Hamostaseologie 2013; 33(03): 195-200
DOI: 10.5482/HAMO-13-06-0029
Review
Schattauer GmbH

Diagnosis of recurrent deep vein thrombosis

Diagnose der rezidivierenden tiefen Beinvenenthrombose
S. M. Schellong
1   Department of Internal Medicine II, Teaching Hospital of Technical University of Dresden, Germany
› Institutsangaben
Weitere Informationen

Publikationsverlauf

received: 02. Juni 2013

accepted: 18. Juni 2013

Publikationsdatum:
28. Dezember 2017 (online)

Summary

Deep vein thrombosis is a chronic disease with a continuing risk of recurrence. In a patient with recurrence long term prognosis and treatment are significantly altered both carrying their own risks not only in the acute phase but mainly in the long term perspective. Thus, accurate diagnosis of recurrence is of utmost importance for the fate of the patient. Diagnosis of a first DVT episode is well established and follows an algorithm including clinical prediction rules, D-Dimer testing and compression ultrasound. Due to the previous episode the efficiency of all three elements is impaired in a patient with suspected recurrence. This opens up areas of uncertainty which have to be filled by individual clinical judgement. Guidelines reflect this difficulty by providing mainly weak recommendations based on sparse data. The present review summarizes what is known about the performance of tools for DVT diagnosis, discusses recent guidelines, and finally gives personally weighed recommendations how to deal with this peculiar diagnostic situation. In conclusion, it will turn out that the well accepted diagnostic algorithm for a first DVT may be applied as well if the lower efficiency is regarded. Compression ultrasound largely benefits from a baseline assessment at the end of the previous episode. The order of tests may be discussed according to local and regional attitudes.

Zusammenfassung

Die tiefe Beinvenenthrombose ist eine chronische Erkrankung mit einem fortdauernden Risiko für ein Rezidiv. Tritt ein Rezidiv ein, sind Prognose und Behandlung des Patienten deutlich verändert, wobei beide ihre spezifischen Risiken nicht nur in der Akutphase, sondern besonders im Langzeitverlauf haben. Daher ist die korrekte Diagnose eines Rezidivs von größter Bedeutung. Die Diagnose einer ersten Episode folgt gut fundierten Algorithmen, deren Elemente die klinische Vortestwahrscheinlichkeit, der D-Dimer-Test und der Kompressionsultraschall der Beinvenen darstellen. Die Effizienz aller drei Elemente ist bei einem Patienten mit Verdacht auf Rezidiv durch die vorhergehende Episode verschlechtert. Dies gibt Raum für klinische Unsicherheiten, der nur mit persönlicher Einschätzung auf dem Boden von Erfahrung gefüllt werden kann. Die verfügbaren Leitlinien spiegeln diesen Umstand wider, indem sie überwiegend schwache Empfehlungen auf der Basis nur weniger Daten geben. Die vorliegende Übersicht fasst zusammen, was über die einzelnen diagnostischen Werkzeuge bekannt ist, diskutiert jüngste Leitlinien und gibt schließlich Empfehlungen aufgrund einer persönlichen Gewichtung. Es stellt sich heraus, dass der für eine erste Episode gültige Algorithmus auch bei der Diagnose des Rezidivs verwendet werden kann, wenn man sich der schlechteren Effizienz bewusst ist. Der Ultraschall profitiert wesentlich, wenn ein Vorbefund vom Behandlungsende der vorausgegangenen Episode vorliegt. Mit welchem der verfügbaren Werkzeuge man im Einzelfall beginnt, kann durchaus an lokale oder regionale Gewohnheiten angepasst werden.

