Diagnostic performance of complete lower limb venous ultrasound in patients with clinically suspected acute pulmonary embolism

Antoine Elias; Daniel Colombier; Gérard Victor; Marie Elias; Catherine Arnaud; Henri Juchet; Jean-Louis Ducassé; Alain Didier; Cyrille Colin; Hervé Rousseau; Françoise Nguyen; Francis Joffre

doi:10.1160/TH03-05-0278

Thrombosis and Haemostasis, Inhaltsverzeichnis

Thromb Haemost 2004; 91(01): 187-195
DOI: 10.1160/TH03-05-0278

New Technologies and Diagnostic Tools

Schattauer GmbH

Diagnostic performance of complete lower limb venous ultrasound in patients with clinically suspected acute pulmonary embolism

Antoine Elias

¹Departments of Vascular Medicine, Rangueil University Hospital Centre,Toulouse, France

,

Daniel Colombier

²Departments of Radiology, Rangueil University Hospital Centre,Toulouse, France

,

Gérard Victor

³Departments of Nuclear Medicine, Rangueil University Hospital Centre,Toulouse, France

,

Marie Elias

¹Departments of Vascular Medicine, Rangueil University Hospital Centre,Toulouse, France

,

Catherine Arnaud

⁴Faculty of Medicine, Department of Epidemiology and Health Economics, Community Health,Toulouse, France

,

Henri Juchet

⁵Departments of Emergency, Rangueil University Hospital Centre,Toulouse, France

,

Jean-Louis Ducassé

⁵Departments of Emergency, Rangueil University Hospital Centre,Toulouse, France

,

Alain Didier

⁶Departments of Pulmonology, Rangueil University Hospital Centre,Toulouse, France

,

Cyrille Colin

⁷Department of Medical Information of the Hospices Civils de Lyon, Lyons, France

,

Hervé Rousseau

²Departments of Radiology, Rangueil University Hospital Centre,Toulouse, France

,

Françoise Nguyen

⁸Haemostasis, Rangueil University Hospital Centre,Toulouse, France

,

Francis Joffre

²Departments of Radiology, Rangueil University Hospital Centre,Toulouse, France

› Institutsangaben

Abstract

Summary

A limited ultrasound (US) confined to the popliteal and femoral veins is usually performed to detect deep vein thrombosis (DVT) in patients with clinically suspected acute pulmonary embolism (PE). Our objective was to assess the diagnostic accuracy of complete lower limb US examining both the proximal and distal veins in this setting. In this prospective study, 210 consecutive patients were included. Complete US was performed by independent operators and compared blindly with a reference strategy combining clinical probability, ventilation perfusion scan and pulmonary angiography to a three-month clinical follow-up. Simultaneously,VIDAS D-dimer (DD) assay and helical computed tomography (HCT) of the lungs were assessed independently and blindly. PE was present in 74 patients (35%). Complete US detected DVT in 91 patients (43%), proximal in 51 and distal in 40. Sensitivity and specificity with a 0.95 confidence interval were respectively 0.93 [0.85 – 0.97] and 0.84 [0.77 – 0.89]. Limited US detected DVT in only 46 patients (22%). Sensitivity and specificity were respectively 0.55 [0.44 – 0.66] and 0.96 [0.92 – 0.98]. For DD they were 0.92 [0.83 – 0.96] and 0.24 [0.17 – 0.32] and for HCT 0.84 [0.73 – 0.90] and 0.87 [0.80 – 0.92]. Complete lower limb US has higher sensitivity and capacity to exclude PE than limited US, but a slightly lower specificity. Complete US results also compared favourably with those of HCT and DD.The utility of including this method in diagnostic strategies for PE needs to be assessed in cost-effectiveness analysis and in outcome studies.

