Looking for Deep Vein Thrombosis in Suspected Pulmonary Embolism

Joseph Emmerich

doi:10.1055/s-2001-18486

Seminars in Vascular Medicine, Inhaltsverzeichnis

Semin Vasc Med 2001; 01(2): 181-188
DOI: 10.1055/s-2001-18486

Looking for Deep Vein Thrombosis in Suspected Pulmonary Embolism

Joseph Emmerich

Vascular Medicine Department, Hôpital Européen G. Pompidou, Paris, France

Abstract

ABSTRACT

Pulmonary embolism (PE) and deep vein thrombosis are two facets of the same disease, that is, venous thromboembolism (VTE). In patients with angiographically proven PE, the prevalence of proximal deep vein thrombosis by venography is around 70%. The sensitivity of compression ultrasonography (US) for the diagnosis of acute VTE in patients with a suspicion of PE is between 40 and 60%, with a high specificity (96 to 100%). Taking into account the 20 to 30% prevalence of PE in a population consulting for suspicion of this disease, the first line use of compression US will allow the diagnosis of acute VTE in half of patients with confirmed PE, that is, in 10 to 15% of patients addressed for suspicion of PE. In outpatients, the first line use of D-dimers which will exclude acute VTE in one-third of the initial population will slightly increase the reliability of compression US as a first imaging test. New tools of looking for deep vein thrombosis, such as computed tomographic venography coupled with computed tomographic pulmonary angiography, could become an interesting approach in the diagnostic strategy of PE, but require adequate evaluation in prospective studies.

KEYWORD

Pulmonary embolism - deep vein thrombosis - compression ultrasonography - CT venography - diagnosis

