DEEPVEINTHROMBOSIS(DVT):

DIAGNOSIS

OBJECTIVE:
Toprovideanevidencedbasedapproachtotheevaluationofpatientswithaclinicalsuspicion
ofdeepveinthrombosis(DVT).

BACKGROUND:
Anestimated45,000patientsinCanadaareaffectedbyDVTeachyear,withanincidenceof
approximately12casesper1,000personsannually.Thistranslatesinto24DVTsperyearina
typical,soloCanadianfamilypractice.Sinceonly1020%ofpatientswithsuspectedDVT
actuallyhavethedisease,atypicalfamilypracticewillevaluate2040patientswithsymptoms
and/orsignssuggestiveofDVTeachyear.
TheabilitytorapidlyandaccuratelyassesspatientsforDVTiscrucial.Avalidateddiagnostic
algorithmshouldbefolloweduntiladefinitivediagnosticconclusionisreachedineachpatient.
TreatmentofDVTiscrucialtopreventthrombusextensionandpulmonaryembolism(PE),and
shouldoftenbestartedevenpriortoconfirmationofDVTpresence(seeDeepVeinThrombosis
(DVT):Treatmentguide).TheaccurateexclusionofDVTalsoeliminatesunnecessaryexposure
toanticoagulants,associatedwithinconvenienceandriskofbleeding.

DIAGNOSIS:
ThediagnosisofDVTisbasedon:
1) Pretestprobability(clinicalsuspicion)
ThereareseveralformalriskmodelsavailabletoassessthepretestprobabilityofDVT.The
WellsScoreisthemostwidelyused(seeTable1).Physicianscanalsousetheirclinical
gestalttodeterminepretestprobability.Theaccuracyofthistypeofintuitiveapproach,
however,isdependentonphysicianexperience.Useofastructuredscoreisencouraged.

TABLE1:TWOLEVELWELLSSCOREFORDVTDIAGNOSIS
CLINICALFINDINGS

POINTS

Paralysis,paresisorrecentorthopediccastingoflowerextremity
Bedridden>3daysrecentlyormajorsurgerywithinpast12weeks
Localizedtendernessofthedeepveins
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1
1
1
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Swellingofentireleg
Calfswelling3cmgreaterthanotherleg(measured10cmbelowthetibial
tuberosity)
Pittingedemagreaterinthesymptomaticleg

Nonvaricosecollateralsuperficialveins

Activecancerorcancertreatedwithin6months
PreviouslydocumentedDVT
AlternativediagnosisatleastaslikelyasDVT(Baker'scyst,cellulitis,muscle
damage,superficialveinthrombosis,postthromboticsyndrome,inguinal
lymphadenopathy,extrinsicvenouscompression)

WELLSSCORE PROBABILITYOFDVT
<2
2

6%
28%

1
1
1
1
2

STRATA
Unlikely
Likely

2) VenousCompressionUltrasound(CUS)
ProximallegCUSexaminesthecompressibilityofthefemoralandpoplitealveins.Failureto
demonstratefullcompressibilityofaproximalveininapatientwithoutpriorDVTishighly
diagnosticofDVT.Becausedistalthrombosismayextendproximallyin~20%ofcases,an
initialnegativeproximalCUSshouldberepeatedafter57daysinpatientswithahigh
clinicalsuspicionofDVTandarenotanticoagulated.Althoughinternationalguidelines
recommendagainstdistalveinimaging(toreducedetectionandoftenunnecessary
treatmentofdistalDVT),somecentresroutinelyperformwholelegCUStoeliminatethe
needforserialstudies.WhileanegativewholelegCUSexcludesDVT,thefindingofan
isolatedcalfDVTleadstosomeuncertaintyaboutmanagementi.e.eithertotreatorto
performserialCUStolookforextension.Ingeneral,cliniciansmaychoosetotreatifthe
patientisverysymptomatic,bleedriskislowand/orprobabilityofclotextensionishigh
(seeDeepVeinThrombosis(DVT):Treatmentguide).
3) DDimer
DDimerisasensitivebutnonspecificmeasureofthrombosis.AlthoughDdimeriselevated
inpatientswithDVT,itisalsoelevatedinavarietyofothercommonconditionsincluding,
butnotlimitedto,inflammatorydiseases,malignancy,pregnancy,surgery,trauma,and
advancedage.ThisrendersthetestusefultohelpruleoutDVTwhennegative,butofno
diagnosticvaluewhenpositive.AlthoughthereareseveralDdimerassaysavailable,those
thataretypicallyusedinCanadaareallhighlysensitiveassays(sensitivityofgreaterthan
90%)andcanbeusedincombinationwithanunlikelypretestprobability(Wellsorclinical
gestalt)toexcludeDVT.However,cliniciansshouldcheckwiththeirlaboratorytoconfirm
thestatusoftheDdimerassayused.Realistically,communitybasedphysiciansareunlikely
toreceivetimelyDdimerresultsfromoutsidelaboratoriesandmaynotbeabletouse
strategiesinvolvingthesetests.Alternativemanagementapproachesincludediagnostic
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algorithmsincorporatingpretestprobabilityassessmentwithcompressionCUS(outlined
below)ordirectreferraltoanEmergencyDepartmentorThrombosisClinic.

