Subsequent testing is guided by these evaluations and test availability (Table 6). If the D-dimer results cannot be obtained with 4 hours, interim anticoagulation should be offered while awaiting the results. This applies to VTE, because progressive VTE may be fatal and anticoagulant therapy is very effective. It’s prevalence is one patient per thousand people per year and out of 100,000 hospital admissions, 239 are from VTE [2-4]. Diagnosis of VTE starts with an assessment of CPTP. Currently, MRI is rarely used for the diagnosis of PE because it less accurate, available, and well evaluated than CTPA.18,41Â. US can accurately assess venous compressibility in the arm (up to and including the axillary vein) and the jugular vein, and can assess the subclavian vein using color-flow Doppler, but US is unable to reliably assess the innominate veins and superior vena cava.33  US generally has high negative predictive value for upper-extremity DVT; it can be repeated after ∼4 to 7 days if findings are indeterminate or there is high CPTP.29,34Â. ... Because clinical signs and … Department of Medicine, McMaster University, Hamilton, ON, Canada. Traditionally, a single cutoff has been used to define a negative D-dimer assay. Secondary criteria include a larger vein diameter on the affected side, and absent or scant echoes within the clot. Test results that identify patients as having a ≤2% risk of VTE in the next 3 months are judged to exclude deep vein thrombosis (DVT) or pulmonary embolism (PE). 12 Key messages. A score of ≥2 has been termed “DVT likely.” This group makes up ∼40% of patients and has a prevalence of DVT of ∼33%. The purpose of this article was to review the validity and utility of the suggested ultrasound diagnostic criteria for DVT recurrence, and to review how CUS compares to other diagnostic imaging methods. The combination of nonhigh CPTP and negative D-dimer testing excludes DVT or PE in one-third to a half of outpatients. Because the signs and symptoms of deep venous thrombosis and pulmonary embolism are common but non-specific, they often present a diagnostic challenge. Both underdiagnosis and overdiagnosis are associated with substantial morbidity and mortality. Early enzyme linked immunosorbent assay D-dimer tests took a long time to do, limiting their usefulness in acute care. Seinturier C, Bosson JL, Colonna M, Imbert B, Carpentier PH. Venous US is the imaging test of choice for diagnosing DVT. D-dimer tests vary in terms of the measurement method and the D-dimer level that is used to categorize a test as positive or negative. Also, a diagnosis of VTE is a major psychological burden for some patients. Copyright ©2020 by American Society of Hematology, What posttest probability “rules-in” or “rules-out” DVT or PE, Clinical pretest probability (CPTP) for DVT and PE, Venography for leg and upper-extremity DVT, CT and magnetic resonance imaging (MRI) venography for DVT, Sequence of testing for DVT and PE, and results that are diagnostic, https://doi.org/10.1182/asheducation-2016.1.397, deep venous thrombosis of upper extremity, Active cancer (treatment ongoing or within previous 6 mo or palliative)Â, Paralysis, paresis, or recent plaster immobilization of the lower extremitiesÂ, Recently bedridden >3 d or major surgery within 4 wksÂ, Localized tenderness along the distribution of the deep venous systemÂ, Calf swelling 3 cm greater than on asymptomatic side (measured 10 cm below tibial tuberosity)Â, Pitting edema confined to the symptomatic legÂ, Alternative diagnosis as likely or greater than that of DVTÂ, Alternative diagnosis is less likely than PEÂ, Immobilization or surgery in previous 4-wk periodÂ, Malignancy or treatment of it in previous 6-mo periodÂ,  Noncompressibility of proximal veins (calf vein trifurcation included)Â,  Noncompressibility of distal veins, when findings are extensiveÂ,  Intraluminal defect (unequivocal) with associated absence of flow in the iliac veins or inferior vena cava, when compressibility cannot be assessedÂ,  Intraluminal filling defect in proximal or distal deep veinsÂ,  Negative very sensitive test (eg, D-dimer <500 μg/L) AND low or moderate CPTPÂ,  Negative moderately sensitive test (including D-dimer <1000 μg/L) AND low CPTPÂ,  Fully compressible proximal veins AND low CPTPÂ,  Fully compressible proximal veins AND moderately or very sensitive D-dimer testÂ,  Fully compressible proximal and distal veins (whole-leg US)Â,  Fully compressible proximal veins AND normal repeat proximal US after 7 dÂ,  All deep veins seen and no intraluminal filling defectsÂ,  A new, noncompressible proximal vein segmentÂ,  A 4-mm increase in diameter of the common femoral or popliteal vein compared with a previous testÂ,  A unequivocal extension of thrombosis (eg, additional 10 cm) within the femoral veinÂ,  Intraluminal filling defect in proximal or distal deep veins (new, or >3 mo after last event)Â,  ≤1 mm increase in diameter of the common femoral, and femoral and popliteal veins compared with a previous test AND remains unchanged on repeat testing after 2 d and 7 dÂ,  Noncompressibility of the axillary, brachial veins, or jugular veinÂ,  Intraluminal defect (unequivocal) with associated absence of flow in the subclavian veinÂ,  Intraluminal filling defect within brachial vein to superior vena cavaÂ,  No DVT within brachial to subclavian veins AND not suspected of having a more central DVTÂ,  No DVT on US AND normal repeat US after 7 dÂ,  Negative very sensitive test (eg, D-dimer <500 μg/L) AND low or unlikely CPTPÂ,  No intraluminal filling defect within brachial vein to superior vena cavaÂ,  Intraluminal filling defect in a lobar or main pulmonary arteryÂ,  Intraluminal filling defect in a segmental pulmonary artery AND moderate or high CPTPÂ,  High-probability scan AND moderate or high CPTPÂ, Positive diagnostic test for DVT (with a nondiagnostic V/Q scan or CTPA, or scan not done)Â, Perfusion scan (usually part of V/Q scan)Â,  Negative moderately sensitive test AND low CPTPÂ,  In patients over 50 y, D-dimer level <10 times the patient's age AND a low or moderate CPTPÂ, Nondiagnostic V/Q scan or CTPA AND normal proximal venous US AND one of:Â,  Negative moderately or very sensitive D-dimer testÂ,  Normal repeat proximal US after 7 d and 14 dÂ, May identify a suspected alternative to PE (eg, progressive malignancy; aortic dissection)Â, May identify a suspected alternative to DVT (eg, ruptured Baker cyst; hematoma)Â, Favors whole-leg US over serial proximal USÂ, D-dimer will be high even if no DVT or PE (eg, postoperative; inpatient; sepsis)Â, Younger, particularly if females and pregnantÂ, Lung disease or abnormal chest radiographÂ. 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