Volltext

Referenzen

REFERENCES

1 Oger E, for the EPI-GETBO Study Group. Incidence of venous thromboembolism: a community-based study in Western France. Thromb Haemost . 2000; 83 657-660
2 Urokinase Pulmonary Emboism Trial. A national cooperative study. Circulation . 1973 (suppl II); 47 (1-108)
3 Meignan M, Rosso J, Gauthier H. Systematic lung scans reveal a high frequency of silent pulmonary embolism in patients with proximal deep venous thrombosis. Arch Intern Med . 2000; 160 159-164
4 Hull R D, Hirsh J, Carter C J. Pulmonary angiography, ventilation lung scanning and venography for clinically suspected pulmonary embolism with abnormal perfusion lung scan. Ann Intern Med . 1983; 98 891-899
5 Girard P, Musset D, Parent F, Maitre S, Philippoteau C, Simonneau G. High prevalence of detectable deep venous thrombosis in patients with acute pulmonary embolism. Chest . 1999; 116 903-908
6 Dalen J E, Brooks H L, Johnson L W, Meister S G, Szucs M M, Dexter L. Pulmonary angiography in acute pulmonary embolism: indications, techniques and results in 367 patients. Am Heart J . 1971; 81 175-185
7 Hirsh J, Bettman M, Coates G, Hull R D. Diagnosis of pulmonary embolism. In: Colman RW, Hirsh J, Marder VJ, Salzman EW, eds. Hemostasis and Thrombosis: Basic Principles and Clinical Practice 3rd ed. Philadelphia, PA: Lippincott Co 1994: 1322-1330
8 Prins M H, Turpie A GG. Diagnosis and treatment of venous thromboembolism. In: Bloom AL, Forbes CD, Thomas DP, Tuddenham GD, eds. Haemostasis and Thrombosis 3rd ed. Philadelphia: Churchill Livingstone 1994: 1381-1414
9 Michiels J J. Rational diagnosis of pulmonary embolism (RADIAPE) in symptomatic outpatients with suspected PE: an improved strategy to exclude or diagnose venous thromboembolism by the sequential use of a clinical model, rapid ELISA D-Dimer test, perfusion lung scan, ultrasonography, spiral CT, and pulmonary angiography. Sem Thromb Hemost . 1998; 24 413-418
10 Mills S R, Jackson D C, Older R A, Heaston D K, Moore A V. The incidence, etiologies and avoidance of complications of pulmonary angiography in a large series. Radiology . 1980; 136 295-299
11 Stein P D, Athanasoulis C, Alavi A. Complications and validity of pulmonary angiography in acute pulmonary embolism. Circulation . 1992; 85 462-468
12 Nicod P, Peterson K L, Levine M S. Pulmonary angiography in severe chronic pulmonary hypertension. Ann Intern Med . 1987; 107 565-568
13 Perlmutt L M, Braun S D, Newman G E, Oke E J, Dunnick N R. Pulmonary arteriography in the high-risk patient. Radiology . 1987; 162 187-189
14 Meyer G, Gisselbrecht M, Diehl J L, Journois D, Sors H. Incidence and predictors of major hemorrhagic complications from thrombolytic therapy in patients with massive pulmonary embolism. Am J Med . 1998; 105 472-477
15 PIOPED investigators. Value of the ventilation/perfusion scan in acute pulmonary embolism. Results of the Prospective Investigation of Pulmonary Embolism Diagnosis (PIOPED). JAMA. 1990; 263 2753-2759
16 Mullins M D, Becker D M, Hagpiel K D, Philbrick J T. The role of spiral volumetric computed tomography in the diagnosis of pulmonary embolism. Arch Intern Med . 2000; 160 293-298
17 Rathbun S W, Raskob G E, Whitsett T L. Sensitivity and specificity of helical computed tomography in the diagnosis of pulmonary embolism: a systematic review. Ann Intern Med . 2000; 132 227-232
18 Reber G, de Moerloose P. D-Dimer assay for the exclusion of venous thromboembolism. Sem Thromb Hemostas . 2000; 26 919-924
19 Wells P S, Anderson D R, Ginsberg J. Assessment of deep vein thrombosis or pulmonary embolism by the combined use of clinical model and noninvasive diagnostic tests. Sem Thromb Hemostas . 2000; 26 643-656
20 Hull R D, Hirsh J, Carter C J. Pulmonary angiography, ventilation lung scanning, and venography for clinically suspected pulmonary embolism with abnormal perfusion lung scan. Ann Intern Med . 1983; 98 891-899
21 Schiff M J, Feinberg A W, Naidich J B. Noninvasive venous examinations as a screening test for pulmonary embolism. Arch Intern Med . 1987; 147 505-507
22 Beecham R P, Dorfmman G S, Cronan J J, Spearman M P, Murphy T P, Scola F H. Is bilateral lower extremity compression sonography useful and cost-effective in the evaluation of suspected pulmonary embolism?. AJR Am J Roentgenol . 1993; 161 1289-1292