DIAGNOSTICSTRATEGY:
PatientswithsuspectedDVTshouldfirstundergoahistoryandphysicalexamfocusedonthe
componentsoftheWellsScore.Patientswithanunlikelypretestprobabilityshouldthen
undergoDdimertestingwithmanagementasoutlinedinFigure1below.Ddimertestingisnot
recommendedinpatientswithalikelypretestprobabilityandproximalCUSisthe
recommendedfirstlinetest.ThosewithanegativeproximalCUSshouldundergoDdimer
testingorrepeatCUSinoneweektoeliminatethepossibilityofamisseddistalDVTthatmight
extendproximally.
IfisolateddistalDVTisfoundonwholelegCUS,anticoagulationshouldbeofferedifsevere
symptomsarepresentoriftheriskofproximalextensionishigh.Alternatively,patientsmaybe
followedwithserialCUSovera12weekperiod,afterwhichtimeextensionisunlikely.Those
unlikelyorunabletoreturnforfollowuptestingshouldgenerallybetreated.Riskfactorsfor
proximalextensionofadistalDVTinclude:positiveDDimer,calfDVTthatisextensiveorclose
totheproximalveins,absenceofareversibleprovokingriskfactor,cancer,previoushistoryof
venousthromboembolism,lowerextremityimmobilization(e.g.plastercasting,neuromuscular
disease),andinpatientstatus.

Figure1.SuggesteddiagnosticstrategyforpatientswithsuspectedDVT.*Clinicalprobability
canbeassessedbyWellsscoreorexperiencedcliniciangestalt.**Ddimershouldbemeasured
usingahighlysensitiveassaytoruleoutDVTusingthisalgorithm.

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SPECIALCONSIDERATIONS:
Timingofdiagnostictesting:
Testingshouldbeundertakenasquicklyaspossible.However,iftherewillbeasignificant
delay,patientswithamoderate/highorlikelypretestprobabilityofDVTshouldreceivea
rapidlyactinganticoagulant(e.g.lowmolecularweightheparinoranewer/directoral
anticoagulant)untiltestingisperformed,unlesstheyareathighriskofbleedingorhave
anothercontraindicationtoanticoagulanttherapy.

