FREE NEJM E-TOC    HOME   |   SUBSCRIBE   |   CURRENT ISSUE   |   PAST ISSUES   |   COLLECTIONS   |   Search Term  Advanced Search

Sign in | Get NEJM's E-Mail Table of Contents — Free | Subscribe

Volume 329:1365-1369 November 4, 1993 Number 19 Next

	Full Text Letters Add to Personal Archive Add to Citation Manager Notify a Friend E-mail When Cited PubMed Citation

ABSTRACT

Background Impedance plethysmography performed serially over a one-week period has been shown to be an effective diagnostic strategy for patients with clinically suspected acute deep-vein thrombosis. Compression ultrasonography has a high sensitivity and specificity for the detection of proximal-vein thrombosis. The clinical value of repeated ultrasonography in the management of symptomatic deep-vein thrombosis is unknown.

Methods We conducted a randomized trial in 985 consecutive outpatients with clinically suspected deep-vein thrombosis to compare the diagnostic value of serial impedance plethysmography (494 patients) and serial compression ultrasonography (491 patients). We compared the positive predictive values of both tests for the diagnosis of venous thrombosis, using contrast venography as a reference. The frequencies of venous thromboembolism during a six-month follow-up period were also compared in patients with repeatedly normal results in order to evaluate the safety of withholding anticoagulant therapy from such patients.

Results The positive predictive value of an abnormal ultrasonogram was 94 percent (95 percent confidence interval, 87 to 98 percent), whereas the predictive value of impedance plethysmography was 83 percent (95 percent confidence interval, 75 to 90 percent) (P = 0.02). In patients with repeatedly normal results, the incidence of venous thromboembolism during the six-month follow-up period was 1.5 percent (95 percent confidence interval, 0.5 to 3.3 percent) for serial compression ultrasonography, as compared with 2.5 percent (95 percent confidence interval, 1.2 to 4.6 percent) for serial impedance plethysmography.

Conclusions In making the diagnosis of deep-vein thrombosis in symptomatic outpatients, serial compression ultrasonography is preferable to impedance plethysmography, in view of its superior performance in detecting venous thrombosis.

Source Information

From the Center for Hemostasis, Thrombosis, Atherosclerosis and Inflammation Research, Academic Medical Center, Amsterdam (H.H., H.R.B., A.W.A.L., J.W.C.); the Hamilton Civic Hospitals General Division, Hamilton General Hospital-McMaster Clinic, Hamilton, Ont., Canada (A.W.A.L., A.G.G.T.); and the Thrombosis Service, Amsterdam (L.P.C.).

Address reprint requests to Dr. Buller at the Center for Hemostasis, Thrombosis, Atherosclerosis and Inflammation Research, Academic Medical Center, Meibergdreef 9, 1105 AZ Amsterdam Zuidoost, the Netherlands.

Full Text of this Article

Related Letters:

The Diagnosis of Deep-Vein Thrombosis
Moser K. M., Fedullo P. F., Heijboer H., Buller H. R., ten Cate J. W.
Extract | Full Text  
N Engl J Med 1994; 330:863-864, Mar 24, 1994. Correspondence

This article has been cited by other articles:

