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International Angiology 2002 March;21(1):9-19


lingua: Inglese

Exclusion and diagnosis of deep vein thrombosis in outpatients by sequential noninvasive tools

Michiels J. J. 1, 7, Kasbergen H. 4, Oudega R. 5, Van Der Graaf F. 6, De Maeseneer M. 3, Van Der Planken M. 2, Schroyens W. 1

From the Hemostasis and Thrombosis Research, 1 Department of Hematology, 2 Laboratory of Hematology and Hemostasis, and 3 Vascular Laboratory, University Hospital Antwerp, Belgium 4 Medical Diagnostic Center, Rijnmond, Rotterdam, The Netherlands 5 General Practioner, Nunspeet and Medical Coordinating Center North/West Veluwe, NL 6 Clinical Laboratories, Sint Joseph Hospital Veldhoven, The Netherlands 7 Goodheart Institute, Hemostasis Thrombosis Science Center and International Institute of Thrombosis and Vascular Diseases, Rotterdam, The Netherlands


Phlebography is the ref­er­ence gold stan­dard for the diag­no­sis of deep vein throm­bo­sis (DVT), but due to its inva­sive ­nature and asso­ciat­ed side ­effects it has been ­replaced by com­pres­sion ultra­so­nog­ra­phy (CUS). Patients sus­pect­ed of DVT are sub­ject­ed to leg vein CUS that actu­al­ly con­firms DVT in only 16 to 28% of out­pa­tients in large pros­pec­tive man­age­ment stud­ies. CUS has a high pos­i­tive pre­dic­tive value of more than 98% for prox­i­mal DVT but usu­al­ly miss­es calf vein throm­bo­sis. Its neg­a­tive pre­dic­tive value for prox­i­mal DVT is about 97-98%, on the basis of which repeat­ed scan­ning at day 7 after a neg­a­tive first CUS (seri­al CUS) in out­pa­tients with a first sus­pi­cion of DVT is advo­cat­ed. Serial ultrasonography is cost­ly and can be sim­pli­fied and ­improved by the addi­tion of clin­i­cal score and D-dimer test­ing. The safe exclu­sion of DVT by a rapid sen­si­tive D-dimer test in com­bi­na­tion with clin­i­cal score and/or CUS ­requires a neg­a­tive pre­dic­tive value of >99%. The neg­a­tive pre­dic­tive value for DVT is deter­mined by the sen­si­tiv­ity of the rapid ELISA D-dimer test and the prev­a­lence of DVT in sub­groups of out­pa­tients sus­pect­ed of the con­di­tion. The prev­a­lence of DVT in out­pa­tients with a low, mod­er­ate and high clin­i­cal score var­ies wide­ly from 3-10%, 15-30% and >70%, respec­tive­ly. The com­bi­na­tion of a low clin­i­cal score (prev­a­lence DVT 3-5%) and a neg­a­tive rapid ELISA D-dimer alone test will have a very high neg­a­tive pre­dic­tive value of >99.9% to ­exclude DVT with­out the need of CUS test­ing. The com­bi­na­tion of a neg­a­tive CUS and a neg­a­tive rapid ELISA D-dimer test safe­ly ­excludes DVT in ­patients with sus­pect­ed DVT irre­spec­tive of the clin­i­cal score. The com­bi­na­tion of a neg­a­tive CUS, a low clin­i­cal score and a pos­i­tive ELISA D-dimer but <1000 ng/ml ­excludes DVT with a neg­a­tive pre­dic­tive value of >99% with­out the need to ­repeat CUS. Patients with a neg­a­tive CUS, scan but a pos­i­tive ELISA D-dimer, and a mod­er­ate or high clin­i­cal score are still at risk with a prob­abil­ity of DVT of 3-5% and 20-30%, respec­tive­ly and are thus can­di­dates for repeat­ed ultra­sound scan­ning. The rapid ELISA D-dimer first fol­lowed by risk-based no, sin­gle or repeat­ed CUS will be the most cost-effec­tive strat­e­gy.

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