SuspectedrecurrentDVT:
InthecaseofsuspectedrecurrentipsilateralDVT,CUScanbeproblematicbecauseresidual
compressionabnormalitiesareoftenpresentfromthepreviousDVT.Insuchcases,itis
importanttocompareCUSresultswiththosefrompriorexaminations.RecurrentDVTcanonly
bedefinitivelydiagnosedwithevidenceofnewthrombosis,includingnoncompressibilityin
previouslynormalvenoussegmentsorincreasesofatleast4mmincompressiondiameter
frompriorstudies.Consultationwithanexpertinthefieldmaybehelpfulwhentheseoccuror
whennopriorCUSisavailableforcomparison.
Pediatrics:
DiagnosisofDVTisinitiatedwithaCUS.WhileCUStestingisnoninvasive,itmaynotbe
accuratefortheupperextremityvenoussystemandtherehavebeenfewstudiesinthelower
venoussystem.IftheclinicalsuspicionishighforDVTwithanegativeCUS,theuseofmagnetic
resonanceimagingorcomputedtomographymaybeconsidered.Studiesusingpretest
likelihoodaspartofadiagnosticplanhavenotbeencompletedinpediatricpatients.See
ClinicalGuide:PediatricThrombosis.
UpperextremityDVT(UEDVT):
[SeealsoClinicalGuide:CentralVenousCatheterRelatedVenousThrombosis]
UEDVTisuncommonwithanannualincidenceofapproximately3/100,000persons.Most
patientswithUEDVThaveriskfactorsincluding:centralvenouscatheter,recentpacemakeror
malignancy.SpontaneousUEDVTisoftenrelatedtoeffortandnarrowingofthethoracicoutlet
(PagetSchroettersyndrome,thoracicoutletsyndrome).Clinicalmanifestationsincludeacute
andchronicarmpain,swelling,discoloration,anddilatedcollateralveinsoverthearm,neckor
upperchest.
CombinedCUSandcolorDopplerflowstudiesgenerallyareusedtoevaluatepatientswith
suspectedUEDVT.IftheinitialUSisnegative,thediagnosiscanbeconsideredexcludedunless
theclinicalsuspicionishigh.Iftheclinicalsuspicionremainshigh,furthertestingwithDdimer
(withadditionalimagingifpositive),repeatingtheUS,ortraditionalcontrastvenography,CT
venography,orMRIissuggested.PretestprobabilityscoresandDdimertestinghavenotbeen
wellvalidatedforsuspectedUEDVT.
SuspectedDVTinpregnancy:
Duringpregnancy,DVTisfoundintheleftlegin80%ofcasesandthereisahighfrequencyof
iliofemoral(64%)andisolatediliacvein(17%)thrombosisamongpregnantwomenwith
confirmedDVT.StandardUSstrategiesmaybelesssensitiveinpregnantwomenbecausethey
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donotconsidertheincreasedfrequencyofpelvicandiliacveinthrombosisseenduring
pregnancyandbecauseofthelackofsensitivityofstandardUSforDVTrestrictedtothese
areas.StructuredDVTpredictionruleshavenotbeenvalidatedforuseduringpregnancyand
theusualrecommendedDdimercutpointsareoflimitedutilityinthispopulation.
PregnantwomenwithsuspectedDVTshouldundergoUSofthedeepvenoussystemfromthe
iliactothepoplitealvein,alongwithDopplerexaminationoftheexternaliliacvein.Iftheinitial
studyisnegative,repeattestingshouldbeperformedatleastonceoverthenext7days.
Dependingonlocalavailabilityandexpertise,MRIcanbeusedtoconfirmabnormalities
restrictedtotheiliacvein.

OTHERRELEVANTTHROMBOSISCANADACLINICALGUIDES:

CentralVenousCatheterRelatedVenousThrombosis
PulmonaryEmbolism(PE):Diagnosis
DeepVenousThrombosis(DVT):Treatment

REFERENCES:
BatesSM,etal.DiagnosisofDVT:AntithromboticTherapyandPreventionofThrombosis,9th
ed:AmericanCollegeofChestPhysiciansEvidenceBasedClinicalPracticeGuidelines.Chest
2012;141(2Suppl):e351S418S.
ChanWS,etal.Venousthromboembolismandantithrombotictherapyinpregnancy:SOGC
ClinicalPracticeGuideline.JObstetGynaecolCan2014;36(6):527553.
KleinjanA,etal.Safetyandfeasibilityofadiagnosticalgorithmcombiningclinicalprobability,D
dimertesting,andultrasonographyforsuspectedupperextremitydeepvenousthrombosis:a
prospectivemanagementstudy.AnnInternMed2014:160(7):451457.
MonagleP,ChanAK,GoldenbergNA,etal.Antithrombotictherapyinneonatesandchildren:
AntithromboticTherapyandPreventionofThrombosis,9thed:AmericanCollegeofChest
PhysiciansEvidenceBasedClinicalPracticeGuidelines.Chest2012;141(2Suppl):e737S801S.
NationalInstituteforHealthandClinicalExcellence.VenousThromboembolicDiseases:The
ManagementofVenousThromboembolicDiseasesandtheRoleofThrombophiliaTesting.
NationalClinicalGuidelineCentre(UK)andLondon:RoyalCollegeofPhysicians(UK);2012June:
http://www.nice.org.uk/guidance/cg144/resources/guidancevenousthromboembolic
diseasesthemanagementofvenousthromboembolicdiseasesandtheroleofthrombophilia
testingpdf.

DateofVersion:2015Nov02

Pleasenotethattheinformationcontainedhereinisnottobeinterpretedasanalternativetomedical
advice from your doctor or other professional healthcare provider. If you have any specific questions
about any medical matter, you should consult your doctor or other professional healthcare providers,

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and as such you should never delay seeking medical advice, disregard medical advice or discontinue
medicaltreatmentbecauseoftheinformationcontainedherein.

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