<p>Deep Venous Thrombosis in a Patient with a Moderate Pretest Probability and a Negative D-Dimer Test: A Review of the Diagnostic Algorithms</p>

Abstract

Modern diagnostic strategies of venous thromboembolism (VTE) have been developed. In this review, the diagnostic algorithms for deep-vein thrombosis (DVT) and their parameters are discussed individually in the context of reporting a case of DVT in a 43-yearold Caucasian female with a moderate pretest probability stratified by Wells' score and a negative high quality D-dimer test. The patient was on treatment with Xarelto (rivaroxaban), 20 mg PO daily at the time of presentation. The diagnosis was verified through a complete lower limb ultrasound (US). This case highlights the diagnostic challenges and pitfalls of the current algorithms, especially those seen in a subgroup of patients such as patients with cancer, pregnancy, recurrent VTE or are on anticoagulation therapy at the time of presentation. The diagnosis of DVT is less plausible in a patient who is on anticoagulation therapy, but physicians should be aware of such a possibility. Physicians should also know in advance the numerous clinically relevant limitations of D-dimer testing before interpreting the results. Unifying the current diagnostic strategies, modifying the current Wells' score and using the protocol of a whole-leg compression US instead of the limited US protocol are among the several cautious suggestions that have been proposed based on this review to possibly decrease the incidence of missed DVT.

Developing Deep Venous Thrombosis while on Rivaroxaban: A Review of Rivaroxaban

“…The author suggests that a more frequent follow up for those patients who are elderly and/or have polypharmacy could be warranted to ensure compliance, doses, and check for DDI when taking DOACs. The previously reported patient [1] was assessed to be compliant and was receiving an accurate dose of 20 mg for the treatment of a previously PE at the time of presentation with no other medications. TEG test was not done, and anti-Factor Xa chromogenic assays are unavailable in the center.…”

“…A detailed description of the clinical presentation and the analysis of this previously reported case could be found in Al-Khafaji et al [1]. A 43-year-old Caucasian female was on a full anticoagulation therapy by using rivaroxaban (Xarelto) 20 mg PO daily due to a previously verified bilateral (PE) 5 months earlier, when she presented to the Accident & Emergency Room (A and E) on the third day of her symptoms as a referred case by the general practitioner for a suspected DVT due to slight right leg swelling.…”