Because the clinical diagnosis of deep-vein thrombosis and pulmonary embolism is nonspecific, integrated diagnostic approaches for patients with suspected venous thromboembolism have been developed over the years, involving both non-invasive bedside tools (clinical decision rules and D-dimer blood tests) for patients with low pretest probability and diagnostic techniques (compression ultrasound for deep-vein thrombosis and computed tomography pulmonary angiography for pulmonary embolism) for those with a high pretest probability. This combination has led to standardized diagnostic algorithms with proven safety for excluding venous thrombotic disease. At the same time, it has become apparent that, as a result of the natural history of venous thrombosis, there are special patient populations in which the current standard diagnostic algorithms are not sufficient. In this review, we present 3 evidence-based patient cases to underline recent developments in the imaging diagnosis of venous thromboembolism.
Learning Objectives• In a first episode of deep-vein thrombosis, compression ultrasonography is a very accurate imaging method. In recurrent deep-vein thrombosis, this accuracy is less because residual thrombosis is present. A reference compression ultrasonography may help establish an accurate diagnosis. Direct thrombus imaging by magnetic resonance technique, a technique that can actually differentiate between old and new thrombi, is now being validated for this purpose and may become the gold standard.• In elderly patients, the use of an age-adjusted D-dimer cutoff will lead to less need for imaging without jeopardizing safety. For elderly patients with suspected pulmonary embolism and severe renal insufficiency, compression ultrasonography of the legs is a reasonable way to start imaging.• All pregnant patients with clinically suspected pulmonary embolism should undergo a full diagnostic workup; this includes imaging with computed tomography-pulmonary angiography or ventilation-perfusion scan as an alternative.Venous thromboembolism (VTE), which refers to a diagnosis of deep-vein thrombosis (DVT) and/or pulmonary embolism (PE), is worldwide the third most frequently diagnosed cardiovascular disorder. VTE may be complicated by recurrent thrombosis, anticoagulant associated bleeding, post-thrombotic syndrome, and chronic thromboembolic pulmonary hypertension. 1-3 Over the years, the diagnostic approach has evolved from clinical diagnosis to fully standardized diagnostic management algorithms, in which validated pretest clinical decision rules, D-dimer testing, and foremost straightforward diagnostic imaging allow for safe, convenient, and cost-effective management of patients. 4 Patients with a low pretest probability and a normal D-dimer can have VTE excluded without the need for imaging, although there is a trend for increased imaging taking place, leading to ever-increasing demands on busy emergency departments. 5 Despite all advancements during the past decade, the imaging diagnosis of VTE remains challenging ...