• Bernardi, E., Camporese, G., Buller, H. R., Siragusa, S., Imberti, D., Berchio, A., Ghirarduzzi, A., Verlato, F., Anastasio, R., Prati, C., Piccioli, A., Pesavento, R., Bova, C., Maltempi, P., Zanatta, N., Cogo, A., Cappelli, R., Bucherini, E., Cuppini, S., Noventa, F., Prandoni, P., for the Erasmus Study Group, (2008). Serial 2-Point Ultrasonography Plus D-Dimer vs Whole-Leg Color-Coded Doppler Ultrasonography for Diagnosing Suspected Symptomatic Deep Vein Thrombosis: A Randomized Controlled Trial. JAMA 300: 1653-1659 [Abstract] [Full Text]  
• Dewar, C, Selby, C, Jamieson, K, Rogers, S (2008). Emergency department nurse-based outpatient diagnosis of DVT using an evidence-based protocol. Emerg. Med. J. 25: 411-416 [Abstract] [Full Text]  
• Scarvelis, D., Wells, P. S. (2006). Diagnosis and treatment of deep-vein thrombosis.. CMAJ 175: 1087-1092 [Abstract] [Full Text]  
• Subramaniam, R. M., Heath, R., Chou, T., Cox, K., Davis, G., Swarbrick, M. (2005). Deep Venous Thrombosis: Withholding Anticoagulation Therapy after Negative Complete Lower Limb US Findings. Radiology 237: 348-352 [Abstract] [Full Text]  
• Fuchs, S., Heyse, T., Rudofsky, G., Gosheger, G., Chylarecki, C. (2005). Continuous passive motion in the prevention of deep-vein thrombosis: A RANDOMISED COMPARISON IN TRAUMA PATIENTS. J Bone Joint Surg Br 87-B: 1117-1122 [Abstract] [Full Text]  
• Oudega, R., Hoes, A. W., Moons, K. G.M. (2005). The Wells Rule Does Not Adequately Rule Out Deep Venous Thrombosis in Primary Care Patients. ANN INTERN MED 143: 100-107 [Abstract] [Full Text]  
• Syed, F.F., Beeching, N.J. (2005). Lower-limb deep-vein thrombosis in a general hospital: risk factors, outcomes and the contribution of intravenous drug use. QJM 98: 139-145 [Abstract] [Full Text]  
• Oudega, R., Moons, K. G., Hoes, A. W (2005). Limited value of patient history and physical examination in diagnosing deep vein thrombosis in primary care. Fam Pract 22: 86-91 [Abstract] [Full Text]  
• Neale, D, Tovey, C, Vali, A, Davies, S, Myers, K, Obiako, M, Ramkumar, V, Hafiz, A (2004). Evaluation of the Simplify D-dimer assay as a screening test for the diagnosis of deep vein thrombosis in an emergency department. Emerg. Med. J. 21: 663-666 [Abstract] [Full Text]  
• Fancher, T. L, White, R. H, Kravitz, R. L (2004). Combined use of rapid D-dimer testing and estimation of clinical probability in the diagnosis of deep vein thrombosis: systematic review. BMJ 329: 821- [Abstract] [Full Text]  
• Riddle, D. L, Wells, P. S (2004). Diagnosis of Lower-Extremity Deep Vein Thrombosis in Outpatients. ptjournal 84: 729-735 [Full Text]  
• Stevens, S. M., Elliott, C. G., Chan, K. J., Egger, M. J., Ahmed, K. M. (2004). Withholding Anticoagulation after a Negative Result on Duplex Ultrasonography for Suspected Symptomatic Deep Venous Thrombosis. ANN INTERN MED 140: 985-991 [Abstract] [Full Text]  
• Frost, S. D., Brotman, D. J., Michota, F. A. (2003). Rational Use of D-Dimer Measurement to Exclude Acute Venous Thromboembolic Disease. Mayo Clin Proc. 78: 1385-1391 [Abstract]  
• Wells, P. S., Anderson, D. R., Rodger, M., Forgie, M., Kearon, C., Dreyer, J., Kovacs, G., Mitchell, M., Lewandowski, B., Kovacs, M. J. (2003). Evaluation of D-Dimer in the Diagnosis of Suspected Deep-Vein Thrombosis. NEJM 349: 1227-1235 [Abstract] [Full Text]  
