Diagnosis Of DVT

Publication Date: February 1, 2012
Last Updated: March 14, 2022

Recommendations

Diagnosis of Suspected First Lower Extremity DVT

Alternatives to Venography for the Evaluation of Suspected First Lower Extremity DVT

In patients with a suspected fi rst lower extremity DVT, we suggest that the choice of diagnostic tests process should be guided by the clinical assessment of pretest probability, rather than by performing the same diagnostic tests in all patients. (2, B)
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In patients with a low pretest probability of fi rst lower extremity DVT, we recommend one of the following initial tests:
  • (i) a moderately sensitive D-dimer
  • (ii) a highly sensitive d-dimer, or
  • (iii) CUS of the proximal veins rather than
  • (i) no diagnostic testing
(1, B)
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(ii) venography, (1, B)
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or (iii) whole-leg US. (2, B)
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We suggest initial use of a moderately sensitive or (2, C)
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or highly sensitive D-dimer rather than proximal compression ultrasonography (CUS). (2, B)
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If the D-dimer is negative, we recommend no further testing over further investigation with
  • (i) proximal CUS
  • (ii) whole-leg US, or
  • (iii) venography.
(1, B)
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If the proximal CUS is negative, we recommend no further testing compared with
  • (i) repeat proximal CUS after 1 week
  • (ii) whole-leg US, or
  • (iii) venography.
(1, B)
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If the D-dimer is positive, we suggest further testing with CUS of the proximal veins rather than
  • (i) whole-leg US or
(2, C)
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  • or (ii) venography.
(1, B)
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If CUS of the proximal veins is positive, we suggest treating for DVT and performing no further test ing over performing confirmatory venography. (2, C)
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In patients with a moderate pretest probability of first lower extremity DVT, we recommend one of the following initial tests:
  • (i) a highly sensitive D-dimer, or
  • (ii) proximal CUS, or
  • (iii) whole-leg US,
(1, B)
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rather than
  • (i) no testing or
  • (ii) venography.
(1, B)
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We suggest initial use of a highly sensitive D-dimer rather than US. (2, C)
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If the highly sensitive D-dimer is negative, we recommend no further testing over further investigation with
  • (i) proximal CUS,
  • (ii) whole-leg US, or
  • (iii) venography.
(1, B)
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If the highly sensitive D-dimer is positive, we recommend proximal CUS or whole-leg US rather than no testing or venography. (1, B)
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If proximal CUS is chosen as the initial test and is negative, we recommend
  • (i) repeat proximal CUS in 1 week or
  • (ii) testing with a moderate or highly sensitive D-dimer assay
over no further testing or (1, C)
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  • venography.
(2, B)
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  • In patients with a negative proximal CUS but a positive D-dimer, we recommend repeat proximal CUS in 1 week over no further testing or
(1, B)
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venography. (2, B)
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In patients with
  • (i) negative serial proximal CUS or
  • (ii) a negative single proximal CUS and negative moderate or highly sensitive D-dimer,
we recommend no further testing rather than further testing with
  • (i) whole-leg US or
  • (ii) venography.
(1, B)
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  • If whole-leg US is negative, we recommend no further testing over
  • (i) repeat US in 1 week,
  • (ii) D-dimer testing, or
  • (iii) venography.
(1, B)
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  • If proximal CUS is positive, we recommend treating for DVT rather than confirmatory venography.
(1, B)
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If isolated distal DVT is detected on whole-leg US, we suggest serial testing to rule out proximal extension over treatment. (2, C)
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In patients with a high pretest probability of fi rst lower extremity DVT, we recommend either
  • (i) proximal CUS or
  • (ii) whole-leg US
  • over no testing or venography.
(1, B)
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If proximal CUS or whole-leg US is positive for DVT, we recommend treatment rather than confirmatory venography. (1, B)
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In patients with a negative proximal CUS

we recommend additional testing with a highly sensitive D-dimer or whole-leg US or repeat proximal CUS in 1 week over no further testing or (1, B)
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venography. (2, B)
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We recommend that patients with a single negative proximal CUS and positive D-dimer undergo whole-leg US or repeat proximal CUS in 1 week over no further testing or (1, B)
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venography. (2, B)
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In patients with negative serial proximal CUS, a negative single proximal CUS and negative highly sensitive D-dimer, or a negative whole-leg US, we recommend no further testing over venography or additional US. (, )

(Grade 1B for negative serial proximal CUS and for negative single proximal CUS and highly sensitive D-dimer; Grade 2B for negative whole-leg US)

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We recommend that in patients with high pretest probability, moderately or highly sensitive D-dimer assays should not be used as stand-alone tests to rule out DVT. (1, B)
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If risk stratification is not performed in patients with suspected first lower extremity DVT, we recommend one of the following initial tests:
  • (i) proximal CUS or
  • (ii) whole-leg US, rather than
  • (i) no testing,
(1, B)
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  • (ii) venography or
(1, B)
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  • D-dimer testing.
(2, B)
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We recommend that patients with a negative proximal CUS undergo testing with a moderate or high sensitivity D-dimer, whole-leg US, or repeat proximal CUS in 1 week over no further testing or (1, B)
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  • venography.
(2, B)
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In patients with a negative proximal CUS, we suggest D-dimer rather than routine serial CUS or (2, B)
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  • whole-leg US.
(2, C)
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We recommend that patients with a single negative proximal CUS and positive D-dimer undergo further testing with repeat proximal CUS in 1 week or whole-leg US rather than no further testing. (1, B)
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We recommend that in patients with
  • (i) negative serial proximal CUS
  • (ii) a negative D-dimer following a negative initial proximal CUS, or
  • (iii) negative whole-leg US
no further testing be performed rather than venography. (1, B)
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If proximal US is positive for DVT, we recommend treatment rather than confirmatory venography. (1, B)
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If isolated distal DVT is detected on whole-leg US, we suggest serial testing to rule out proximal extension over treatment. (2, C)
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In patients with suspected first lower extremity DVT, we recommend against the routine use of CT venography or MRI. (1, C)
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Overview

Title

Diagnosis Of DVT

Authoring Organization

American College of Chest Physicians