Population Covered By The Guidance
This pathway provides guidance on the imaging of adult patients with suspected lower limb deep venous thrombosis
Lead Researcher: Arjun Shivananda
Experts & Contributors: Ravinder Dhillon, Rachael O'Rourke
Editorial Panel: Core membership
Link to Editorial Panel
Date reviewed: September 2017
Date Published: December 2017
Leg Deep Vein Thrombosis
Leg Deep Vein Thrombosis
- Clinical prediction rules (e.g. Wells Criteria) may be used to categorise patients into low, medium or high risk
- Low risk and negative serum D-Dimer effectively excludes DVT
- Medium and high risk patients should undergo Doppler ultrasound without D-Dimer estimation
- Ultrasound is highly sensitive for proximal lower limb deep vein thrombosis
- US is less sensitive for deep calf vein thrombosis and for iliac vein thrombosis
- After a negative Doppler ultrasound, follow-up US in patients with high clinical suspicion may be indicated to exclude a calf thrombosis that is propagating proximally
Date of literature search: September 2017
References are graded from Level I to V according to the Oxford Centre for Evidence-Based Medicine, Levels of Evidence. Download the document
- Wells PS, Hirsh J, Anderson DR, Lensing AW, Foster G, Kearon C, et al. Accuracy of clinical assessment of deep-vein thrombosis. Lancet. 1995;345(8961):1326-30. (Level II evidence). View the reference
- Wells PS, Anderson DR, Rodger M, Forgie M, Kearon C, Dreyer J, et al. Evaluation of D-dimer in the diagnosis of suspected deep-vein thrombosis. N Engl J Med. 2003;349(13):1227-35. (Level II evidence). View the reference
- Perrier A, Desmarais S, Miron MJ, de Moerloose P, Lepage R, Slosman D, et al. Non-invasive diagnosis of venous thromboembolism in outpatients. Lancet. 1999;353(9148):190-5. (Level II evidence). View the reference
- Wells PS, Anderson DR, Bormanis J, Guy F, Mitchell M, Gray L, et al. Value of assessment of pretest probability of deep-vein thrombosis in clinical management. Lancet. 1997;350(9094):1795-8. (Level II evidence). View the reference
- Min SK, Kim YH, Joh JH, Kang JM, Park UJ, Kim HK, et al. Diagnosis and Treatment of Lower Extremity Deep Vein Thrombosis: Korean Practice Guidelines Vasc Specialist Int. 2016;32(3):77-104. (Guidelines). View the reference
- Goodacre S, Sampson F, Thomas S, van Beek E, Sutton A. Systematic review and meta-analysis of the diagnostic accuracy of ultrasonography for deep vein thrombosis. BMC Med Imaging. 2005;5:6. (Level II evidence). View the reference
- Kitchen L, Lawrence M, Speicher M, Frumkin K. Emergency Department Management of Suspected Calf-Vein Deep Venous Thrombosis: A Diagnostic Algorithm. West J Emerg Med. 2016;17(4):384-90. (Review article). View the reference
- Kearon C, Julian JA, Newman TE, Ginsberg JS. Noninvasive diagnosis of deep venous thrombosis. McMaster Diagnostic Imaging Practice Guidelines Initiative. Ann Intern Med. 1998;128(8):663-77. (Review article). View the reference
- Tapson VF, Carroll BA, Davidson BL, Elliott CG, Fedullo PF, Hales CA, et al. The diagnostic approach to acute venous thromboembolism. Clinical practice guideline. American Thoracic Society. Am J Respir Crit Care Med. 1999;160(3):1043-66. (Guidelines). View the reference
- Keeling DM, Mackie IJ, Moody A, Watson HG. The diagnosis of deep vein thrombosis in symptomatic outpatients and the potential for clinical assessment and D-dimer assays to reduce the need for diagnostic imaging. Br J Haematol. 2004;124(1):15-25. (Review article). View the reference
- Stein PD, Hull RD, Patel KC, Olson RE, Ghali WA, Brant R, et al. D-dimer for the exclusion of acute venous thrombosis and pulmonary embolism: a systematic review Ann Intern Med. 2004;140(8):589-602. (Level I evidence). View the reference
- Sule AA, Chin TJ, Handa P, Earnest A. Should symptomatic, isolated distal deep vein thrombosis be treated with anticoagulation? The International Journal of Angiology : Official Publication of the International College of Angiology, Inc. 2009;18(2):83-7. (Level IV evidence). View the reference
- Goodacre S, Sampson FC, Sutton AJ, Mason S, Morris F. Variation in the diagnostic performance of D-dimer for suspected deep vein thrombosis. Qjm. 2005;98(7):513-27. (Review article). View the reference
- Freyburger G, Trillaud H, Labrouche S, Gauthier P, Javorschi S, Bernard P, et al. D-dimer strategy in thrombosis exclusion--a gold standard study in 100 patients suspected of deep venous thrombosis or pulmonary embolism: 8 DD methods compared. Thromb Haemost. 1998;79(1):32-7. (Level II evidence). View the reference
- Owaidah T, AlGhasham N, AlGhamdi S, AlKhafaji D, B AL, Zeitouni M, et al. Evaluation of the usefulness of a D dimer test in combination with clinical pretest probability score in the prediction and exclusion of Venous Thromboembolism by medical residents. Thromb J. 2014;12(1):28. (Level III evidence). View the reference
- Ho WK, Hankey GJ, Lee CH, Eikelboom JW. Venous thromboembolism: diagnosis and management of deep venous thrombosis. Med J Aust. 2005;182(9):476-81. (Review article). View the reference
Pathway User Guide
Yellow Boxes Denotes extra information. Some contain single or multiple white sub-boxes, click a white box to reveal detailed information in a pop-up.