 
  • References

  • 1 Heit JA. Predicting the risk of venous thromboembolism recurrence. Am J Hematol 2012; 87 (Suppl. 01) S63-S67.
  • 2 Baglin T, Luddington R, Brown K, Baglin C. Incidence of recurrent venousthromboembolism in relation to clinical and thrombophilic risk factors:prospective cohort study. Lancet 2003; 362: 523-526.
  • 3 Boutitie F, Pinede L, Schulman S. et al. Influence of preceding length of anticoagulant treatment and initialpresentation of venous thromboembolism on risk of recurrence after stoppingtreatment. BMJ. 2011 342. doi:10.1136/bmj.d3036.
  • 4 Goodacre S, Sutton AJ, Sampson FC. Meta-analysis: The value of clinical assessment in the diagnosis of deep venous thrombosis. Ann Intern Med 2005; 143: 129-139.
  • 5 Wells PS, Anderson DR, Bormanis J. et al. Value of assessment of pretest probability of deep-vein thrombosis in clinical management. Lancet 1997; 350: 1795-1798.
  • 6 Wells PS, Anderson DR, Rodger M. et al. Evaluation of D-dimer in the diagnosis of suspected deep-vein thrombosis. N Engl J Med 2003; 349: 1227-1235.
  • 7 Di Nisio M, Squizzato A, Rutjes AW. et al. Diagnostic accuracy of D-dimer test for exclusion of venous thromboembolism. J Thromb Haemost 2007; 05: 296-304.
  • 8 Elias A, Bonfils S, Daoud-Elias M. et al. Influence of long term oral anticoagulants upon prothrombin fragment 1 + 2, thrombin-antithrombin III complex and D-Dimer levels in patients affected by proximal deep vein thrombosis. Thromb Haemost 1993; 69: 302-305.
  • 9 Douketis J, Tosetto A, Marcucci MT. et al. Patientlevel meta-analysis. Ann Intern Med 2010; 153: 523-531.
  • 10 Rathbun SW, Whitsett TL, Raskob GE. Negative D-dimer result to exclude recurrent deep venous thrombosis. Ann Intern Med 2004; 14: 839-845.
  • 11 Bates SM, Kearon C, Kahn SR. et al. A negative D-dimer excludes recurrent deep vein thrombosi. Blood 2007; 110: 214a.
  • 12 Aguilar C, del Villar V. Combined D-dimer and clinical probability are useful for exclusion of recurrent deep venous thrombosis. Am J Hematol 2007; 82: 41-44.
  • 13 Prandoni P, Villalta S, Bagatella P. et al. The clinical course of deep-vein thrombosis. Haematologica 1997; 82: 423-428.
  • 14 Tan van Rooden, van Rooden CJ, Westerbeek RE, Huisman MV. Diagnostic management of clinically suspected acute deep vein thrombosis. Br J Haematol 2009; 146: 347-360.
  • 15 Schouten HJ, Koek HL, Oudega R. et al. Validation of two age dependent D-dimer cut-off values for exclusion of deep vein thrombosis in suspected elderly patients in primary care. Br Med J 2012; 344: e2085.
  • 16 Kearon C, Julian JA, Newman TE, Ginsberg JS. Noninvasive diagnosis of deep venous thrombosis. Ann Intern Med 1998; 128: 663-677.
  • 17 Goodacre S, Sampson F, Thomas S. et al. Systematic review and meta-analysis of the diagnostic accuracy of ultrasonography for deep vein thrombosis. BMC Medical Imaging 2005; 05: 6-14.
  • 18 Cogo A, Lensing AW, Koopman MM. et al. Compression ultrasonography for diagnostic management of patients with clinically suspected deep vein thrombosis. Br Med J 1998; 316: 17-20.
  • 19 Johnson SA, Stevens SM, Woller SC. et al. Risk of deep vein thrombosis following a single negative whole-leg compression ultrasound. JAMA 2010; 303: 438-445.
  • 20 Bernardi E, Camporese G, Büller HR. et al. Erasmus Study Group. Serial 2-point ultrasonography plus D-dimer vs whole-leg color-coded Doppler ultrasonography for diagnosing suspected symptomatic deep vein thrombosis. JAMA 2008; 300: 1653-1659.
  • 21 Gibson NS, Schellong SM, Kheir DY. et al. Safety and sensitivity of two ultrasound strategies in patients with clinically suspected deep venous thrombosis. J Thromb Haemost 2009; 07: 2035-2041.
