Diagnosis Of DVT

Publication Date: February 1, 2012
Last Updated: March 14, 2022

Recommendations

Diagnosis of Suspected First Lower Extremity DVT

Alternatives to Venography for the Evaluation of Suspected First Lower Extremity DVT

In patients with a suspected fi rst lower extremity DVT, we suggest that the choice of diagnostic tests process should be guided by the clinical assessment of pretest probability, rather than by performing the same diagnostic tests in all patients. (2, B)
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In patients with a low pretest probability of fi rst lower extremity DVT, we recommend one of the following initial tests:
  • (i) a moderately sensitive D-dimer
  • (ii) a highly sensitive d-dimer, or
  • (iii) CUS of the proximal veins rather than
  • (i) no diagnostic testing
(1, B)
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(ii) venography, (1, B)
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or (iii) whole-leg US. (2, B)
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We suggest initial use of a moderately sensitive or (2, C)
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or highly sensitive D-dimer rather than proximal compression ultrasonography (CUS). (2, B)
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If the D-dimer is negative, we recommend no further testing over further investigation with
  • (i) proximal CUS
  • (ii) whole-leg US, or
  • (iii) venography.
(1, B)
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If the proximal CUS is negative, we recommend no further testing compared with
  • (i) repeat proximal CUS after 1 week
  • (ii) whole-leg US, or
  • (iii) venography.
(1, B)
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If the D-dimer is positive, we suggest further testing with CUS of the proximal veins rather than
  • (i) whole-leg US or
(2, C)
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  • or (ii) venography.
(1, B)
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If CUS of the proximal veins is positive, we suggest treating for DVT and performing no further test ing over performing confirmatory venography. (2, C)
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In patients with a moderate pretest probability of first lower extremity DVT, we recommend one of the following initial tests:
  • (i) a highly sensitive D-dimer, or
  • (ii) proximal CUS, or
  • (iii) whole-leg US,
(1, B)
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rather than
  • (i) no testing or
  • (ii) venography.
(1, B)
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We suggest initial use of a highly sensitive D-dimer rather than US. (2, C)
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If the highly sensitive D-dimer is negative, we recommend no further testing over further investigation with
  • (i) proximal CUS,
  • (ii) whole-leg US, or
  • (iii) venography.
(1, B)
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If the highly sensitive D-dimer is positive, we recommend proximal CUS or whole-leg US rather than no testing or venography. (1, B)
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If proximal CUS is chosen as the initial test and is negative, we recommend
  • (i) repeat proximal CUS in 1 week or
  • (ii) testing with a moderate or highly sensitive D-dimer assay
over no further testing or (1, C)
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  • venography.
(2, B)
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  • In patients with a negative proximal CUS but a positive D-dimer, we recommend repeat proximal CUS in 1 week over no further testing or
(1, B)
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venography. (2, B)
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In patients with
  • (i) negative serial proximal CUS or
  • (ii) a negative single proximal CUS and negative moderate or highly sensitive D-dimer,
we recommend no further testing rather than further testing with
  • (i) whole-leg US or
  • (ii) venography.
(1, B)
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  • If whole-leg US is negative, we recommend no further testing over
  • (i) repeat US in 1 week,
  • (ii) D-dimer testing, or
  • (iii) venography.
(1, B)
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  • If proximal CUS is positive, we recommend treating for DVT rather than confirmatory venography.
(1, B)
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If isolated distal DVT is detected on whole-leg US, we suggest serial testing to rule out proximal extension over treatment. (2, C)
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In patients with a high pretest probability of fi rst lower extremity DVT, we recommend either
  • (i) proximal CUS or
  • (ii) whole-leg US
  • over no testing or venography.
(1, B)
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If proximal CUS or whole-leg US is positive for DVT, we recommend treatment rather than confirmatory venography. (1, B)
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In patients with a negative proximal CUS

we recommend additional testing with a highly sensitive D-dimer or whole-leg US or repeat proximal CUS in 1 week over no further testing or (1, B)
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venography. (2, B)
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We recommend that patients with a single negative proximal CUS and positive D-dimer undergo whole-leg US or repeat proximal CUS in 1 week over no further testing or (1, B)
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venography. (2, B)
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In patients with negative serial proximal CUS, a negative single proximal CUS and negative highly sensitive D-dimer, or a negative whole-leg US, we recommend no further testing over venography or additional US. (, )

