… anticoagulation after a negative result on duplex ultrasonography for suspected symptomatic deep …
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Ultrasonography for Suspected Symptomatic Deep Venous Thrombosis Patients then under-
went objective testing for DVT by comprehensive duplex ultrasonography.
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Annals of Internal Medicine Article Withholding Anticoagulation after a Negative Result on Duplex Ultrasonography for Suspected Symptomatic Deep Venous Thrombosis Scott M. Stevens, MD; C. Gregory Elliott, MD; Karen J. Chan, BS; Marlene J. Egger, PhD; and Kirmanj M. Ahmed, MD Background: Negative results on simplified compression ultra- Results: Comprehensive duplex ultrasonography yielded normal sonography cannot rule out symptomatic deep venous thrombosis results in 384 patients (86.3%) and showed DVT in 61 patients (DVT) without further testing, such as repeated ultrasonography (13.7%). Nineteen cases of DVT (31.1%) were isolated to the several days later. Repeated testing is costly and inconvenient, deep veins of the calf. Nine patients in the negative cohort (2.3%) and patients are sometimes less likely to return for follow-up were excluded from analysis because they received anticoagula- tests. tion for reasons unrelated to venous thromboembolism. Three of Objective: To determine the rate of venous thromboembolism 375 patients (0.80% [95% CI, 0.16% to 2.33%]) in the normal when anticoagulation is withheld in patients with symptoms of cohort had symptomatic venous thrombosis during the 3-month DVT of the leg after negative results on a single examination with follow-up. All 384 patients in the negative cohort completed comprehensive duplex ultrasonography. follow-up. Design: Prospective clinical cohort study. Limitations: The study was conducted at a single tertiary care center by a peripheral vascular staff with substantial experience in Setting: Peripheral vascular laboratory of a tertiary care academic duplex ultrasonography, which may limit the applicability of the hospital. results to other institutions. Pregnant patients were excluded. Patients: 445 consecutive patients in whom a first episode of Conclusions: It is safe to withhold anticoagulation after nega- symptomatic DVT was suspected. tive results on comprehensive duplex ultrasonography in nonpreg- Intervention: The researchers examined the entire leg with nant patients with a suspected first episode of symptomatic DVT comprehensive duplex ultrasonography, using compression and of the leg. New or progressive symptoms should prompt further Doppler techniques. Anticoagulation was withheld from the group testing. with negative results. Patients were observed for thromboembolic events for 3 months. Measurements: All patients who had new or progressive symp- Ann Intern Med. 2004;140:985-991. www.annals.org toms or signs of venous thromboembolism during follow-up un- For author affiliations, see end of text. derwent objective testing. See editorial comment on pp 1052-1053. Ultrasonography is the most commonly used test in the A single noninvasive study that safely rules out DVT United States for diagnosis of deep venous thrombosis would be useful. Comprehensive duplex ultrasonography, (DVT) of the leg (1– 4). The term ultrasonography has been which examines the deep veins from the inguinal ligament applied to a variety of diagnostic techniques. The most to the level of the malleolus, has not been tested prospec- researched technique, simplified compression ultrasonogra- tively to determine whether it is adequate to detect clini- phy, is highly sensitive and specific for symptomatic prox- cally important calf DVT and make routine repeated scan- imal venous thrombosis but does not detect thrombosis in ning unnecessary. To determine whether negative results the distal veins of the calf (1– 8). Distal DVT may propa- on a single examination with comprehensive duplex ultra- gate proximally and lead to venous thromboembolism. sonography are adequately sensitive to justify withholding Therefore, a second examination with simplified compres- anticoagulation in patients with symptoms of DVT of the sion ultrasonography performed 5 to 7 days later is neces- leg, we performed a prospective cohort study of consecu- sary to detect unvisualized calf vein thrombi that have tive patients in whom a first episode of this disorder was propagated proximally (9 –12). suspected. The primary end point was the rate of venous Repeated testing is inconvenient, and not all patients thromboembolism (including death attributed to venous are able to return for serial tests (9, 10, 12). Many thromboembolism) when anticoagulant therapy was with- follow-up tests that yield normal results must be performed held from patients on the basis of negative results on a to detect relatively few patients with disease (9 –13). In the single examination with comprehensive duplex ultrasonog- United States, approximately 500 000 patients are evalu- raphy. We used 3 months of clinical follow-up to test the ated annually for DVT (14). Given that results are normal validity of this approach (16 –18). on approximately 80% of initial ultrasonography examina- tions (15), and only 2% of patients have abnormal results METHODS on serial testing 5 to 7 days later (9, 10), as many as Patients 390 000 repeated tests may be performed annually without From April 2000 through July 2001, we enrolled con- detecting disease. secutive adult patients who were referred to a tertiary care © 2004 American College of Physicians 985
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