  • 22 Prandoni P, Cogo A, Bernardi E. et al. A simple ultrasound approach for detection of recurrent proximal-vein thrombosis. Circulation 1993; 88: 1730-1735.
  • 23 Piovella F, Crippa L, Barone M. et al. Normalization rates of compression ultrasonography in patients with a first episode of deep vein thrombosis of the lower limbs. Haematologica 2002; 87: 515-522.
  • 24 Tan M, Mos ICM, Klok FA, Huisman MV. Residual venous thrombosis as predictive factor for recurrent venous thromboembolism in patients with proximal deep vein thrombosis. Br J Haematol 2011; 1111: 1365-2141.
  • 25 Koopmann MM, Jongbloets L, Lensing AW. et al. Clinical utility of a quantitative B-mode ultrasonography method in patients with suspected recurrent deep vein thrombosis (DVT). Thromb Haemost 1993; 69: 285a.
  • 26 Prandoni P, Lensing AWA, Bernardi E. et al. DERECUS Investigators Group. The diagnostic value of compression ultrasonography in patients with suspected recurrent deep vein thrombosis. Thromb Haemost 2002; 88: 402-406.
  • 27 Prandoni P, Tormene D, Dalla FValle. et al. D-dimer as an adjunct to compression ultrasonography in patients with suspected recurrent deep vein thrombosis. J Thromb Haemost 2007; 05: 1076-1077.
  • 28 Le Gal G, Kovacs MJ, Carrier M. et al. Validation of a diagnostic approach to exclude recurrent venous thromboembolism. J Thromb Haemost 2009; 07: 752-759.
  • 29 Hamadah A, Alwasaidi T, LE Gal G. et al. Baseline imaging after therapy for unprovoked venous thromboembolism. J Thromb Haemost 2011; 09: 2406-2410.
  • 30 Linkins L, Stretton R, Probyn L, Kearon C. Interobserver agreement on ultrasound measurements of residual vein diameter, thrombus echogenicity and Doppler venous flow in patients with previous venous thrombosis. Thromb Res 2006; 117: 241-247.
  • 31 Tan M, Bornais C, Rodger M. Interobserver reliability of compression ultrasound for residual thrombosis after first unprovoked deep vein thrombosis. J Thromb Haemost 2012; 10: 1775-1782.
  • 32 Heijboer H, Jongbloets LM, Büller HR. et al. Clinical utility of real-time compression ultrasonography for diagnostic management of patients with recurrent venous thrombosis. Acta Radiol 1992; 33: 297-300.
  • 33 VAN GOGH Investigators. Buller HR, Cohen AT, Davidson B. et al. Idraparinux versus standard therapy for venous thromboembolic disease. N Engl J Med 2007; 357: 1094-1104.
  • 34 Schellong SM. Distal DVT: worth diagnosing? Yes. J Thromb Haemost 2007; 05 (Suppl): 51-54.
  • 35 Righini M. Is it worth diagnosing and treating distal deep vein thrombosis? No. J Thromb Haemost 2007; 05 (Suppl. 01) 55-59.
  • 36 Palareti G, Schellong S. Isolated distal deep vein thrombosis. J Thromb Haemost 2012; 10: 11-19.
  • 37 Hull RD, Carter CJ, Jay RM. et al. The diagnosis of acute, recurrent, deep-vein thrombosis. Circulation 1983; 67: 901-906.
  • 38 Brighton T, Janssen J, Butler SP. Aging of acute deep vein thrombosis measured by radiolabled 99mTc-rt-PA. J Nucl Med 2007; 48: 873-878.
  • 39 Westerbeek RE, van Rooden CJ, Tan M. et al. Magnetic resonance direct thrombus imaging of the evolution of acute deep vein thrombosis of the leg. J Thromb Haemost 2008; 06: 1087-1092.
  • 40 Bates SM, Jaeschke R, Stevens SM. et al. American College of Chest Physicians. Diagnosis of DVT: Antithrombotic Therapy and Prevention of Thrombosis. Chest 2012; 141: 351S-418S.
  • 41 Ageno W, Squizzato A, Wells P. et al. The diagnosis of symptomatic recurrent pulmonary embolism and deep vein thrombosis. J Thromb Haemost. 2013 doi: 10.1111/jth.12301.
  • 42 Schellong SM, Gerlach H, Hach-Wunderle V. et al. Diagnosis of deep-vein thrombosis: adherence to guidelines and outcomes in real-world health care. Thromb Haemost 2009; 102: 1234-1240.