Diagnostic Imaging Pathways - Deep Venous Thrombosis (Leg)
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Population Covered By The Guidance
This pathway provides guidance on the imaging of adult patients with suspected lower limb deep venous thrombosis.
Date reviewed: September 2017
Date of next review: September 2020
Published: December 2017
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Move the mouse cursor over the PINK text boxes inside the flow chart to bring up a pop up box with salient points.
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The relative radiation level (RRL) of each imaging investigation is displayed in the pop up box.
| SYMBOL | RRL | EFFECTIVE DOSE RANGE |
 | None | 0 |
 | Minimal | < 1 millisieverts |
 | Low | 1-5 mSv |
 | Medium | 5-10 mSv |
 | High | >10 mSv |
Images
Image GalleryNote: These images open in a new page | ||
|---|---|---|
| 1a |  |
Leg Deep Vein Thrombosis Image 1a and 1b (Doppler Ultrasound): Acute thrombosis is indicated by the distended and hypoechoic lumen of the common femoral and external iliac veins with no flow. |
| 1b |  |
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Teaching Points
Teaching Points
- Clinical prediction rules (e.g. Wells Criteria) may be used to categorise patients into low, medium or high risk
- Low risk and negative serum D-Dimer effectively excludes DVT
- Medium and high risk patients should undergo Doppler ultrasound without D-Dimer estimation
- Ultrasound is highly sensitive for proximal lower limb deep vein thrombosis
- US is less sensitive for deep calf vein thrombosis and for iliac vein thrombosis
- After a negative Doppler ultrasound, follow-up US in patients with high clinical suspicion may be indicated to exclude a calf thrombosis that is propagating proximally
hs1
Wells Criteria
This clinical prediction rule is designed to increase the probability of an accurate diagnosis of deep venous thrombosis 1-5- Active cancer patient receiving treatment for cancer within the previous 6 months or currently receiving palliative treatment (1 point)
- Paralysis, paresis, or recent plaster immobilisation of the lower extremities (1 point)
- Recently bedridden for 3 days or more, or major surgery within the previous 12 weeks requiring general or regional anaesthesia (1 point)
- Localised tenderness along in the distribution of the deep venous system (1 point)
- Entire leg swollen (1 point)
- Calf swelling at least 3cm larger than that on the asymptomatic side (measured 10cm below tibial tuberosity) (1 point)
- Pitting oedema confined to the symptomatic leg (1 point)
- Collateral superficial veins (nonvaricose) (1 point)
- Previously documented DVT (1 point)
- Alternative diagnosis at least as likely as DVT (-2 points)
Score of less than 2 = DVT unlikely
hs2
Ultrasound Including Doppler
- Most accurate non-invasive test for the diagnosis of a first symptomatic proximal deep vein thrombosis 6-9
- Involves a combination of: 6, 9
- Compression ultrasonography - starting at the inguinal ligament and generally extending to the venous trifurcation in the calf
- Doppler imaging - particularly useful where compressibility is difficult to assess
- Advantages of ultrasound 10
- Excellent sensitivity for proximal vein thrombosis (97%) 8
- Ability to depict anatomical variants (e.g. duplicated venous segments) and alternative causes of symptoms
- Non-invasive
- No exposure to ionising radiation
- Does not involve the use of contrast agent
- Relatively inexpensive
- Limitations of ultrasound 9, 10
- Venous compressibility may be limited by patient characteristics such as obesity, oedema, and tenderness
- False positives may occur due to extrinsic compression of a vein by pelvic mass or other perivascular pathology
- A negative ultrasound scan in moderate to high risk patients does not reliably exclude the diagnosis of deep vein thrombosis 11
- Less sensitive for detecting distal vein thrombosis (73% sensitivity) and in detecting thrombosis in iliac veins 8
- Serial ultrasound is used to detect those DVTs that were isolated distally in the calf initially and undetected but which subsequently extend into the more proximal veins 10
- Isolated distal calf DVTs rarely lead to significant embolic events 12
hs3
D-Dimer
- Is formed as a result of plasmin generated degradation of thrombin and is therefore a marker of the presence of thrombus 5, 13
- There are various qualitative and quantitative assays available for D-Dimer but in general they have a high sensitivity and negative predictive value for the presence of thrombus 5, 13, 14
- Of the various assays, the quantitative enzyme linked immunosorbent assay (ELISA) has the best negative likelihood ratio and is significantly superior to non-ELISA assays for excluding the presence of deep vein thrombosis. The sensitivity is higher for proximal, compared to distal DVT 11, 13