(Grade 1B for negative serial proximal CUS and for negative single proximal CUS and highly sensitive D-dimer; Grade 2B for negative whole-leg US)

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We recommend that in patients with high pretest probability, moderately or highly sensitive D-dimer assays should not be used as stand-alone tests to rule out DVT. (1, B)
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If risk stratification is not performed in patients with suspected first lower extremity DVT, we recommend one of the following initial tests:
  • (i) proximal CUS or
  • (ii) whole-leg US, rather than
  • (i) no testing,
(1, B)
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  • (ii) venography or
(1, B)
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  • D-dimer testing.
(2, B)
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We recommend that patients with a negative proximal CUS undergo testing with a moderate or high sensitivity D-dimer, whole-leg US, or repeat proximal CUS in 1 week over no further testing or (1, B)
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  • venography.
(2, B)
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In patients with a negative proximal CUS, we suggest D-dimer rather than routine serial CUS or (2, B)
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  • whole-leg US.
(2, C)
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We recommend that patients with a single negative proximal CUS and positive D-dimer undergo further testing with repeat proximal CUS in 1 week or whole-leg US rather than no further testing. (1, B)
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We recommend that in patients with
  • (i) negative serial proximal CUS
  • (ii) a negative D-dimer following a negative initial proximal CUS, or
  • (iii) negative whole-leg US
no further testing be performed rather than venography. (1, B)
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If proximal US is positive for DVT, we recommend treatment rather than confirmatory venography. (1, B)
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If isolated distal DVT is detected on whole-leg US, we suggest serial testing to rule out proximal extension over treatment. (2, C)
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In patients with suspected first lower extremity DVT, we recommend against the routine use of CT venography or MRI. (1, C)
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Diagnosis of Suspected Recurrent Lower Extremity DVT

In patients suspected of having recurrent lower extremity DVT, we recommend initial evaluation with proximal CUS or a highly sensitive D-dimer over venography, CT venography or MRI. (1, B)
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If the highly sensitive D-dimer is positive, we recommend proximal CUS over venography, CT venography, or MRI. (1, B)
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In patients with suspected recurrent lower extremity DVT in whom initial proximal CUS is negative (normal or residual diameter increase of <2 mm), we suggest at least one further proximal CUS (day 7 ± 1) or testing with a moderately or highly sensitive D-dimer (followed by repeat CUS [day 7 ± 1] if positive) rather than no further testing or venography. (2, B)
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We recommend that patients with suspected recurrent lower extremity DVT and a negative highly sensitive D-dimer or negative proximal CUS and negative moderately or highly sensitive D-dimer or negative serial proximal CUS undergo no further testing for suspected recurrent DVT rather than venography. (1, B)
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If CUS of the proximal veins is positive, we recommend treating for DVT and performing no further testing over performing confirmatory venography. (, )
(Grade 1B for the finding of a new noncompressible segment in the common femoral or popliteal vein, Grade 2B for a 4-mm increase in venous diameter during compression compared with that in the same venous segment on a previous result)
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In patients with suspected recurrent lower extremity DVT and abnormal but nondiagnostic US results (eg, an increase in residual venous diameter of <4 but ≥2 mm), we recommend further testing with venography, if available, (1, B)
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  • serial proximal CUS or
(2, B)
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  • or testing with a moderately or highly sensitive D-dimer with serial proximal CUS as above if the test is positive,
(2, B)
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as opposed to other testing strategies or treatment.
In patients with suspected recurrent ipsilateral DVT and an abnormal US without a prior result for comparison,
  • we recommend further testing with venography, if available or
(1, B)
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  • a highly sensitive D-dimer
(2, B)
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over serial proximal CUS. (, )
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In patients with suspected recurrent ipsilateral DVT and an abnormal US without prior result for comparison and a negative highly sensitive D-dimer, we suggest no further testing over venography. (2, C)
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In patients with suspected recurrent ipsilateral DVT and an abnormal US without prior result for comparison and a positive highly sensitive D-dimer, we suggest venography if available over empirical treatment of recurrence. (2, C)
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over serial proximal CUS.

