Abstract
The incidence of venous thromboembolism (VTE), including lower extremity deep vein thrombosis (DVT) and pulmonary embolism (PE) is increasing. The increase in suspicion for VTE has lowered the threshold for performing imaging studies to confirm diagnosis of VTE. However, only 20% of suspected cases have a confirmed diagnosis of VTE. Development of pulmonary embolism rule-out criteria (PERC) and update in pre-test probability have changed the paradigm of ruling-out patient with low index of suspicion. The D-dimer test in conjunction to the pre-test probability has been utilized in VTE diagnosis. The age appropriate D-dimer cutoff and inclusion of YEARS algorithm (signs of the DVT, hemoptysis and whether PE is the likely diagnosis) for the D-dimer cutoff have been recent updates in the evaluation of suspected PE. Multi-detector computed tomography pulmonary angiography (CTPA) and compression ultrasound (CUS) are the preferred imaging modality to diagnose PE and DVT respectively. The VTE diagnostic algorithm do differ in pregnant individuals. The prerequisite of avoiding excessive radiation has recruited planar ventilation-perfusion (V/Q) scan as preferred in pregnant patients to evaluate for PE. The modification of CUS protocol with addition of the Valsalva maneuver should be performed while evaluating DVT in pregnant individual.
Highlights
Venous Thromboembolism (VTE) includes thrombotic disease of venous system, but primarily includes lower extremity deep vein thrombosis (DVT) and pulmonary embolism (PE)
It is estimated that annual incidence of VTE is around 300,000–600,000 cases [4].The incidence of the VTE has increased over time, primarily due to increase in diagnosis of PE [5]
We include the discussion of these advances, that is comprised of the new clinical decision rule, advent in the age appropriate d-dimer cutoff and modification of the Geneva score of assessing the probability of PE
Summary
Venous Thromboembolism (VTE) includes thrombotic disease of venous system, but primarily includes lower extremity deep vein thrombosis (DVT) and pulmonary embolism (PE). This systemic diagnostic approach using pre-test probability and D-dimer testing assist in excluding DVT or PE in an estimated 28% of patients [11,12]. The utility of the pre-test clinical probability and the D-dimer for initial VTE evaluation in patient with cancer is not clear and they should directly proceed to diagnostic imaging studies [17]. The recent updates in the clinical algorithms for excluding the VTE and avoiding the unnecessary testing, evaluating the probability for the VTE, D-dimer for the ruling out VTE, the advances in the imaging studies for VTE evaluation and approach in distinct clinic condition like pregnancy and malignancy. The diagnostic approach differs in patients with prior malignancy and has been discussed in the concluding section of the article
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