• Meroni, P L, Moia, M, Derksen, R H., Tincani, A, McIntyre, J A, Arnout, J M., Koike, T, Piette, J-C, Khamashta, M A, Shoenfeld, Y (2003). Venous thromboembolism in the antiphospholipid syndrome: management guidelines for secondary prophylaxis. Lupus 12: 504-507 [Abstract]  
• Kearon, C. (2003). Natural History of Venous Thromboembolism. Circulation 107: I-22-30 [Abstract] [Full Text]  
• Stein, P. D., Hull, R. D., Ghali, W. A., Patel, K. C., Olson, R. E., Meyers, F. A., Kalra, N. K. (2003). Tracking the Uptake of Evidence: Two Decades of Hospital Practice Trends for Diagnosing Deep Vein Thrombosis and Pulmonary Embolism. Arch Intern Med 163: 1213-1219 [Abstract] [Full Text]  
• Kearon, C. (2003). Diagnosis of pulmonary embolism. CMAJ 168: 183-194 [Abstract] [Full Text]  
• Walsh, K, Kelaher, N, Long, K, Cervi, P (2002). An algorithm for the investigation and management of patients with suspected deep venous thrombosis at a district general hospital. Postgrad. Med. J. 78: 742-745 [Abstract] [Full Text]  
• Bates, S. M., Ginsberg, J. S. (2002). How we manage venous thromboembolism during pregnancy. Blood 100: 3470-3478 [Abstract] [Full Text]  
• Maskell, N A, Cooke, S, Meecham Jones, D J, Prior, J G, Butland, R J A (2002). The use of automated strain gauge plethysmography in the diagnosis of deep vein thrombosis. Br. J. Radiol. 75: 648-651 [Abstract] [Full Text]  
• Kraaijenhagen, R. A., Piovella, F., Bernardi, E., Verlato, F., Beckers, E. A. M., Koopman, M. M. W., Barone, M., Camporese, G., Potter van Loon, B. J., Prins, M. H., Prandoni, P., Buller, H. R. (2002). Simplification of the Diagnostic Management of Suspected Deep Vein Thrombosis. Arch Intern Med 162: 907-911 [Abstract] [Full Text]  
• Kelly, J., Rudd, A., Lewis, R. R., Hunt, B. J. (2002). Plasma D-Dimers in the Diagnosis of Venous Thromboembolism. Arch Intern Med 162: 747-756 [Abstract] [Full Text]  
• Kelly, J., Rudd, A., Lewis, R.R., Hunt, B.J. (2001). Screening for subclinical deep-vein thrombosis. QJM 94: 511-519 [Full Text]  
• Donkers-van Rossum, A.B. (2001). Diagnostic strategies for suspected pulmonary embolism. Eur Respir J 18: 589-597 [Abstract] [Full Text]  
• Spritzer, C. E., Arata, M. A., Freed, K. S. (2001). Isolated Pelvic Deep Venous Thrombosis: Relative Frequency as Detected with MR Imaging. Radiology 219: 521-525 [Abstract] [Full Text]  
• (2000). Guidelines on diagnosis and management of acute pulmonary embolism. Eur Heart J 21: 1301-1336  
• Birdwell, B. G., Raskob, G. E., Whitsett, T. L., Durica, S. S., Comp, P. C., George, J. N., Tytle, T. L., Owen, W. L., McKee, P. A. (2000). Predictive Value of Compression Ultrasonography for Deep Vein Thrombosis in Symptomatic Outpatients: Clinical Implications of the Site of Vein Noncompressibility. Arch Intern Med 160: 309-313 [Abstract] [Full Text]  
• Le Blanche, A. F., Siguret, V., Settegrana, C., Bohus, S., Le Masne de Chermont, E., Andreux, J.-P., Gaussem, P. (1999). Ruling Out Acute Deep Vein Thrombosis by ELISA Plasma D-Dimer Assay Versus Ultrasound in Inpatients More Than 70 Years Old. ANGIOLOGY 50: 873-882 [Abstract]  