23 Killewich L A, Nunnelee J D, Auer A I. Value of lower extremity venous duplex examination in the diagnosis of pulmonary embolism. J Vasc Surg . 1993; 17 934-938
24 Hull R D, Raskob G E, Ginsberg J S. A noninvasive strategy for the treatment of patients with suspected pulmonary embolism. Arch Intern Med . 1994; 154 289-297
25 Smith L L, Conrad I, Sirr S. Pulmonary embolism: confirmation with venous duplex US as adjunct to lung scanning. Radiology . 1994; 191 143-147
26 Rosen M P, Sheiman R G, Weintraub J, McArdle C. Compression sonography in patients with indeterminate or low-probability lung scans: lack of usefulness in the absence of both symptoms of deep-vein thrombosis and thromboembolic risk factors. AJR Am J Roentgenol . 1996; 166 285-289
27 Turkstra F, Kuijer M M, van Beek J R E, Brandjes D P, ten Cate W J, Büller H R. Diagnostic utility of ultrasonography of leg veins in patients suspected of having pulmonary embolism. Ann Intern Med . 1997; 126 775-781
28 Wells P S, Ginsberg J S, Anderson D R. Use of a clinical model for safe management of patients with suspected pulmonary embolism. Ann Intern Med . 1998; 129 997-1005
29 Ginsberg J S, Wells P S, Kearon C. Sensitivity and specificity of a rapid whole-blood assay for D-dimer in the diagnosis of pulmonary embolism. Ann Intern Med . 1998; 129 1006-1011
30 Meyerovitz M F, Mannting F, Polak J F, Goldhaber S Z. Frequency of pulmonary embolism in patients with low-probability lung scan and negative lower extremity venous ultrasound. Chest . 1999; 115 980-982
31 Miron M J, Perrier A, Bounameaux H. Contribution of noninvasive evaluation to the diagnosis of pulmonary embolism in hospitalized patients. Eur Respir J . 1999; 13 1365-1370
32 Perrier A, Desmarais S, Miron M J. Non-invasive diagnosis of venous thromboembolism in outpatients. Lancet . 1999; 353 190-195
33 Perrier A, Bounameaux H, Morabian A. 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; 156 531-536
34 Sevitt S. Venous thrombosis and pulmonary embolism: their prevention by oral anticoagulants. Am J Med . 1962; 33 703-716
35 Berqvist D, Lindblad B. A 30-year survey of pulmonary embolism verified at autopsy: an analysis of 1274 surgical patients. Br J Surg . 1985; 72 105-109
36 Ryu J H, Swensen S J, Olson E J, Pellikka P A. Diagnosis of pulmonary embolism with use of computed tomographic angiography. Mayo Clin Proc . 2001; 76 59-65
37 Simonneau G, Sors H, Charbonnier B. A comparison of low-molecular-weight heparin with unfractionated heparin for acute pulmonary embolism. N Engl J Med . 1997; 337 663-669
38 Fraser J D, Anderson D R. Deep venous thrombosis: recent advances and optimal investgations with US. Radiology . 1999; 211 9-24
39 Kearon C, Ginsberg J S, Hirsh J. The role of venous ultrasonography in the diagnosis of suspected deep venous thrombosis and pulmonary embolism. Ann Intern Med . 1998; 129 1044-1049
40 Cogo A, Lensing A WA, Koopman M MW. Compression ultrasonography for diagnostic management of patients with clinically suspected deep vein thrombosis: prospective cohort study. BMJ . 1998; 316 17-20
41 Wells P S, Anderson D R, Bormani J. Value of assessment of pretest probability of deep-vein tombosis in clinical management. Lancet . 1997; 350 1795-1798
42 Bernardi E, Prandoni P, Lensing A W. D-dimer testing as an adjunct to ultrasonography in patients with clinically suspected deep vein thrombosis; prospective cohort study. The Multicentre Italian D-dimer Ultrasound Study Investigators Group. BMJ . 1998; 317 1037-1040
43 Bounameaux H, Perrier A. Compression ultrasonography for diagnosing deep vein thrombosis. Repeat testing is unjustified. BMJ . 1998; 316 1534-1535
44 Perone N, Bounameaux H, Perrier A. Comparison of four strategies for diagnosing deep vein thrombosis: a cost-effectiveness analysis. Am J Med . 2001; 110 33-40
45 Wells P S, Anderson D R. Modern approach to diagnosis in patients with suspected deep vein thrombosis. Haemostasis . 1999 (suppl 1); 29 (10-20)
46 Kearon C, Julian J A, Newman T E. Noninvasive diagnosis of deep venous thrombosis: McMaster diagnostic imaging practice guidelines initiative. Ann Intern Med . 1998; 128 663-677
47 Jongbloets L M, Lensing A W, Koopman M M, Büller H R, ten Cate W J. Limitations of compression ultrasound for the detection of symptomless postoperative deep vein thrombosis. Lancet . 1994; 343 1142-1144
