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] ; Kashish Goel, M.D.; Assistant Editor(s)-In-Chief: Justine Cadet

Deep Vein Thrombosis Microchapters
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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.

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.