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Diagnostic Algorithm for Suspected Upper-Extremity Deep Venous Thrombosis

May 8, 2014

Diagnostic Algorithm for Suspected Upper-Extremity Deep Venous Thrombosis

  1. Jamaluddin Moloo, MD, MPH

Clinical score, d-dimer testing, and ultrasonography identified patients with upper-extremity DVT.

  1. Jamaluddin Moloo, MD, MPH

The rate of upper-extremity deep venous thrombosis (DVT) has risen in conjunction with more frequent use of central venous catheters. We have clear algorithms for diagnosing lower-extremity, but not upper-extremity, DVT. In this multicenter study, a diagnostic algorithm was assessed in 406 patients with suspected upper-extremity DVTs. Evaluation included calculating a clinical decision score, d-dimer testing, and ultrasonography. The clinical score consisted of +1 point each for presence of a central venous catheter or lead, localized pain, or unilateral edema and −1 point for a plausible alternate diagnosis. Scores of ≤1 implied that upper-extremity DVT was unlikely. Follow-up was 3 months. Upper-extremity DVTs were verified in 103 patients.

Fifty percent of patients (203) were assigned clinical decision scores of 0 or 1 (upper-extremity DVT unlikely); 90 had normal d-dimer tests and did not undergo further testing or treatment — none developed symptomatic DVTs. The 113 low-scoring patients with abnormal d-dimer tests underwent ultrasonography: Ultrasonography was negative in 73 — they did not receive treatment, and none developed symptomatic DVTs. Upper-extremity DVTs were diagnosed in 12 low-scoring patients. In the 203 patients with higher scores, ultrasonography detected no upper-extremity DVTs in 83; those patients underwent d-dimer testing and repeated ultrasonography if d-dimer test were abnormal, with a yield of 3 additional DVT diagnoses. Rates of upper-extremity DVT were significantly lower in patients with scores ≤1 than in those with scores >1 (6% vs. 44%).

Comment

This algorithm for upper-extremity deep venous thromboses — a clinical decision score, a d-dimer test, and ultrasonography — is similar to strategies for diagnosing lower-extremity DVTs. Given that this algorithm is successful and noninvasive, it could become a standard for clinical practice.

  • Disclosures for Jamaluddin Moloo, MD, MPH at time of publication Grant / research support NIH

Citation(s):

Reader Comments (5)

Che-Chia Chang Other Healthcare Professional, Pharmacology/Pharmacy, AFTYGH, Taiwan

NEJM always provide the best knowledge for readers.

Dr. V Kantariya MD Physician, Family Medicine/General Practice

DVT commonly occurs in the lower extremities, but can occur in other sites. The risk of nonleg VT, predisposing factors and PE or death are unclear. Only 13% of patients diagnosed with nonleg DVT received anticoagulation therapy(JAMA IM, 2014 PROTECT),IVC filters increased VTE recurrence 6.1% vs 0.6% (J.Am.Coll.Cardiol.2014) The Time for Action to improve management of nonlegDVT.

Dr. V Kantariya MD Physician, Family Medicine/General Practice

Non-leg DVT demonstrated increased risk for PE 14,9% vs 1,9% (patients who did not have non-leg DVTs). Only 13% of patients diagnosed with non-leg DVT received anticoagulation therapy." If you will pardon the pun, this represents a call to arms for improved management of non-leg DVT."

Dr. V Kantariya MD Physician, Family Medicine/General Practice

There are two questions: a value of "normal" D-dimer threshold and the cutoffs for "normal" D-dimer according to the patients age to rule out upper-extremity DVT?

Pandalanghat Suresh, Medical Oncologist Physician, Oncology, India

What will be the validity of d-dimer in the setting of hematological or solid tumor patients who are being given multiple blood or component transfusions

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