Diagnosis of deep vein thrombosis of the upper extremity: a systematic review and meta-analysis of test accuracy

Abstract

Upper extremity deep vein thrombosis (UEDVT) accounts for ≤10% of DVT and can be associated with morbidity and mortality. Accurate diagnosis and treatment are necessary for safe and effective patient management. We systematically reviewed the accuracy of D-dimer and duplex ultrasonography (US) for the evaluation of suspected first-episode UEDVT. We searched the Cochrane Central Register, OVID MEDLINE, EMBASE, and PubMed for eligible studies, reference lists of relevant reviews, registered trials, and relevant conference proceedings. We included prospective cross-sectional and cohort studies that evaluated test accuracy. Two investigators independently screened and collected data. The risk of bias was assessed using Quality Assessment of Diagnostic Accuracy Studies 2 and certainty of evidence using the Grading of Recommendations Assessment, Development and Evaluation framework. We pooled estimates of sensitivity and specificity. The review included 9 studies. The pooled estimates for D-dimer sensitivity and specificity were 0.96 (95% confidence interval [CI], 0.87-0.99) and 0.47 (95% CI, 0.43-0.52), respectively. The pooled estimates for duplex US sensitivity and specificity were 0.87 (95% CI, 0.73-0.94) and 0.85 (95% CI, 0.72-0.93), respectively. Certainty of evidence was moderate. In this review, we summarized the test accuracy (sensitivity and specificity) of D-dimer and duplex US for this indication. The sensitivity and specificity of the tests found in the present review should be considered in the context of whether they are used alone or in combination, which is dependent on the prevalence of disease in the population, the clinical setting in which the patient is being evaluated, cost, potential harms, and patient outcomes. This study was registered at PROSPERO as Systematic Review Registration Number CRD42018098488.

Systematic review and meta-analysis of outcomes in patients with suspected deep vein thrombosis

“…The final recommendations for a diagnostic pathway were based on information provided in this review on patient-centered outcomes and based on information provided in the test accuracy review. [2][3][4] In addition to these reviews, the panel considered information on the overall certainty in the evidence, including certainty in the diagnostic test accuracy results, patients' values and preferences, balance of desirable and undesirable effects, resource implications, feasibility, acceptability, and equity considerations.…”

“…9 The primary source of information was obtained from the studies that were included for the analysis of test accuracy, represented in Figure 1 and discussed in a separate paper. 3,4 The secondary source included studies identified as having potential information for outcomes when the initial search was completed, regardless of whether the study contained test accuracy information. The final source was any additional studies suggested by experts in the field or other guidelines.…”

“…This systematic review was performed in conjunction with upper and lower extremity DVT test accuracy reviews that evaluated optimal diagnostic pathways based on PTP to inform an overall guideline on management of venous thromboembolism, detailed further in "Methods." [2][3][4]…”

Insights into Fibrinogen-Mediated COVID-19 Hypercoagubility in Critically Ill Patients

“…[5][6][7] The elevation of d-dimer levels is considered nonspecific as d-dimers are markers of clot degradation and are acute phase reactants often elevated in inflammatory states not necessarily associated with hypercoagulability. 8 Conventional coagulation tests are usually not abnormal in the presence of clinical hypercoagulability. For example, patients with liver disease often have abnormal conventional coagulation tests such as an elevated international normalized ratio 9 or decreased platelets 10 indicating hypocoagulability but may exhibit normal or even increased thrombin formation.…”

Upper Extremity Deep Vein Thrombosis: Current Knowledge and Future Directions

“…While the reference imaging standard for UEDVT diagnosis is assumed to be venography, 18 this has been extrapolated from lower limb DVT studies where it is the reference standard. In idiopathic UEDVT there are no studies where patients with suspected thrombosis and negative venography are followed for 90 days to confirm no subsequent diagnosis of UEDVT is made.…”