensitive D-dimer (most preferred)
 
 
 
 
 
Repeat proximal US within 1 week
 
Whole leg US
 
Venography (less preferred)
 
 
 
Proximal
 
Distal
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Negative
 
Positive
 
Negative
 
Positive
 
Negative
 
Positive
 
Treat DVT
 
Serial US (1st line)
OR
Treat DVT
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
DVT is excluded
 
Repeat proximal US within 1 week
OR
Venography
 
DVT is excluded
 
Treat DVT
 
DVT is excluded
 
Treat DVT
 
 

Complete Diagnostic Approach for Suspected Recurrent Lower Extremity DVT

Shown below is the diagnostic approach to suspected recurrent DVT. The recommended initial test is either proximal ultrasound (US) or highly sensitive D-dimer tetsing rather than venography, CT venography or MR imagining. Initial D-dimer testing is recommended over proximal US in case there is no prior ultrasound for comparison. Note the following definitions:

  • Negative US:
    • Normal US, or
    • Increase in residual diameter of less than 2 mman, or
    • Area of prior noncompressibility with a decreased or stable residual diameter
  • Nondiagnostic US:
    • Ultrasound that is technically limited, or
    • Area of prior noncompressibility with an increment in residual venous diameter of < 4 mm yet ≥ 2 mm, or
    • Area of prior noncompressibility in the absence of a previous measurement of the residual diameter
  • Positive US:
    • New noncompressible segment, or
    • Area of prior noncompressibility with an increment in residual venous diameter of ≥ 4 mm[4]
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
The patient has recurrent DVT
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Proceed with one of the following:
Proximal US
Highly sensitive D-dimer
Venography (less preferred)
CT venography (less preferred)
MR imaging (less preferred)
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Proximal US
 
 
 
 
 
 
 
 
 
Highly sensitive D-dimer
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Negative
 
Non diagnostic
 
Positive
 
 
 
Negative
 
Positive
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Proceed with one of the following:
Highly/moderately sensitive D-dimer
Repeat proximal US within 1 week
Venography (less preferred)
No further testing (less preferred)
 
Click here for the diagnostic approach in case of non diagnostic US
 
Treat
OR
Venography (less preferred)
 
 
 
DVT is excluded
 
Proximal US
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Highly/moderately sensitive D-dimer
 
 
 
 
 
Repeat US
 
 
 
 
 
Venography
 
No further testing
 
Negative
 
Non diagnostic
 
Positive
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Negative
 
Positive
 
Negative
 
Positive
 
Negative
 
Positive
 
 
 
Repeat proximal US within 1 week
OR
Venography (less preferred)
OR
No further testing (less preferred)
 
Click here for the diagnostic approach in case of non diagnostic US
 
Treat
OR
Venography (less preferred)
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
DVT is excluded
 
Repeat proximal US within 1 week
OR
Venography (less preferred)
OR
No further testing (less preferred)
 
DVT is excluded
 
Treat
OR
Venography (less preferred)
 
DVT is excluded
 
Treat DVT
 
 
 
If proximal US is repeated, what is the result?
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
If proximal US is repeated, what is the result?
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Negative
 
Positive
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Negative
 
Positive
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
DVT is excluded
 
Treat
OR
Venography (less preferred)
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
DVT is excluded
 
Treat
OR
Venography (less preferred)
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 

Diagnostic Approach for Non Diagnostic Ultrasound

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
The patient has a non diagnostic proximal US
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Are prior US results available?
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Yes
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
No
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Proceed with ONE of the following:
Venography (most preferred)
Repeat proximal US within 1 week
Highly/moderately sensitive D-dimer
Treat DVT (less preferred)
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Proceed with ONE of the following:
Venography (most preferred)
Highly sensitive D-dimer
Repeat proximal US (less preferred)
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Venography (most preferred)
 
 
 
 
 
Repeat proximal US within 1 week
 
 
 
 
 
Highly/moderately sensitive D-dimer
 
Treat DVT (less preferred)
 
Venography (most preferred)
 
 
 
 
 
Highly sensitive D-dimer
 
Repeat proximal US within 1 week (less preferred)
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Negative
 
Positive
 
Negative
 
Positive
 
Negative
 
Positive
 
Negative
 
Positive
 
Negative
 
Positive
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
DVT is excluded
 
Treat DVT
 
DVT is excluded
 
Treat DVT
OR
Venography (less preferred)
 
DVT is excluded
 
Repeat proximal US within 1 week
 
DVT is excluded
 
Treat DVT
 
DVT is excluded
 
Venography
OR
Treat DVT (less preferred)
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Negative
 
Positive
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
DVT is excluded
 
Venography (less preferred)
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 

Diagnostic Approach for Venography

 
 
What is the result of the venography?
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Negative
 
Positive
 
 
 
 
 
 
 
 
 
 
 
 
DVT is excluded
 
Treat DVT
 

References

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