- A negative quantitative ELISA D-Dimer result is as diagnostically useful for excluding DVT as a negative duplex Doppler ultrasound 5, 11
- If a patient is assessed, based on pre-test probability as unlikely to have leg DVT returns a negative D-Dimer result, there is generally considered to be no requirement for a Doppler ultrasound 2, 11, 15
- An elevated D-Dimer level is non-specific for venous thromboembolism, and diagnostic imaging is required to confirm the presence of disease 16
- D-Dimer has a limited role in hospitalised patients, and ultrasonography should be performed if deep venous thrombosis is suspected
References
References
Date of literature search: September 2017
References are graded from Level I to V according to the Oxford Centre for Evidence-Based Medicine, Levels of Evidence. Download the document
- Wells PS, Hirsh J, Anderson DR, Lensing AW, Foster G, Kearon C, et al. Accuracy of clinical assessment of deep-vein thrombosis. Lancet. 1995;345(8961):1326-30. (Level II evidence). View the reference
- Wells PS, Anderson DR, Rodger M, Forgie M, Kearon C, Dreyer J, et al. Evaluation of D-dimer in the diagnosis of suspected deep-vein thrombosis. N Engl J Med. 2003;349(13):1227-35. (Level II evidence). View the reference
- Perrier A, Desmarais S, Miron MJ, de Moerloose P, Lepage R, Slosman D, et al. Non-invasive diagnosis of venous thromboembolism in outpatients. Lancet. 1999;353(9148):190-5. (Level II evidence). View the reference
- Wells PS, Anderson DR, Bormanis J, Guy F, Mitchell M, Gray L, et al. Value of assessment of pretest probability of deep-vein thrombosis in clinical management. Lancet. 1997;350(9094):1795-8. (Level II evidence). View the reference
- Min SK, Kim YH, Joh JH, Kang JM, Park UJ, Kim HK, et al. Diagnosis and Treatment of Lower Extremity Deep Vein Thrombosis: Korean Practice Guidelines Vasc Specialist Int. 2016;32(3):77-104. (Guidelines). View the reference
- Goodacre S, Sampson F, Thomas S, van Beek E, Sutton A. Systematic review and meta-analysis of the diagnostic accuracy of ultrasonography for deep vein thrombosis. BMC Med Imaging. 2005;5:6. (Level II evidence). View the reference
- Kitchen L, Lawrence M, Speicher M, Frumkin K. Emergency Department Management of Suspected Calf-Vein Deep Venous Thrombosis: A Diagnostic Algorithm. West J Emerg Med. 2016;17(4):384-90. (Review article). View the reference
- Kearon C, Julian JA, Newman TE, Ginsberg JS. Noninvasive diagnosis of deep venous thrombosis. McMaster Diagnostic Imaging Practice Guidelines Initiative. Ann Intern Med. 1998;128(8):663-77. (Review article). View the reference
- Tapson VF, Carroll BA, Davidson BL, Elliott CG, Fedullo PF, Hales CA, et al. The diagnostic approach to acute venous thromboembolism. Clinical practice guideline. American Thoracic Society. Am J Respir Crit Care Med. 1999;160(3):1043-66. (Guidelines). View the reference
- Keeling DM, Mackie IJ, Moody A, Watson HG. The diagnosis of deep vein thrombosis in symptomatic outpatients and the potential for clinical assessment and D-dimer assays to reduce the need for diagnostic imaging. Br J Haematol. 2004;124(1):15-25. (Review article). View the reference
- Stein PD, Hull RD, Patel KC, Olson RE, Ghali WA, Brant R, et al. D-dimer for the exclusion of acute venous thrombosis and pulmonary embolism: a systematic review Ann Intern Med. 2004;140(8):589-602. (Level I evidence). View the reference
- Sule AA, Chin TJ, Handa P, Earnest A. Should symptomatic, isolated distal deep vein thrombosis be treated with anticoagulation? The International Journal of Angiology : Official Publication of the International College of Angiology, Inc. 2009;18(2):83-7. (Level IV evidence). View the reference
- Goodacre S, Sampson FC, Sutton AJ, Mason S, Morris F. Variation in the diagnostic performance of D-dimer for suspected deep vein thrombosis. Qjm. 2005;98(7):513-27. (Review article). View the reference
- Freyburger G, Trillaud H, Labrouche S, Gauthier P, Javorschi S, Bernard P, et al. D-dimer strategy in thrombosis exclusion--a gold standard study in 100 patients suspected of deep venous thrombosis or pulmonary embolism: 8 DD methods compared. Thromb Haemost. 1998;79(1):32-7. (Level II evidence). View the reference
- Owaidah T, AlGhasham N, AlGhamdi S, AlKhafaji D, B AL, Zeitouni M, et al. Evaluation of the usefulness of a D dimer test in combination with clinical pretest probability score in the prediction and exclusion of Venous Thromboembolism by medical residents. Thromb J. 2014;12(1):28. (Level III evidence). View the reference
- Ho WK, Hankey GJ, Lee CH, Eikelboom JW. Venous thromboembolism: diagnosis and management of deep venous thrombosis. Med J Aust. 2005;182(9):476-81. (Review article). View the reference
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