White Boxes: Denotes standard pathway steps. (If inside a yellow box, they open a specific pop-up).
Zoom & Pan Controls: Use + / − or the slider to zoom. Reset returns to default. Tick Panning to drag the diagram when zoomed.
Blue “View Full Screen” Button: Opens the whole diagram in a large, full-screen pop-up window. Use Close to exit.
The relative radiation level (RRL) of each imaging investigation is displayed in the pop up box.
| SYMBOL | RRL | EFFECTIVE DOSE RANGE |
|---|---|---|
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None | 0 |
 |
Minimal | < 1 millisieverts |
 |
Low | 1-5 mSv |
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Medium | 5-10 mSv |
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High | >10 mSv |
Disclaimer
Status Of Recommendations Each pathway is designed to assist clinicians in situations when faced with a large array of possible diagnostic tests and examinations. However, it is recognised that diagnostic practice may differ from a particular pathway depending on local availability of equipment and expertise, as well as the experience of individual clinicians. Therefore each pathway is neither a rigid set of rules, nor a substitute for clinical assessment, and individual patient circumstances should always be considered.
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Ultrasound Including Doppler
Ultrasound Including Doppler
The most accurate non-invasive test for the diagnosis of DVT
- Most accurate non-invasive test for the diagnosis of a first symptomatic proximal deep vein thrombosis
- Involves a combination of:
- Compression ultrasonography - starting at the inguinal ligament and generally extending to the venous trifurcation in the calf
- Doppler imaging - particularly useful where compressibility is difficult to assess
- Advantages of ultrasound
- Excellent sensitivity for proximal vein thrombosis (97%)
- Ability to depict anatomical variants (e.g. duplicated venous segments) and alternative causes of symptoms
- Non-invasive
- No exposure to ionising radiation
- Does not involve the use of contrast agent
- Relatively inexpensive
- Limitations of ultrasound
- Venous compressibility may be limited by patient characteristics such as obesity, oedema, and tenderness
- False positives may occur due to extrinsic compression of a vein by pelvic mass or other perivascular pathology
- A negative ultrasound scan in moderate to high risk patients does not reliably exclude the diagnosis of deep vein thrombosis
- Less sensitive for detecting distal vein thrombosis (73% sensitivity) and in detecting thrombosis in iliac veins
- Serial ultrasound is used to detect those DVTs that were isolated distally in the calf initially and undetected but which subsequently extend into the more proximal veins
- Isolated distal calf DVTs rarely lead to significant embolic events
Ultrasound Including Doppler
Repeat Ultrasound
The rationale for repeating the ultrasound is to detect clots that were isolated in the calf and undetected on initial scanning but which have since extended proximally into the thigh
- Most accurate non-invasive test for the diagnosis of a first symptomatic proximal deep vein thrombosis
- Involves a combination of:
- Compression ultrasonography - starting at the inguinal ligament and generally extending to the venous trifurcation in the calf
- Doppler imaging - particularly useful where compressibility is difficult to assess
- Advantages of ultrasound
- Excellent sensitivity for proximal vein thrombosis (97%)
- Ability to depict anatomical variants (e.g. duplicated venous segments) and alternative causes of symptoms
- Non-invasive
- No exposure to ionising radiation
- Does not involve the use of contrast agent
- Relatively inexpensive
- Limitations of ultrasound
- Venous compressibility may be limited by patient characteristics such as obesity, oedema, and tenderness
- False positives may occur due to extrinsic compression of a vein by pelvic mass or other perivascular pathology
- A negative ultrasound scan in moderate to high risk patients does not reliably exclude the diagnosis of deep vein thrombosis
- Less sensitive for detecting distal vein thrombosis (73% sensitivity) and in detecting thrombosis in iliac veins
- Serial ultrasound is used to detect those DVTs that were isolated distally in the calf initially and undetected but which subsequently extend into the more proximal veins
- Isolated distal calf DVTs rarely lead to significant embolic events