Semin Thromb Hemost 2001; 27(1): 003-008
DOI: 10.1055/s-2001-12842
Copyright © 2001 by Thieme Medical Publishers, Inc., 333 Seventh Avenue, New York, NY 10001, USA. Tel.: +1(212) 584-4662

Noninvasive Diagnosis of Deep Vein Thrombosis in Postoperative Patients

Clive Kearon
  • Hamilton Civic Hospitals Research Centre and McMaster University, Hamilton, Ontario
Further Information

Publication History

Publication Date:
31 December 2001 (online)

ABSTRACT

The accuracy of noninvasive testing for the diagnosis of deep vein thrombosis (DVT) generally is less in asymptomatic patients than it is in those with symptoms suggestive of thrombosis. This is because asymptomatic DVT often is confined to the distal veins and, when it involves the proximal veins, the thrombi usually are smaller than in symptomatic patients with proximal thrombosis. Because the positive predictive value of noninvasive tests for asymptomatic DVT generally is 80% or less, abnormal results should be confirmed by venography.

There are two main reasons why asymptomatic DVT is sought in the postoperative period: (1) to identify the need for full-dose anticoagulant therapy to prevent symptomatic episodes of venous thromboembolism (VTE), including fatal pulmonary embolism (this represents a form of secondary prophylaxis), and (2) to use this outcome as a surrogate for episodes of clinically important VTE in studies that are designed to evaluate methods of venous thrombosis prophylaxis. In relation to the first of these indications, evidence suggests that routine surveillance of high-risk patients to detect asymptomatic postoperative DVT does not result in improved clinical outcomes in patients who received appropriate VTE prophylaxis. In relation to the second indication, there is concern that asymptomatic VTE may not be a reliable surrogate for clinically important VTE, particularly if the effectiveness of different antithrombotic agents is being compared. Coupled with the comparatively low accuracy of noninvasive testing for asymptomatic DVT, this suggests that the results of such testing are unsuitable for the evaluation of new methods of prophylaxis in clinical trials.