Diagnosis of Pregnancy-Related DVT

In pregnant patients suspected of having lower extremity DVT,
  • we recommend initial evaluation with proximal CUS over other initial tests, including a whole-leg US,
(2, C)
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  • moderately sensitive D-dimer,
(2, C)
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  • highly sensitive D-dimer or
(1, B)
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  • venography.
(1, B)
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In pregnant patients with suspected DVT in whom initial proximal CUS is negative,
  • we suggest further testing with eitherserial proximal CUS (day 3 and day 7) or
(1, B)
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  • or a sensitive D-dimer done at the time of presentation
(2, B)
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over no further testing for DVT. (, )
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We recommend that patients with an initial negative proximal CUS and a subsequent negative sensitive D-dimer or negative serial proximal CUS undergo no further testing for DVT. (1, B)
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  • and that patients with positive D-dimer have an additional follow-up proximal CUS (day 3 and day 7) rather than venography or
(1, B)
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  • or whole-leg US.
(2, C)
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In pregnant patients with symptoms suggestive of isolated iliac vein thrombosis (swelling of the entire leg, with or without flank, buttock, or back pain) and no evidence of DVT on standard proximal CUS,
  • we suggest further testing with either Doppler US of the iliac vein,
(2, C)
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  • venography,
(2, C)
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  • or direct MRI,
(2, C)
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rather than standard serial CUS of the proximal deep veins.

Diagnosis of Upper Extremity DVT

In patients suspected of having upper extremity DVT, we suggest initial evaluation with combined-modality US (compression with either Doppler or color Doppler) over other initial tests, including highly sensitive D-dimer or venography. (2, C)
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In patients with suspected upper extremity DVT in whom initial US is negative for thrombosis despite a high clinical suspicion of DVT, we suggest further testing with a moderate or highly sensitive D-dimer, serial US, or venographic-based imaging (traditional, CT scan, or MRI) rather than no further testing. (2, C)
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In patients with suspected upper extremity DVT and an initial negative combined modality US and subsequent negative moderate or highly sensitive D-dimer or CT scan or MRI, we recommend no further testing, rather than confi rmatory venography. (1, C)
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We suggest that patients with an initial negative combinedmodality US and positive D-dimer or those with less than complete evaluation by US undergo venography rather than no further testing, unless there is an alternative explanation for their symptoms, (2, B)
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in which case testing to evaluate for the presence of an alternative diagnosis should be performed. We suggest that patients with a positive D-dimer or those with less than complete evaluation by US but an alternative explanation for their symptoms undergo confirmatory testing and treatment of this alternative explanation rather than venography. (2, C)
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Recommendation Grading

Overview

Title

Diagnosis Of DVT

Authoring Organization

American College of Chest Physicians

Publication Month/Year

February 1, 2012

Last Updated Month/Year

May 15, 2023

Document Type

Guideline

External Publication Status

Published

Country of Publication

US

Document Objectives

Objective testing for DVT is crucial because clinical assessment alone is unreliable and the consequences of misdiagnosis are serious. This guideline focuses on the identification of optimal strategies for the diagnosis of DVT in ambulatory adults.

Target Patient Population

Ambulatory adults with DVT

Inclusion Criteria

Female, Male, Adolescent, Adult, Older adult

Health Care Settings

Ambulatory, Emergency care, Long term care, Outpatient

Intended Users

Nurse, nurse practitioner, physician, physician assistant

Scope

Assessment and screening, Diagnosis, Prevention, Management, Treatment

Diseases/Conditions (MeSH)

D054556 - Venous Thromboembolism, D020246 - Venous Thrombosis, D003933 - Diagnosis, D056824 - Upper Extremity Deep Vein Thrombosis

Keywords

anticoagulation, diagnosis, Antithrombotic Agents, deep vein thrombosis, deep venous thrombosis, Anticoagulation

Supplemental Methodology Resources

Data Supplement