• Tapson, V. (1999). The Diagnostic Approach to Acute Venous Thromboembolism . Clinical Practice Guideline. Am. J. Respir. Crit. Care Med. 160: 1043-1066 [Full Text]  
• Cornuz, J., Pearson, S. D., Polak, J. F. (1999). Deep Venous Thrombosis: Complete Lower Extremity Venous US Evaluation in Patients without Known Risk Factors—Outcome Study. Radiology 211: 637-641 [Abstract] [Full Text]  
• Fraser, J. D., Anderson, D. R. (1999). Deep Venous Thrombosis: Recent Advances and Optimal Investigation with US. Radiology 211: 9-24 [Full Text]  
• Bloemenkamp, K. W. M., Rosendaal, F. R., Buller, H. R., Helmerhorst, F. M., Colly, L. P., Vandenbroucke, J. P. (1999). Risk of Venous Thrombosis With Use of Current Low-Dose Oral Contraceptives Is Not Explained by Diagnostic Suspicion and Referral Bias. Arch Intern Med 159: 65-70 [Abstract] [Full Text]  
• Maessen-Visch, M. B., Hamulyak, K., Tazelaar, D. J., Crombag, N. H. C. M. N., Neumann, H. A. M. (1999). The Prevalence of Factor V Leiden Mutation in Patients With Leg Ulcers and Venous Insufficiency. Arch Dermatol 135: 41-44 [Abstract] [Full Text]  
• Kahn, S. R. (1998). The Clinical Diagnosis of Deep Venous Thrombosis: Integrating Incidence, Risk Factors, and Symptoms and Signs. Arch Intern Med 158: 2315-2323 [Abstract] [Full Text]  
• Bernardi, E., Prandoni, P., Lensing, A. W A, Agnelli, G., Guazzaloca, G., Scannapieco, G., Piovella, F., Verlato, F., Tomasi, C., Moia, M., Scarano, L., Girolami, A. (1998). D-dimer testing as an adjunct to ultrasonography in patients with clinically suspected deep vein thrombosis: prospective cohort study. BMJ 317: 1037-1040 [Abstract] [Full Text]  
• Leclerc, J. R., Gent, M., Hirsh, J., Geerts, W. H., Ginsberg, J. S., for the Canadian Collaborative Group, (1998). The Incidence of Symptomatic Venous Thromboembolism During and After Prophylaxis With Enoxaparin: A Multi-institutional Cohort Study of Patients Who Underwent Hip or Knee Arthroplasty. Arch Intern Med 158: 873-878 [Abstract] [Full Text]  
• Anand, S. S., Wells, P. S., Hunt, D., Brill-Edwards, P., Cook, D., Ginsberg, J. S. (1998). Does This Patient Have Deep Vein Thrombosis?. JAMA 279: 1094-1099 [Abstract] [Full Text]  
• Davidson, B. L, Deppert, E. J (1998). Ultrasound for the diagnosis of deep vein thrombosis: where to now?. BMJ 316: 2-3 [Full Text]  
• Cogo, A., Lensing, A. W A, Koopman, M. M W, Piovella, F., Siragusa, S., Wells, P. S, Villalta, S., Büller, H. R, Turpie, A. G G, Prandoni, P. (1998). Compression ultrasonography for diagnostic management of patients with clinically suspected deep vein thrombosis: prospective cohort study. BMJ 316: 17-20 [Abstract] [Full Text]  
• Hull, R. D., Pineo, G. F. (1997). Overview of Treatment of Venous Thromboembolism Based on Levels of Evidence. CLIN APPL THROMB HEMOST 3: S68-S71  
• Ginsberg, J. S., Kearon, C., Douketis, J., Turpie, A. G. G., Brill-Edwards, P., Stevens, P., Panju, A., Patel, A., Crowther, M., Andrew, M., Massicotte, M. P., Hirsh, J., Weitz, J. I. (1997). The Use of D-Dimer Testing and Impedance Plethysmographic Examination in Patients With Clinical Indications of Deep Vein Thrombosis. Arch Intern Med 157: 1077-1081 [Abstract]  
