Diagnosis Of Proximal Deep Vein Thrombosis Research Articles

Accuracy of three-point compression ultrasound for the diagnosis of proximal deep-vein thrombosis in emergency department.

Background:This study aimed to assess the accuracy of three-point compression ultrasonography (3PCUS) performed for the diagnosis of proximal deep-vein thrombosis (DVT) in Emergency Department (ED) compared with the results of duplex US (DUS) (whole-leg compression ultrasound).Materials and Methods:The current prospective cross-sectional study with diagnostic test assessment was conducted on adult patients who were referred to the ED of a general teaching hospital in Shiraz, southern part of Iran (September 2016–May 2017), suspected of lower-extremity DVT, using a convenience sampling. The results of 3PCUS performed by ED residents were compared with the results of DUS performed by the radiology residents, which was considered as a criterion standard.Results:A total of 240 patients were enrolled, with a mean (standard deviation) age of 59.46 (16.58). 3PCUS has a sensitivity and a specificity of 100% (95% confidence interval [CI], 96.55%–100%) and 93.33% (95% CI, 87.72%–96.91%), respectively, in comparison with DUS (whole-leg compression ultrasound). Negative predictive value and positive predictive value were 100% and 92.11% (95% CI, 86.12%–95.64%), respectively, with an accuracy of 96.25% (95% CI, 93%–98.27%).Conclusion:The results of this study showed that 3PCUS of the lower extremities with a portable US machine, performed by the ED's residents, can accurately identify the presence or absence of lower-extremity DVT.

Prevalence and Predictors of DVT in Medical ICU Patients Undergoing Diagnostic Duplex Ultrasonography

SESSION TITLE: Hematology/Oncology in the ICU SESSION TYPE: Original Investigation Slide PRESENTED ON: Monday, October 30, 2017 at 04:30 PM - 05:30 PM PURPOSE: Deep vein thrombosis (DVT) is a recognized but preventable cause of morbidity and mortality in the ICU. There is limited data on the risk of DVT or predisposing factors among non-surgical ICU patients with multiple medical comorbidities. Our aim is to retrospectively examine the prevalence and risk factors for proximal DVT and potential effect on clinical outcomes in critically ill medical patients in which diagnostic duplex ultrasonography (DUS) was performed. METHODS: Retrospective case-control study examining the prevalence of DVT in 678 patients admitted to two tertiary care level academic Medical ICUs (MICU) from July 2014 to July 2015 in the Bronx, NY. Persons with a diagnosis of proximal DVT on DUS were compared to a cohort of patients without DVT. Sequential Organ Failure Assessment (SOFA) scores were calculated for all patients to assess disease severity and comparability. Primary outcomes were ICU length of stay and mortality. Secondary outcomes were need for invasive mechanical ventilation (IMV), hemodialysis, sepsis, SOFA scores, vasopressor/inotrope use, central venous catheter (CVC) placement, history of DVT and malignancy. Stepwise logistic regression analysis was utilized to determine predictors of DVT occurrence. RESULTS: Of the 678 patients admitted to the MICU, 245 (36%) patients underwent duplex ultrasonography (DUS) to evaluate for DVT. 141 (57%) were male, mean age was 64.4±16.7 years, and BMI 29.8±11.5 kg/m2. Dyspnea (31%) and immobility (23%) were the most common indications for DUS testing. The prevalence of DVT was 19% (47) amongst tested patients. Of the patients with DVT, we noted increased rates of CVC placement (25% vs.15% p=0.05), and vasopressor/inotrope use (26% vs.16% p=0.05) compared to persons without DVT on DUS. Those on routine DVT thromboprophylaxis, chemical or mechanical, had fewer DVTs (15% vs 29% p=0.01). Between cases and controls, there were no significant differences in the need for IMV, hemodialysis, sepsis, SOFA scores, and history of malignancy. There were also no significant differences in ICU length of stay (DVT:4.4±6 days vs no DVT:4.8±59 days p=0.35) or mortality (DVT:10.6% vs no DVT:11.8% p=0.34). Stepwise regression modeling demonstrated a prior history of DVT was a significant predictor for development of DVT (OR 5.68, 95% CI [1.81, 17.83] p<0.01). CONCLUSIONS: A significant percentage of patients tested had proximal DVT even with appropriate use of DVT thromboprophylaxis. A history of DVT in a patient was the sole predictor for development of DVT on DUS testing in our MICU population. Our study demonstrated vasopressor/inotrope use and the central venous catheters used for medication delivery were associated with presence of DVT. Sepsis was not an independent risk factor for DVT. CLINICAL IMPLICATIONS: Despite the use of universal, guideline-recommended thromboprophylaxis, critically ill patients still demonstrate high rates of DVT. In the presence of known risk factors elicited from our cohort - history of DVT, CVC placement, and use of vasopressors/inotropes - our study highlights the need for targeted screening via DUS in the medical ICU. Further studies with larger patient populations are needed to fully elucidate the impact of acute DVT on morbidity and mortality in the medical ICU. DISCLOSURE: The following authors have nothing to disclose: Charlisa Gibson, Mai Colvin, Michael Park, Qingying Lai, Gavin Harris, Chirag Shah, Matthew Langston No Product/Research Disclosure Information

