Complete venous ultrasound in outpatients with suspected pulmonary embolism

Summary.  Background: Compression ultrasonography (US) confined to the proximal veins is usually performed to detect deep vein thrombosis (DVT) in patients with suspected pulmonary embolism (PE). Recent studies suggested a limited yield of proximal US when multislice computed tomography (MSCT) was used. Objectives: To assess whether performing an additional distal vein US would increase the diagnostic yield of the test. Patients and methods: Data of 855 consecutive outpatients included in a multicenter randomized controlled trial were analyzed. Patients were investigated by a sequential diagnostic strategy including clinical probability assessment, D‐dimer measurement, proximal US and MSCT. Proximal US was completed by an examination of the distal veins, the result of which was not disclosed to the physician in charge of the patient. Results: US was positive in 21% of patients, of whom 10% (53/541) had proximal DVT and 11% (59/541) isolated distal DVT. Of the 59 patients with distal DVT, 21 (36%) had no PE on MSCT. Twenty of those 21 patients were not given anticoagulant therapy and had an uneventful follow‐up. The diagnostic performance of distal US for the diagnosis of PE was as follows: sensitivity 22% [95% confidence interval (CI) 17–29]; specificity 94% (95% CI 91–96); positive likelihood ratio 3.9 (95% CI 2.4–6.4). Conclusions: In patients with suspected PE, distal US has limited diagnostic performance, and its additional use only modestly increases the yield of US. Moreover, it carries a high false‐positive rate, impeding the use of distal US as a confirmatory test for PE.

[1]  H. Bounameaux,et al.  Clinical relevance of distal deep vein thrombosis , 2005, Thrombosis and Haemostasis.

[2]  T. Perneger,et al.  Diagnosis of pulmonary embolism by multidetector CT alone or combined with venous ultrasonography of the leg: a randomised non-inferiority trial , 2008, The Lancet.

[3]  G. Gal,et al.  Influence of age on the cost‐effectiveness of diagnostic strategies for suspected pulmonary embolism , 2007, Journal of thrombosis and haemostasis : JTH.

[4]  M. Righini Is it worth diagnosing and treating distal deep vein thrombosis? No , 2007, Journal of thrombosis and haemostasis : JTH.

[5]  S. Schellong Distal DVT: worth diagnosing? Yes , 2007, Journal of thrombosis and haemostasis : JTH.

[6]  P. Roy,et al.  A positive compression ultrasonography of the lower limb veins is highly predictive of pulmonary embolism on computed tomography in suspected patients , 2006, Thrombosis and Haemostasis.

[7]  Pamela K Woodard,et al.  Multidetector computed tomography for acute pulmonary embolism. , 2006, The New England journal of medicine.

[8]  Arnaud Perrier,et al.  Prediction of Pulmonary Embolism in the Emergency Department: The Revised Geneva Score , 2006, Annals of Internal Medicine.

[9]  Pieter W Kamphuisen,et al.  Effectiveness of managing suspected pulmonary embolism using an algorithm combining clinical probability, D-dimer testing, and computed tomography. , 2006, JAMA.

[10]  H. Bounameaux,et al.  Clinical relevance of distal deep vein thrombosis , 2005, Thrombosis and Haemostasis.

[11]  R. Subramaniam,et al.  Deep venous thrombosis: withholding anticoagulation therapy after negative complete lower limb US findings. , 2005, Radiology.

[12]  A. Turpie Multidetector-row computed tomography in suspected pulmonary embolism. , 2005, The New England journal of medicine.

[13]  G. Chatellier,et al.  Systematic review and meta-analysis of strategies for the diagnosis of suspected pulmonary embolism , 2005, BMJ : British Medical Journal.

[14]  Karen J. Chan,et al.  Withholding Anticoagulation after a Negative Result on Duplex Ultrasonography for Suspected Symptomatic Deep Venous Thrombosis , 2004, Annals of Internal Medicine.

[15]  A. Didier,et al.  Diagnostic performance of complete lower limb venous ultrasound in patients with clinically suspected acute pulmonary embolism , 2003, Thrombosis and Haemostasis.

[16]  Antoine Elias,et al.  A single complete ultrasound investigation of the venous network for the diagnostic management of patients with a clinically suspected first episode of deep venous thrombosis of the lower limbs , 2003, Thrombosis and Haemostasis.

[17]  E. Oger,et al.  High Prevalence of Asymptomatic Deep Vein Thrombosis on Admission in a Medical Unit among Elderly Patients , 2002, Thrombosis and Haemostasis.

[18]  H. Büller,et al.  Compression Ultrasonography of the Leg Veins in Patients with Clinically Suspected Pulmonary Embolism , 2000, Thrombosis and Haemostasis.

[19]  G. Simonneau,et al.  High prevalence of detectable deep venous thrombosis in patients with acute pulmonary embolism. , 1999, Chest.

[20]  D. Slosman,et al.  Non-invasive diagnosis of venous thromboembolism in outpatients , 1999, The Lancet.

[21]  P. Carpentier,et al.  Diameters of acute proximal and distal deep venous thrombosis of the lower limbs. , 1998, International angiology : a journal of the International Union of Angiology.

[22]  J. T. ten Cate,et al.  Diagnostic Utility of Ultrasonography of Leg Veins in Patients Suspected of Having Pulmonary Embolism , 1997, Annals of Internal Medicine.

[23]  D. Slosman,et al.  Diagnosis of pulmonary embolism by a decision analysis-based strategy including clinical probability, D-dimer levels, and ultrasonography: a management study. , 1996, Archives of internal medicine.

[24]  A. Sing,et al.  The significance of venography in the management of patients with clinically suspected pulmonary embolism , 1991, Journal of internal medicine.

[25]  J. Martin,et al.  Autopsy Proven Pulmonary Embolism in Hospital Patients: Are We Detecting Enough Deep Vein Thrombosis? , 1989, Journal of the Royal Society of Medicine.

[26]  H. Büller,et al.  Detection of deep-vein thrombosis by real-time B-mode ultrasonography. , 1989, The New England journal of medicine.

[27]  R. Blumhardt Pulmonary angiography, ventilation lung scanning, and venography for clinically suspected pulmonary embolism with abnormal perfusion lung scan. , 1986, Investigative radiology.

[28]  B. Lindblad,et al.  A 30‐year survey of pulmonary embolism verified at autopsy: An analysis of 1274 surgical patients , 1985, The British journal of surgery.

[29]  Gabriele Siegert,et al.  Complete compression ultrasonography of the leg veins as a single test for the diagnosis of deep vein thrombosis , 2003, Thrombosis and Haemostasis.

[30]  F. Christiansen Diagnostic imaging of acute pulmonary embolism. , 1997, Acta radiologica. Supplementum.

[31]  P. de Moerloose,et al.  Contribution of a New, Rapid, Individual and Quantitative Automated D-Dimer ELISA to Exclude Pulmonary Embolism , 1996, Thrombosis and Haemostasis.

[32]  S. Daeschner Pulmonary embolism. , 1988, Nursing.