Emergency Department Management of Suspected Calf-Vein Deep Venous Thrombosis: A Diagnostic Algorithm

Abstract

IntroductionUnilateral leg swelling with suspicion of deep venous thrombosis (DVT) is a common emergency department (ED) presentation. Proximal DVT (thrombus in the popliteal or femoral veins) can usually be diagnosed and treated at the initial ED encounter. When proximal DVT has been ruled out, isolated calf-vein deep venous thrombosis (IC-DVT) often remains a consideration. The current standard for the diagnosis of IC-DVT is whole-leg vascular duplex ultrasonography (WLUS), a test that is unavailable in many hospitals outside normal business hours. When WLUS is not available from the ED, recommendations for managing suspected IC-DVT vary. The objectives of the study is to use current evidence and recommendations to (1) propose a diagnostic algorithm for IC-DVT when definitive testing (WLUS) is unavailable; and (2) summarize the controversy surrounding IC-DVT treatment.DiscussionThe Figure combines D-dimer testing with serial CUS or a single deferred FLUS for the diagnosis of IC-DVT. Such an algorithm has the potential to safely direct the management of suspected IC-DVT when definitive testing is unavailable. Whether or not to treat diagnosed IC-DVT remains widely debated and awaiting further evidence.ConclusionWhen IC-DVT is not ruled out in the ED, the suggested algorithm, although not prospectively validated by a controlled study, offers an approach to diagnosis that is consistent with current data and recommendations. When IC-DVT is diagnosed, current references suggest that a decision between anticoagulation and continued follow-up outpatient testing can be based on shared decision-making. The risks of proximal progression and life-threatening embolization should be balanced against the generally more benign natural history of such thrombi, and an individual patient’s risk factors for both thrombus propagation and complications of anticoagulation.

Editor's Choice – European Society for Vascular Surgery (ESVS) 2021 Clinical Practice Guidelines on the Management of Venous Thrombosis

“…A repeat, WLUS should be performed if an initial limited examination has been performed to exclude proximal DVT. 239 Historically, isolated calf DVT has received little attention because of the perception that it is less clinically significant, owing to the lower risk of recurrent VTE, particularly proximal DVT and PE, and the ongoing debate about whether a diagnosis of calf DVT alters patient outcomes. 240 However, a recent systematic review estimated the rate of propagation of calf DVT to the popliteal (Table 18).…”

Deuxième niveau de compétence pour l’échographie clinique en médecine d’urgence. Recommandations de la Société française de médecine d’urgence par consensus formalisé

“…L'échographie veineuse quatre points de compression, fémoraux et poplités, est l'examen non invasif de choix aux urgences pour le diagnostic des thromboses veineuses profondes à risque emboligène (RV+ de 30, RV-de 0,04) [44]. Il existe des stratégies diagnostiques évaluées avec une échographie veineuse « quatre points » réalisée par l'urgentiste [45]. L'apport du Doppler ou la réalisation d'une échographie jambe entière n'entraîne pas une diminution de la morbimortalité par rapport à l'échographie quatre points [46].…”

Novel Diagnostic Options without Contrast Media or Radiation: Triggered Angiography Non-Contrast-Enhanced Sequence Magnetic Resonance Imaging in Treating Different Leg Venous Diseases

“…Venous diseases in the lower extremities include minor varicose veins and static ulcers (SUs), ranging from ambulatory venous hypertension to potentially deadly occlusive diseases, such as deep vein thrombosis (DVT) [ 1 , 2 , 3 ]. Currently, only a few options are available for the objective venous evaluation of the lower limbs [ 4 , 5 , 6 , 7 ]. The venous system is not exactly enhanced by the computed tomography (CT) venogram, and a high-quality enhancement requires specific access (from a morbid limb).…”