Initial and Mid-Term Outcomes of Pulse Infusion Thrombolysis Using a Unique Pump System and Stent Placement for Deep Vein Thrombosis

The aim of this study was to evaluate the initial and mid-term results of pulse infusion thrombolysis (PIT) using a unique pump system and stent placement for proximal deep vein thrombosis (DVT) in Japanese. Among the patients who were admitted to our institute under diagnosis of proximal DVT between April 2001 and March 2005, 11 patients (4 men, mean age 61 years) who underwent PIT and angioplasty followed by stent placement were enrolled in this retrospective analysis. Urokinase or monteplase was used as a thrombolytic agent. Venous or stent patency was assessed by color Doppler ultrasound or enhanced computed tomography for a mean follow-up duration of 54 months. Sites of thrombus were left lower limbs in 10 cases and left upper limb in one case. Initial technical (complete venous flow recovery) and clinical (disappearance of pain and swelling of diseased leg or arm) success was achieved in all patients. Two of 11 patients showed stent occlusion with leg swelling and pain one month later and 3 years later, respectively. These patients had associated protein S deficiency. PIT and stent deployment for DVT is safe and effective with favorable initial and mid-term clinical results and without major complications in Japanese, except for cases of congenital coagulation abnormality.

Accuracy of compression ultrasound in screening for deep venous thrombosis in acutely ill medical patients

The value of vein ultrasonography for diagnosis of symptomatic deep vein thrombosis (DVT) is widely accepted. We are unaware of published data comparing ultrasonography with the "gold standard" of venography for DVT diagnosis in asymptomatic persons in the patient group of acutely ill medical patients. It was the objective of this study to evaluate sensitivity and specificity of compression ultrasound (CUS) examinations in the diagnosis of proximal and distal DVT in acutely ill medical patients [with congestive heart failure (NYHA class III and IV), exacerbations of respiratory disease, infectious disease, and inflammatory diseases] considered to be at moderate risk of venous thromboembolism (VTE). CUS examination was performed prior to ascending venography on day 6-15 of the hospital stay. Both investigations were done on the same day, each interpreted without knowledge of the other's result. Proximal and calf veins were separately evaluated. Technically satisfactory venography was obtained in 160 patients. In 12 of 160 patients (7.5%, 95% CI=[4.0%-12.7%]), venography confirmed the presence of DVT, all of which was asymptomatic. Proximal DVT was detected in five patients (3.1%, 95% CI=[1.0%-7.1%]) and distal DVT in seven patients (4.4%, 95% CI=[1.8%-8.8%]). CUS of proximal veins was technically satisfactory in all 160 patients and CUS of distal veins in 150 patients. In three of five patients with venographically proven proximal DVT, the diagnosis was confirmed by CUS (sensitivity 60%, 95%CI=[23%-88%]). In one patient, the CUS was false positive (specificity 99.4%, 95%CI=[96%-99%]). Positive and negative predictive values (PPV and NPV) of CUS in the diagnosis of proximal DVT were 75% (95%CI=[30%-95%]) and 98% (95% CI=[95%-99%]), respectively. In two of seven patients with venographically proven calf DVT, the diagnosis was confirmed by CUS (sensitivity 28.6%, 95%CI=[8%-64%]) and in two patients, CUS was false positive (specificity 98.6, 95%CI=[95%-99%]). PPV and NPV of CUS in diagnosis of distal DVT were 50% (95%CI=[15-85%]) and 96% (95% CI=[92%-98%]), respectively. In conclusion, CUS underestimates the incidence of proximal and distal DVT compared to contrast venography in acutely ill medical patients without thrombosis symptoms.

Pharmacy-managed program for home treatment of deep vein thrombosis with enoxaparin.

A program for home treatment of uncomplicated acute proximal deep vein thrombosis (DVT) with enoxaparin is described. In fall 1995 an HMO in Southern California began developing a pharmacy-managed program in which selected patients with acute proximal DVT receive home treatment with enoxaparin. Advantages of the program included expected cost avoidance. The safety and efficacy of such therapy were verified, and quality control measures were established. Patients are referred to the program by the physicians making the diagnosis of proximal DVT. Upon referral, patients are placed in a holding area. A pharmacist orders laboratory tests and then prescribes warfarin and enoxaparin doses. Patients are given their first doses, taught to safely self-administer enoxaparin, and sent home. Follow-up care, monitoring, and blood sampling are provided through a home health agency. A pharmacist monitors the International Normalized Ratio (INR) and telephones the patient daily to specify the day's warfarin dose. Patients receive concurrent enoxaparin and warfarin therapy for at least five days until the INR is > 2; enoxaparin is then discontinued and patients are transferred to an outpatient anticoagulation service for continued monitoring. From April 1, 1996, to March 27, 1997, 55 patients were treated under the program; all eligible patients were enrolled. A total of 294 hospital days were avoided. There were no complications or hospital admissions due to bleeding. A comprehensive program for home treatment of uncomplicated acute proximal DVT with enoxaparin was implemented at an HMO.