48 Magnusson M, Eriksson B I, Kälebo P, Sivertsson R. Is colour Doppler ultrasound a sensitive screening method in diagnosing deep vein thrombosis after hip surgery?. Thromb Haemost . 1996; 2 242-245
49 Lensing A WA, Doris I, McGrath F P. A comparison of compression ultrasound with color Doppler ultrasound for the diagnosis of symptomless postoperative deep vein thrombosis. Arch Intern Med . 1997; 157 765-768
50 Davidson B L, Elliot G C, Lensing A W. Low accuracy of color Doppler ultrasound to detect proximal leg vein thrombosis during screening of asymptomatic high-risk patient. Ann Intern Med . 1992; 117 735-738
51 Wells P S, Lensing A W, Davidson B L, Prins M H, Hirsh J. Accuracy of ultrasound for the diagnosis of deep venous thrombosis in asymptomatic patients after orthopedic surgery. A meta-analysis. Ann Intern Med . 1995; 122 47-53
52 Robinson K S, Anderson D R, Gross M. Ultrasonographic screening before hospital discharge for deep venous thrombosis after arthroplasty: the post-arthroplasty screening study. A randomized, controlled trial. Ann Intern Med . 1997; 127 439-445
53 Clinical Practice Guideline. The diagnostic approach to acute venous thromboembolism. Am J Respir Crit Care Med . 1999; 160 1043-1066
54 Meyerovitz M F, Mannting F, Polak J F, Goldhaber S Z. Frequency of pulmonary embolism in patients with low-probability lung scan and negative lower extremity venous ultrasound. Chest . 1999; 115 980-982
55 Perrier A, Miron M J, Desmarais S. Using clinical evaluation and lung scan to rule out suspected pulmonary embolism. Is it a valid option in patients with normal results of lower-limb venous compression ultrasonography?. Arch Intern Med . 2000; 160 512-516
56 Fennerty T. Pulmonary embolism: hospitals should develop their own strategies for diagnosis and management. BMJ . 1998; 317 91-92
57 Heijboer H, Büller H R, Lensing A WA. A comparison of real-time ultrasonography with impedance plethysmography for the diagnosis of deep-vein thrombosis in symptomatic outpatients. N Engl J Med . 1993; 329 1365-1369
58 Spritzer C E, Sostman H D, Wilkes D C, Coleman R E. Deep venous thrombosis: experience with gradient-echo MR imaging in 66 patients. Radiology . 1990; 177 235-241
59 Totterman S, Francis C W, Foster T H. Diagnosis of femoropopliteal venous thrombosis with MR imaging: a comparison of four MR pulse sequences. AJR Am J Roentgenol . 1990; 154 175-178
60 Erdman W A, Jayson H T, Redman H C. Deep venous thrombosis of extremities: role of MRI in the diagnosis. Radiology . 1990; 174 425-431
61 Spritzer C E, Norconk J J, Sostman H D, Coleman R E. Detection of deep venous thrombosis by MRI. Chest . 1993; 104 54-60
62 Carpenter J P, Holland G A, Baum R A. Magnetic resonance venography for the detection of deep venous thrombosis: comparison with contrast venography and duplex Doppler ultrasonography. J Vasc Surg . 1993; 18 734-741
63 Dupas B, El Kouri D, Curtet C. Angiomagnetic resonance imaging of iliofemorocaval venous thrombosis. Lancet . 1995; 346 17-19
64 Baldt M M, Zontsich T, Stumpflen A. Deep venous thrombosis of the lower extremity: efficacy of spiral CT venography compared with conventional venography in diagnosis. Radiology . 1996; 200 423-428
65 Bauer A R, Flynn R R. Computed tomography diagnosis of venous thrombosis of the lower extremities and pelvis with contrast materials. Surg Gynecol Obstet . 1988; 167 12-15
66 Shah A A, Buckshee N, Yankelevitz D F, Henschke C I. Assessment of deep venous thrombosis using routine pelvic CT. AJR Am J Roentgenol . 1999; 173 659-663
67 Loud P A, Katz D S, Klippenstein D L, Shah R D, Grossman Z D. Combined CT venography and pulmonary angiography in suspected thromboembolis disease: diagnostic accuracy for deep venous evaluation. AJR Am J Roentgenol . 2000; 174 61-65
68 Garg K, Kemp J L, Wojcik D. Thromboembolic disease: comparison of combined CT pulmonary angiography and venography with bilateral leg sonography in 70 patients. Am J Roentgenol . 2000; 175 997-1001
69 Duwe K, Shiau M, Budorick N E. Evaluation of the lower extremity veins in patients with suspected pulmonary embolism: a retrospective comparison of helical CT venography and sonography. AJR Am J Roentgenol . 2000; 175 1525-1531
70 Cham M D, Yankelevitz D F, Shaham D. Deep venous thrombosis: detection by using indirect CT venography. Radiology . 2000; 216 744-751