RSS-Feed abonnieren
DOI: 10.1055/s-2007-986465
Diagnostik der venösen Thrombembolie - Ist der Goldstandard 'Phlebografie' bald überholt?
Diagnostic of venous thromboembolism - Is the gold standard 'venogaphy' outdated in the nearer future?
In den letzten 15 Jahren hat sich der diagnostische Ablauf zur Abklärung eines Verdachtes auf eine tiefe Beinvenenthrombose (TVT) oder eine Lungenembolie (LE) erheblich geändert. Obwohl die Phlebografie trotz ihres vergleichsweise hohen Risikopotenzials nach wie vor als Goldstandard gilt, kann durch Einsatz von Scoresystemen, D-Dimer-Bestimmung und Venenultraschall bei der Diagnose einer tiefen Beinvenenthrombose zumeist auf sie verzichtet werden. Gleiches gilt für die Abklärung der Lungenembolie: Die Kombination aus D-Dimer-Test und Beinvenenultraschall gefolgt von szintigrafischen oder computertomografischen Verfahren hat die Pulmonalisangiografie nahezu vollständig verdrängt. Die leitliniengerechte Kombination der verschiedenen Tests im Rahmen eines diagnostischen Stufenplanes versetzt den Klinikarzt also in die Lage, tiefe Venenthrombosen und Lungenembolien schnell und sicher zu diagnostizieren. Auf Großgeräteuntersuchungen kann dabei zumeist verzichtet werden.
Diagnostic strategies to diagnose deep vein thrombosis (DVT) and pulmonary embolism (PE) have changed significantly over the last 15 years. Whereas venography still is the gold standard for detecting DVT, the introduction of DVT-scores, d-dimer-testing and venous ultrasound made it replaceable in most cases for detecting venous thromboembolisms. The same is true for the diagnostic approach to pulmonary embolism: the combination of d-dimer-testing and venous ultrasound followed by szintigraphic or computertomographic lung scan almost replaced pulmonal angiography. This review focuses on different diagnostic strategies for clinicians in hospitals using practical approaches. Combination of these procedures in a graduated scheme - as postulated in guidelines - enables clinicians to diagnose deep vein thrombosis and pulmonary embolism fast and on a firm basis. Therefore the use of venography is not mandatory in most cases.
Key words
deep venous thrombosis - DVT - pulmonary embolism - pretest probability - d-dimer - venous ultrasound - venographyPublikationsverlauf
Artikel online veröffentlicht:
23. August 2007
© Georg Thieme Verlag Stuttgart · New York
-
Literatur
-
Anderson DR,
Kovacs MJ,
Kovacs G.
et al. Combined use of clinical assessment and d-dimer to improve the
management of patients presenting to the emergency department with
suspected deep vein thrombosis (the EDITED study).. J Thromb Haemost 2003; 1: 645-651
MissingFormLabel
-
Baldt MM,
Zontsich T,
Stümpflen A.
et al. Deep venous thrombosis of the lower extremity: efficacy of spiral CT
venography compared with conventional venography in diagnosis.. Radiology 1996; 200:
423-428
MissingFormLabel
-
Bastuji-Garin S,
Schaeffer A,
Wolkenstein P.
et al.
Pulmonary embolism; lung scanning interpretation: about words.. Chest 1998; 114: 1551-1555
MissingFormLabel
-
Begemann PG,
Bonacker M,
Kemper J.
et al. Evaluation of the deep venous system in patients with suspected
pulmonary embolism with multi-detector CT: a prospektive study in
comparison to doppler sonography.. J Comput Assist Tomogr 2003; 27: 399-409
MissingFormLabel
- Bockenstedt P. D-dimer in venous thromboembolism.. N Engl J Med 2003; 13: 1203-1204
MissingFormLabel
-
Carrier M,
Wells PS.
Rodger MA. Excluding pulmonary embolism at the bedside with low pre-test
probability and D-dimer: Safety and clinical utility of 4 methods to
assign pre-test probability.. Thromb Res 2006; 117: 469-474
MissingFormLabel
-
Cogo A,
Lensing AWA,
Koopman MMW.
et al.
