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David Plaut: Off the Cuff

A Diagnostic Algorithm for Suspected Upper-Extremity Deep Venous Thrombosis

Published May 20, 2014 2:02 PM by David Plaut

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.


posted by David Plaut


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