Safety and Feasibility of a Diagnostic Algorithm Combining Clinical Probability, d-Dimer Testing, and Ultrasonography for Suspected Upper Extremity Deep Venous Thrombosis: A Prospective Management Study

Study Questions:

What is the safety and feasibility of a new diagnostic algorithm in patients with clinically suspected upper extremity deep venous thrombosis (UEDVT)?

Methods:

This was a diagnostic management study in 16 hospitals in Europe and the United States. A total of 406 in-patients and outpatients with suspected UEDVT were enrolled. The algorithm consisted of the sequential application of a clinical decision score, D-dimer testing, and ultrasonography. Patients were first categorized as likely or unlikely to have UEDVT; in those with an unlikely score and normal D-dimer levels, UEDVT was excluded. All other patients had (repeated) compression ultrasonography. The primary outcome was the 3-month incidence of symptomatic UEDVT and pulmonary embolism in patients with a normal diagnostic workup.

Results:

The algorithm was feasible and completed in 390 of the 406 patients (96%). In 87 patients (21%), an unlikely score combined with normal D-dimer levels excluded UEDVT. Superficial venous thrombosis and UEDVT were diagnosed in 54 (13%) and 103 (25%) patients, respectively. All 249 patients with a normal diagnostic workup, including those with protocol violations (n = 16), were followed for 3 months. One patient developed UEDVT during follow-up, for an overall failure rate of 0.4% (95% confidence interval, 0.0%-2.2%).

Conclusions:

The authors concluded that the combination of a clinical decision score, D-dimer testing, and ultrasonography can safely and effectively exclude UEDVT.

Perspective:

This study suggests that a noninvasive diagnostic algorithm combining the Constans clinical score, D-dimer testing, and ultrasonography is safe in excluding UEDVT and superficial venous thrombosis, and is feasible in 96% of patients. This approach shows promise as a noninvasive approach for identifying UEDVT because it is simple, quick, noninvasive, and similar to the well-established algorithm for diagnosis of suspected DVT of the leg, which could facilitate its implementation in clinical practice.

Clinical Topics: Vascular Medicine

Keywords: Fibrin Fibrinogen Degradation Products, Pulmonary Embolism, Venous Thrombosis, Europe, United States


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