Compression ultrasonography for diagnostic management of patients
with clinically suspected deep vein thrombosis: prospective cohort
study.. BMJ 1998; 316: 17-20
MissingFormLabel
-
Cogo A,
Lensing AWA,
Prandoni P.
Hirsh J. Distribution of thrombosis in patients with symptomatic deep vein
thrombosis. Implications for simplifying the diagnostic process with
compression ultrasound.. Arch Intern Med 1993; 153: 2777-2780
MissingFormLabel
-
Dunnick NR,
Newman GE,
Perlmutt LM.
Braun SD. Pulmonary embolism.. Curr Probl Diagn Radiol 1988; 17: 197-237
MissingFormLabel
-
Dupas B,
El DKouri,
Curtet C.
et al.
Angiomagnetic resonance imaging of iliofemorocaval venous
thrombosis.. Lancet 1995; 346: 17-19
MissingFormLabel
-
Elias A,
Cazanave A,
Elias M.
et al.
Diagnostic management of pulmonary embolism using clinical
assessment, plasma D-dimer assay, complete lower limb venous
ultrasound and helical computed tomography of pulmonary arteries. A
multicentre clinical outcome study.. Thromb Haemost 2005; 93: 982-988
MissingFormLabel
-
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: 221-227
MissingFormLabel
-
Evans AJ,
Sostman HD,
Knelson MH.
et al. 1992 ARRS Executive Council Award. Detection of deep venous
thrombosis: prospective comparison of MR imaging with contrast
venography.. Am J Radiol 1993; 161: 131-139
MissingFormLabel
-
Fancher TL,
White RH.
Kravitz RL. Combined use of rapid D-dimer testing and estimation of clinical
probability in the diagnosis of deep vein thrombosis: systematic
review.. BMJ 2004; 329: 821
MissingFormLabel
-
Galle C,
Papazyan JP,
Miron MJ.
et al. Prediction of pulmonary embolism extent by clinical findings,
D-dimer level and deep vein thrombosis shown by ultrasound.. Thromb Haemost 2001;
86: 1156-1160
MissingFormLabel
-
Gottlieb RH,
Widjaja J,
Tian L.
et al. Calf sonography for detecting deep venous thrombosis in symptomatic
patients: experience and review of the literature.. J Clin Ultrasound 1999; 27: 415-420
MissingFormLabel
- Haeger K. Problems of acute venous thrombosis: the interpretation of signs and
symptoms.. Angiology 1969; 20: 219-223
MissingFormLabel
-
Heijboer H,
Buller HR,
Lensing AWA.
et al. A comparison of real time compression ultrasonography with impedance
plethysmography for the diagnosis of deep-vein thrombosis in
symptomatic outpatients.. N Engl J Med 1993; 329: 1365-1369
MissingFormLabel
-
Kakkar VV,
Howe CT,
Flanc C.
Clarke MB. Natural history of postoperative deep-vein thrombosis.. Lancet 1969;
2: 230-232
MissingFormLabel
-
Kakkar VV,
Howe CT,
Nicolaides AN.
et al. Deep vein thrombosis of the leg: is there a „high risk”
group?. Am J Surg 1970; 120: 527-530
MissingFormLabel
-
Kanne JP.
Lalani TA. Role of computed tomography and magnetic resonance imaging for deep
venous thrombosis and pulmonary embolism.. Circulation 2004; 109: I15-I21
MissingFormLabel
-
Kassai B,
Boissel JP,
Cucherat M.
et al. A systematic review of the accuracy of ultrasound in the diagnosis
of deep venous thrombosis in asymptomatic patients.. Thromb Haemost 2004; 91: 655-666
MissingFormLabel
-
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: 1044-1049
MissingFormLabel
-
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: 663-677
MissingFormLabel
-
Keeling DM,
Mackie IJ,
Moody A.
et al. 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.. Brit J Haematol 2004; 124: 15-25
MissingFormLabel
-
Kelly J,
Rudd A,
Lewis RR.
