A Diagnostic Algorithm for Suspected Upper-Extremity Deep Venous Thrombosis
The prevalence of upper-extremity deep venous thrombosis
(DVT) has risen in conjunction with more frequent use of central venous
catheters. There are clear algorithms for diagnosing lower-extremity (e.g.
Wells), but not for upper-extremity, DVT. A multicenter study, a diagnostic
algorithm was evaluated in 406 patients with suspected upper-extremity DVTs.
The study included calculating a clinical decision score consisted of +1 point
each for the 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. The algorithm in addition to the
score included D-dimer testing, and ultrasonography. The patients were
follow-up after 3 months.
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%).
This study verifies the value of using d-dimer measurements
to rule out DVT.
Jamaluddin Moloo, reviewing Kleinjan A et al. Ann Intern Med
2014 Apr 1.