Safety of a strategy combining D-dimer testing and whole-leg ultrasonography to rule out deep vein thrombosis

Abstract

Guidelines for the diagnostic workup of deep vein thrombosis (DVT) recommend assessing the clinical pretest probability before proceeding to D-dimer testing and/or compression ultrasonography (CUS) if the patient has high pretest probability or positive D-dimer. Referring only patients with positive D-dimer for whole-leg CUS irrespective of pretest probability may simplify the workup of DVT. In this prospective management outcome study, we assessed the safety of such a strategy. We included consecutive outpatients referred to the Emergency Department at Østfold Hospital, Norway, with suspected DVT between February 2015 and November 2018. STA-Liatest D-Di Plus D-dimer was analyzed for all patients, and only patients with levels ≥0.5 µg/mL were referred for CUS. All patients with negative D-dimer or negative CUS were followed for 3 months to assess the venous thromboembolic rate. One thousand three hundred ninety-seven patients were included. Median age was 64 years (interquartile range, 52-73 years), and 770 patients (55%) were female. D-dimer was negative in 415 patients (29.7%) and positive in 982 patients (70.3%). DVT was diagnosed in 277 patients (19.8%). Six patients in whom DVT was ruled out at baseline were diagnosed with DVT within 3 months of follow-up for a thromboembolic rate of 0.5% (95% confidence interval, 0.2-1.2). A simple diagnostic approach with initial stand-alone D-dimer followed by a single whole-leg CUS in patients with positive D-dimer safely ruled out DVT. We consider this strategy to be a valuable alternative to the conventional workup of DVT in outpatients. This trial was registered at www.clinicaltrials.gov as #NCT02486445.

Risk factors for hypercoagulability after laparoscopic hepatic haemangioma resection

“…[ 37 , 38 ] It is one of the markers that respond to a hypercoagulable state and secondary hyperfibrinolysis in vivo , as its elevation reflects enhanced secondary fibrinolytic activity and excessive thrombin production. [ 39 , 40 ] Myocardial infarction, venous thrombosis or PE, diffuse intravascular coagulation can all lead to increased D-Di. [ 41 ] Elevated D-Di after laparoscopic hepatic haemangioma resection reminds hyperfibrinolytic hydrolysis.…”

Could a D-dimer/fibrinogen ratio have a role in ruling-out venous thromboembolism?

“…The highly selected population in the evaluation had a 27% rule-in rate for DVT and/or PE, meaning that this was not a typical emergency medicine screening population. Research on other emergency medicine populations has identified a variable prevalence of VTE but generally much lower, ranging from 7.4% to 20% 10–12. Patients were identified by finding those that had obtained imaging.…”

Pulmonary Embolism in Pregnancy: A Review for Clinical Practitioners

“…The effectiveness of CUS without considering the clinical context (a sign of thrombosis) is limited [54,56]. It should be interpreted by including C-PTP and/or calf swelling with a diameter ≥ 3 cm greater than that of the asymptomatic calf [53,57]. The more sensitive method is magnetic resonance venography (sensitivity 92%, specificity 99%) and should be performed as the next diagnostic step if an isolated deep vein thrombosis in the pelvis is suspected but cannot be safely ruled out using ultrasonography due to the low sensitivity of 50% (the specificity was 99%) [58].…”