Hunt BJ. Plasma D-dimers in the diagnosis of venous thromboembolism.. Arch Intern
Med 2002; 162: 747-756
MissingFormLabel
-
Labropoulos N,
Webb KM,
Kang SS.
et al. Patterns and distribution of isolated calf deep vein
thrombosis.. J Vasc Surg 1999; 30: 787-791
MissingFormLabel
-
Lensing AWA,
Prandoni P,
Brandjes D.
et al. Detection of deep vein thrombosis by real-time B-mode
ultrasonography.. N Engl J Med 1989; 320: 342-345
MissingFormLabel
-
Michiels JJ,
Gadisseur A.
Van M DerPlanken. et al. A critical appraisal of non-invasive diagnosis and exclusion
of deep
vein thrombosis and pulmonary embolism in outpatients with suspected
deep vein thrombosis or pulmonary embolism: how many tests do we
need?. Int Angiol 2005; 24: 27-39
MissingFormLabel
- 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: 2753-1759
MissingFormLabel
-
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
MissingFormLabel
-
Perrier A.
Bounameaux H. Ultrasonography of leg veins in patients suspected of having
pulmonary embolism.. Ann Intern Med 1998; 128: 243
MissingFormLabel
-
Perrier A,
Buswell L,
Bounameaux H.
et al. Cost-effectiveness of noninvasive diagnostic aids in suspected
pulmonary embolism.. Arch Intern Med 1997; 157: 2309-2316
MissingFormLabel
-
Perrier A,
Desmarais S,
Miron MJ.
et al. Non-invasive diagnosis of venous thromboembolism in
outpatients.. Lancet 1999; 353: 190-195
MissingFormLabel
-
Perrier A,
Nendaz MR,
Sarasin FP.
et al. Cost-effectiveness analysis of diagnostic strategies for suspected
pulmonary embolism including helical computed tomography.. Am J Respir Crit Care Med
2003; 167: 39-44
MissingFormLabel
-
Perrier A,
Roy PM,
Aujesky D.
et al. Diagnosing pulmonary embolism in outpatients with clinical
assessment, D-dimer measurement, venous ultrasound, and helical
computed tomography: a multicenter management study.. Am J Med 2004; 116: 291-299
MissingFormLabel
-
Quiroz R,
Kucher N,
Zou KH.
et al. Clinical validity of a negative computed tomography scan in patients
with suspected pulmonary embolism: a systematic review.. JAMA 2005; 293: 2012-2017
MissingFormLabel
-
Schellong SM,
Schwarz T,
Halbritter K.
et al. Complete compression ultrasonography of the leg as a single test for
the diagnosis of deep vein thrombosis.. Thromb Haemost 2003; 89: 228-234
MissingFormLabel
-
Schwarz T,
Schmid BA.
Schellong SM. Interobserver agreement of complete compression ultrasound for
clinically suspected deep vein thrombosis.. Clin Appl Thrombosis/Hemostasis 2002;
8: 45-49
MissingFormLabel
-
Spritzer CE,
Evans AC.
Kay HH. Magnetic resonance imaging of deep venous thrombosis in pregnant
women with lower extremity edema.. Obstet Gynecol 1995; 85: 603-607
MissingFormLabel
-
Spritzer CE,
Norconk JrJJ,
Sostman HD.
Coleman RE. Detection of deep venous thrombosis by magnetic resonance
imaging.. Chest 1993; 104: 54-50
MissingFormLabel
-
Tick LW,
Ton E,
van Voorthuizen T.
et al. Practical diagnostic management of patients with clinically
suspected deep vein thrombosis by clinical probability test,
compression ultrasonography, and D-dimer test.. Am J Med 2002; 113: 630-635
MissingFormLabel
-
Van Strijen MJ,
De Monye W,
Kieft GJ.
et al. Accuracy of single-detector spiral CT in the diagnosis of pulmonary
embolism: a prospective multicenter cohort study of consecutive
patients with abnormal perfusion scintigraphy.. J Thromb Haemost 2005; 3: 17-25
MissingFormLabel
-
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
MissingFormLabel
-
Wells PS,
Anderson DR.
Ginsberg J. Assessment of deep vein thrombosis or pulmonary embolism by the
combined use of clinical model and non-invasive tests.. Semin Thromb Hemost 2000;
26: 643-655
MissingFormLabel
-
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
MissingFormLabel
-
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
MissingFormLabel
-
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
MissingFormLabel