REFERENCES

  • 1 Kearon C, Julian J A, Newman T E, Ginsberg J S, for the McMaster Diagnostic Imaging Practice Guidelines Initiative. Non-invasive diagnosis of deep vein thrombosis.  Ann Intern Med . 1998;  128 663-677
  • 2 Wells P S, Lensing A WA, Davidson B L, Prins M H, Hirsh J. Accuracy of ultrasound for the diagnosis of deep venous thrombosis in asymptomatic patients after orthopedic surgery. A meta-analysis.  Ann Intern Med . 1995;  122 47-53
  • 3 Agnelli G, Cosmi B, Radicchia S. Features of thrombi and diagnostic accuracy of impedance plethysmography in symptomatic and asymptomatic deep vein thrombosis.  Thromb Haemost . 1993;  70 266-269
  • 4 Paiement G, Wessinger S J, Waltman A C, Harris W H. Surveillance of deep venous thrombosis in asymptomatic total hip replacement patients. Impedance phlebography and fibrinogen scanning versus roentgenographic phlebography.  Am J Surg . 1988;  255 400-404
  • 5 Cruickshank M K, Levine M N, Hirsh J. An evaluation of impedance plethysmography and 125I-fibrinogen leg scanning in patients following hip surgery.  Thromb Haemost . 1989;  62 830-834
  • 6 Jongbloets L MM, Lensing A WA, Koopman M MW, Büller H R, ten Cate W J. Limitations of compression ultrasound for the detection of symptomless postoperative deep vein thrombosis.  Lancet . 1994;  343 1142-1144
  • 7 Ginsberg J, Caco C C, Brill-Edwards P A. Venous thrombosis in patients who have undergone major hip or knee surgery: Detection with compression US and impedence plethysmography.  Radiology . 1991;  181 651-654
  • 8 Lensing A WA, Prandoni P, Brandjes D. Detection of deep-vein thrombosis by real-time B-mode ultrasonography.  N Engl J Med . 1989;  320 342-345
  • 9 Cogo A, Lensing A WA, Prandoni P, Hirsh J. Distribution of thrombosis in patients with symptomatic deep-vein thrombosis: Implications for simplifying the diagnostic process with compression ultrasound.  Arch Intern Med . 1993;  153 2777-2780
  • 10 Wells P S, Hirsh J, Anderson D R. Accuracy of clinical assessment of deep-vein thrombosis.  Lancet . 1995;  345 1326-1330
  • 11 Hull R, Hirsh J, Sackett D L, Powers P, Turpie A GG, Walker I. Combined use of leg scanning and impedance plethysmography in suspected venous thrombosis. An alternative to venography.  N Engl J Med . 1977;  296 1497-1500
  • 12 Agnelli G, Longetti M, Cosmi B. Diagnostic accuracy of computerized impedence plethysmography in the diagnosis of symptomatic deep vein thrombosis: A controlled venographic study.  Angiology . 1990;  41 559-564
  • 13 Heijboer H, Cogo A, Büller H R, Prandoni P, ten Cate W J. Detection of deep vein thrombosis with impedance plethysmography and real-time compression ultrasonography in hospitalized patients.  Arch Intern Med . 1992;  152 1901-1903
  • 14 Clagett G P, Anderson F A, Geerts W H. Prevention of venous thromboembolism.  Chest . 1998;  114 531S-560S
  • 15 Imperiale T F, Speroff T. A meta-analysis of methods to prevent venous thromboembolism following total hip replacement.  JAMA . 1994;  271 1780-1785
  • 16 Howard A W, Aaron S D. Low molecular weight heparin decreases proximal and distal deep venous thrombosis following total knee arthroplasty.  Thromb Haemost . 1998;  79 902-906
  • 17 Colwell Jr W C, Hinson J, McCutcheon J W, Paulson R. Comparison of enoxaparin and warfarin for the prevention of venous thromboembolic disease after total hip arthroplasty.  J Bone Joint Surg . 1999;  81A 932-940
  • 18 Robinson K S, Anderson D R, Gross M. Ultrasonographic screening before hospital discharge for deep venous thrombosis after arthroplasty: The Post-Arthoplasty Screening Study. A randomized, controlled trial.  Ann Intern Med . 1997;  127 439-445
  • 19 Leclerc J R, Gent M, Hirsh J, Geerts W, Ginsberg J S. The incidence of symptomatic venous thromboembolism during and after prophylaxis with enoxaparin.  Arch Intern Med . 1998;  158 873-878
  • 20 White R H, Romano P S, Zhou H, Rodrigo J, Bargar W. Incidence and time course of thromboembolic outcomes following total hip or knee arthroplasty.  Arch Intern Med . 1998;  158 1525-1531
  • 21 Clagett G P, Reisch J S. Prevention of venous thromboembolism in general surgical patients. Results of meta-analysis.  Ann Surg . 1988;  208 227-240
  • 22 Lensing A WA, Hirsh J. 125I-fibrinogen leg scanning: Reassessment of its role for the diagnosis of venous thrombosis in post-operative patients.  Thromb Haemost . 1993;  69 2-7
  • 23 Hull R, Hirsh J, Sackett D L, Stoddart G L. Cost-effectiveness of primary and secondary prevention of fatal pulmonary embolism in high-risk surgical patients.  Can Med Assoc J . 1982;  127 990-995
  • 24 Hull R D, Raskob G E, Rosenbloom D. Heparin for 5 days as compared with 10 days in the initial treatment of proximal venous thrombosis.  N Engl J Med . 1990;  322 1260-1264
  • 25 Nicolaides A N, Kakkar V V, Field E S, Renney J TG. The origin of deep vein thrombosis: A venographic study.  Br J Radiol . 1971;  44 653-663
  • 26 Kakkar V V, Howe C T, Flanc C, Clarke M B. Natural history of postoperative deep-vein thrombosis.  Lancet . 1969;  2 230-232
  • 27 Lagerstedt C I, Olsson C G, Fagher B O, Oqvist B W, Albrechtsson U. Need for long-term anticoagulant treatment in symptomatic calf-vein thrombosis.  Lancet . 1985;  515-518
  • 28 Stamatakis J D, Kakkar V, Sagar S. Femoral vein thrombosis and total hip replacement.  BMJ . 1977;  2 223-225
  • 29 Moser K M, LeMoine J R. Is embolic risk conditioned by location of deep venous thrombosis?.  Ann Intern Med . 1981;  94 439-444
  • 30 Stein P D, Terrin M L, Hales C A. Clinical, laboratory, roentgenographic, and electrocardiographic findings in patients with acute pulmonary embolism and no pre-existing cardiac or pulmonary disease.  Chest . 1991;  100 598-603
  • 31 Hull R D, Raskob G E, Coates G, Panju A A, Gill G J. A new noninvasive management strategy for patients with suspected pulmonary embolism.  Arch Intern Med . 1989;  149 2549-2555
  • 32 Hull R D, Hirsh J, Carter C J. Pulmonary angiography, ventilation lung scanning, and venography for clinically suspected pulmonary embolism with abnormal perfusion lung scan.  Ann Intern Med . 1983;  98 891-899
  • 33 Salzman E W, Davies G C. Prophylaxis of venous thromboembolism: Analysis of cost effectiveness.  Ann Surg . 1980;  191 207-218
  • 34 Collins R, Scrimgeour A, Yusuf S, Peto R. Reduction in fatal pulmonary embolism and venous thrombosis by perioperative administration of subcutaneous heparin.  N Engl J Med . 1988;  318 1162-1173
  • 35 Geerts W H, Code K I, Jay R M, Chen E, Szalai J P. A prospective study of venous thromboembolism after major trauma.  N Engl J Med . 1994;  331 1601-1606
  • 36 Flinn W R, Sandager G P, Cerullo L J, Havey R J, Yao J ST. Duplex venous scanning for the prospective surveillance of perioperative venous thrombosis.  Arch Surg . 1989;  124 901-905
  • 37 White R H, Goulet J A, Bray T J. Deep vein thrombosis after fracture of the pelvis: Assessment with serial duplexultrasound screening.  J Bone Joint Surg . 1990;  72A 495-500
  • 38 Bucher H C, Guyatt G H, Cook D J, Holbrook A, McAlister F A. Users' guides to the medical literature XIX. Applying clinical trial results A. How to use an article measuring the effect of an intervention on surrogate end points.  JAMA . 1999;  282 771-778
  • 39 Lee A YY, Ginsberg J S. Laboratory diagnosis of venous thromboembolism.  Bailliere's Clinical Haematology . 1998;  11 587-604
  • 40 Tapson V F, Carroll B A, Davidson B L. The diagnostic approach to acute venous thromboembolism.  Am J Respir Crit Care Med . 1999;  160 1043-1066
  • 41 Kearon C, Ginsberg J S, Hirsh J. The role of venous ultrasonography in the diagnosis of suspected deep venous thrombosis and pulmonary embolism.  Ann Intern Med . 1998;  129 1044-1049
  • 42 Palmer A J, Koppenhagen K, Kirchhof B, Weber U, Bergmann R. Efficacy and safety of low molecular weight heparin, unfractionated heparin and warfarin for thrombo-embolism prophylaxis in orthopaedic surgery: A meta- analysis of randomized clinical trials.  Haemostasis . 1997;  27 75-84
    >