Keywords

Pulmonary embolism - deep vein thrombosis - ultrasound/diagnosis

Volltext

Referenzen

References
1 Value of the ventilation/perfusion scan in acute pulmonary embolism. Results of the prospective investigation of pulmonary embolism diagnosis (PIOPED). The PIOPED Investigators. JAMA 1990; 263: 2753-9.
2 Hull RD, Hirsh J, Carter CJ. et al. Pulmonary angiography, ventilation lung scanning, and venography for clinically suspected pulmonary embolism with abnormal perfusion lung scan. Ann Intern Med 1983; 98: 891-9.
3 Perrier A, Desmarais S, Miron MJ. et al. Noninvasive diagnosis of venous thromboembolism in outpatients. Lancet 1999; 353: 190-5.
4 Wells PS, Anderson DR, Rodger M. et al. Excluding pulmonary embolism at the bedside without diagnostic imaging: management of patients with suspected pulmonary embolism presenting to the emergency department by using a simple clinical model and d-dimer. Ann Intern Med 2001; 135: 98-107.
5 Musset D, Parent F, Meyer G. et al. Diagnostic strategy for patients with suspected pulmonary embolism: a prospective multicentre outcome study. Lancet 2002; 360: 1914-20.
6 van Strijen MJ, de Monye W, Schiereck J. et al. Single-detector helical computed tomography as the primary diagnostic test in suspected pulmonary embolism: a multicenter clinical management study of 510 patients. Ann Intern Med 2003; 138: 307-14.
7 Havig O. Deep vein thrombosis and pulmonary embolism. An autopsy study with multiple regression analysis of possible risk factors. Acta Chir Scand Suppl 1977; 478: 1-120.
8 Bergqvist D, Lindblad B. A 30-year survey of pulmonary embolism verified at autopsy: an analysis of 1274 surgical patients. Br J Surg 1985; 72: 105-8.
9 Sandler DA, Martin JF. Autopsy proven pulmonary embolism in hospital patients: are we detecting enough deep vein thrombosis?. J R Soc Med 1989; 82: 203-5.
10 Saeger W, Genzkow M. Venous thromboses and pulmonary embolisms in post-mortem series: probable causes by correlations of clinical data and basic diseases. Pathol Res Pract 1994; 190: 394-9.
11 Kruit WH, de Boer AC, Sing AK. et al. The significance of venography in the management of patients with clinically suspected pulmonary embolism. J Intern Med 1991; 230: 333-9.
12 Girard P, Musset D, Parent F. et al. High prevalence of detectable deep venous thrombosis in patients with acute pulmonary embolism. Chest 1999; 116: 903-8.
13 Perrier A, Bounameaux H, Morabia A. et al. Diagnosis of pulmonary embolism by a decision analysis-based strategy including clinical probability, D-dimer levels, and ultrasonography: a management study. Arch Intern Med 1996; 156: 531-6.
14 Christiansen F. Diagnostic imaging of acute pulmonary embolism. Acta Radiol Suppl 1997; 410: 1-33.
15 Turkstra F, Kuijer PM, van Beek EJ. et al. Diagnostic utility of ultrasonography of leg veins in patients suspected of having pulmonary embolism. Ann Intern Med 1997; 126: 775-81.
16 Mac MRGillavry, Sanson BJ, Buller HR. et al. Compression ultrasonography of the leg veins in patients with clinically suspected pulmonary embolism: is a more extensive assessment of compressibility useful?. Thromb Haemost 2000; 84: 973-6.
17 Anderson DR, Wells PS. D-dimer for the diagnosis of venous thromboembolism. Curr Opin Hematol 2000; 07: 296-301.
18 Sostman HD, Coleman RE, DeLong DM. et al. Evaluation of revised criteria for ventilation-perfusion scintigraphy in patients with suspected pulmonary embolism. Radiology 1994; 193: 103-7.
19 van Rooij WJ, den Heeten GJ, Sluzewski M. Pulmonary embolism: diagnosis in 211 patients with use of selective pulmonary digital subtraction angiography with a flowdirected catheter. Radiology 1995; 195: 793-7.
20 Elias A. [Role of Doppler echography in the diagnosis of venous thrombosis]. Arch Mal Coeur Vaiss 1991; 84: 1669-78.
21 Elias A, Le Corff G, Bouvier JL. et al. Value of real time B mode ultrasound imaging in the diagnosis of deep vein thrombosis of the lower limbs. Int Angiol 1987; 06: 175-82.
22 de Moerloose P, Desmarais S, Bounameaux H. et al. Contribution of a new, rapid, individual and quantitative automated D-dimer ELISA to exclude pulmonary embolism. Thromb Haemost 1996; 75: 11-3.
23 Remy-Jardin M, Remy J, Cauvain O. et al. Diagnosis of central pulmonary embolism with helical CT: role of two-dimensional multiplanar reformations. AJR Am J Roentgenol 1995; 165: 1131-8.
24 Remy-Jardin M, Remy J, Wattinne L. et al. Central pulmonary thromboembolism: diagnosis with spiral volumetric CT with the single-breath-hold technique-comparison with pulmonary angiography. Radiology 1992; 185: 381-7.
25 Altman DG, Gardner MJ, Bryant TN. Statistics with confidence: confidence intervals and statistical guidelines. 2nd ed.. London: BMJ Books; 2000