• Lensing, A. W. A., Doris, C. I., McGrath, F. P., Cogo, A., Sabine, M. J., Ginsberg, J., Prandoni, P., Turpie, A. G. G., Hirsh, J. (1997). A Comparison of Compression Ultrasound With Color Doppler Ultrasound for the Diagnosis of Symptomless Postoperative Deep Vein Thrombosis. Arch Intern Med 157: 765-768 [Abstract]  
• Ginsberg, J. S. (1996). Management of Venous Thromboembolism. NEJM 335: 1816-1829 [Full Text]  
• Hull, R. D., Feldstein, W., Stein, P. D., Pineo, G. F., Raskob, G. E. (1996). Cost-effective Approaches to the Diagnosis of Pulmonary Embolism-Reply. Arch Intern Med 156: 1760-1762 [Abstract]  
• Hampson, N. B. (1996). Cost-effectiveness of Pulmonary Embolism Diagnosis. Arch Intern Med 156: 1589-1589 [Abstract]  
• Hull, R., Pineo, G., Stein, P. (1996). Cost-effectiveness of Pulmonary Embolism Diagnosis-Reply. Arch Intern Med 156: 1589-1589 [Abstract]  
• Koopman, M. M.W., Prandoni, P., Piovella, F., Ockelford, P. A., Brandjes, D. P.M., van der Meer, J., Gallus, A. S., Simonneau, G., Chesterman, C. H., Prins, M. H., Bossuyt, P. M.M., de Haes, H., van den Belt, A. G.M., Sagnard, L., d'Azemar, P., Buller, H. R., The Tasman Study Group, (1996). Treatment of Venous Thrombosis with Intravenous Unfractionated Heparin Administered in the Hospital as Compared with Subcutaneous Low-Molecular-Weight Heparin Administered at Home. NEJM 334: 682-687 [Abstract] [Full Text]  
• Bona, R., Hickey, A., Greenwald, L., Sullivan, E., Livadiotis, P., Johnson, O., Kulak, A., Wajcs, S., Vose, K. (1996). Low Risk of Subsequent Deep-Venous Thrombosis in Patients with a Negative Venous Duplex Scan. CLIN APPL THROMB HEMOST 2: 30-34 [Abstract]  
• Pearson, S. D., Polak, J. L., Cartwright, S., McCabe-Hassan, S., Lee, T. H., Goldhaber, S. Z. (1995). A Critical Pathway to Evaluate Suspected Deep Vein Thrombosis. Arch Intern Med 155: 1773-1778 [Abstract]  
• Reid, M. C., Lachs, M. S., Feinstein, A. R. (1995). Use of Methodological Standards in Diagnostic Test Research: Getting Better but Still Not Good. JAMA 274: 645-651 [Abstract]  
• Toglia, M. R., Parisi, V. M., Udell, J. L., Sigurdsson, V., Preesman, A. H., van Vloten, W. A., Modest, G. A., Kaufmann, J., Weinmann, E. E., Salzman, E. W. (1995). Deep-Vein Thrombosis. NEJM 332: 1447-1448 [Full Text]  
• Wells, P. S., Brill-Edwards, P., Stevens, P., Panju, A., Patel, A., Douketis, J., Massicotte, M. P., Hirsh, J., Weitz, J. I., Kearon, C., Ginsberg, J. S. (1995). A Novel and Rapid Whole-Blood Assay for D-Dimer in Patients With Clinically Suspected Deep Vein Thrombosis. Circulation 91: 2184-2187 [Abstract] [Full Text]  
• Raskob, G. E., Hull, R. D., Pineo, G. F. (1995). Impedance Plethysmography for Suspected Deep-Vein Thrombosis. Arch Intern Med 155: 773-776 [Abstract]  
• Weinmann, E. E., Salzman, E. W. (1994). Deep-Vein Thrombosis. NEJM 331: 1630-1641 [Full Text]  
• Moser, K. M (1994). Diagnosing pulmonary embolism. BMJ 309: 1525-1526 [Full Text]  
• Moser, K. M., Fedullo, P. F., Heijboer, H., Buller, H. R., ten Cate, J. W. (1994). The Diagnosis of Deep-Vein Thrombosis. NEJM 330: 863-864 [Full Text]  
• (1993). COMPRESSION ULTRASOUND ACCURATELY DETECTS DEEP-VEIN THROMBOSIS. JWatch General 1993: 2-2 [Full Text]  
• Verstraete, M. (1993). The Diagnosis and Treatment of Deep-Vein Thrombosis. NEJM 329: 1418-1420 [Full Text]