26 Sutton AJ. Methods for meta-analysis in medical research. Chichester, West Sussex, England ; New York: John Wiley; 2000
27 Lijmer JG, Mol BW, Heisterkamp S. et al. Empirical evidence of design-related bias in studies of diagnostic tests. Jama 1999; 282: 1061-6.
28 Guyatt G, Rennie D. Evidence-Based Medicine Working Group, American Medical Association. Users’ guides to the medical literature: a manual for evidence-based clinical practice. Chicago, IL: AMA Press; 2002
29 Fernandez-Canton G, Lopez IVidaur, Munoz F. et al. Diagnostic utility of color Doppler ultrasound in lower limb deep vein thrombosis in patients with clinical suspicion of pulmonary thromboembolism. Eur J Radiol 1994; 19: 50-5.
30 Kelly J, Hunt BJ, Moody A. Magnetic resonance direct thrombus imaging: a novel technique for imaging venous thromboemboli. Thromb Haemost 2003; 89: 773-82.
31 Giachino A. Relationship between deep-vein thrombosis in the calf and fatal pulmonary embolism. Can J Surg 1988; 31: 129-30.
32 Chapman WH, Foley KT, Lee YT. Pulmonary embolism from a venous thrombosis distal to the popliteal vein. Mil Med 1991; 156: 252-4.
33 Ohgi S, Tachibana M, Ikebuchi M. et al. Pulmonary embolism in patients with isolated soleal vein thrombosis. Angiology 1998; 49: 759-64.
34 Baile EM, King GG, Muller NL. et al. Spiral computed tomography is comparable to angiography for the diagnosis of pulmonary embolism. Am J Respir Crit Care Med 2000; 161: 1010-5.
35 Elias A, Mallard L, Elias M. et al. A single complete ultrasound investigation of the venous network for the diagnostic management of patients with a clinically suspected first episode of deep venous thrombosis of the lower limbs. Thromb Haemost 2003; 89: 221-7.
36 Barrellier MT, Somon T, Speckel D. et al. [Duplex ultrasonography in the diagnosis of deep vein thrombosis of the legs. Agreement between two operators]. J Mal Vasc 1992; 17: 196-201.
37 Wells PS, Ginsberg JS, Anderson DR. et al. Use of a clinical model for safe management of patients with suspected pulmonary embolism. Ann Intern Med 1998; 129: 997-1005.
38 Bendick PJ, Glover JL, Brown OW. et al. Serial duplex ultrasound examinations for deep vein thrombosis in patients with suspected pulmonary embolism. J Vasc Surg 1996; 24: 732-7.
39 Kearon C, Ginsberg JS, Hirsh J. The role of venous ultrasonography in the diagnosis of suspected deep venous thrombosis and pulmonary embolism. Ann Intern Med 1998; 129: 1044-9.
40 van Erkel AR, Pattynama PM. Cost-effective diagnostic algorithms in pulmonary embolism: an updated analysis. Acad Radiol 1998; 05 (Suppl. 02) S321-7.
41 Elias A, Molinier L, Bauvin E. et al. Integrating complete lower limb venous ultrasound into diagnostic strategies for pulmonary embolism: a cost-effectiveness analysis. Thromb Haemost 2004; 91: 205-7.
42 Hunink MGM. Decision making in health and medicine: integrating evidence and values. Cambridge; New York, NY: Cambridge University Press; 2001
43 Perrier A, Bounameaux H. Cost-effective diagnosis of deep vein thrombosis and pulmonary embolism. Thromb Haemost 2001; 86: 475-87.
44 Mullins MD, Becker DM, Hagspiel KD. et al. The role of spiral volumetric computed tomography in the diagnosis of pulmonary embolism. Arch Intern Med 2000; 160: 293-8.
45 Rathbun SW, Raskob GE, Whitsett TL. Sensitivity and specificity of helical computed tomography in the diagnosis of pulmonary embolism: a systematic review. Ann Intern Med 2000; 132: 227-32.
46 Perrier A, Howarth N, Didier D. et al. Performance of helical computed tomography in unselected outpatients with suspected pulmonary embolism. Ann Intern Med 2001; 135: 88-97.
47 Ferretti GR, Bosson JL, Buffaz PD. et al. Acute pulmonary embolism: role of helical CT in 164 patients with intermediate probability at ventilation-perfusion scintigraphy and normal results at duplex US of the legs. Radiology 1997; 205: 453-8.
48 Hartmann IJ, Hagen PJ, Melissant CF. et al. Diagnosing acute pulmonary embolism: effect of chronic obstructive pulmonary disease on the performance of D-dimer testing, ventilation/perfusion scintigraphy, spiral computed tomographic angiography, and conventional angiography. ANTELOPE Study Group. Advances in New Technologies Evaluating the Localization of Pulmonary Embolism. Am J Respir Crit Care Med 2000; 162: 2232-7.
49 Qanadli SD, Hajjam ME, Mesurolle B. et al. Pulmonary embolism detection: prospective evaluation of dual-section helical CT versus selective pulmonary arteriography in 157 patients. Radiology 2000; 217: 447-55.
50 Ghaye B, Szapiro D, Mastora I. et al. Peripheral pulmonary arteries: how far in the lung does multi-detector row spiral CT allow analysis?. Radiology 2001; 219: 629-36.