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Semin intervent Radiol 2001; 18(2): 099-112
DOI: 10.1055/s-2001-15171
Copyright © 2001 by Thieme Medical Publishers, Inc., 333 Seventh Avenue, New York, NY 10001, USA. Tel.: +1(212) 584-4662

Diagnosis of Venous Thromboembolic Disease

Matthew S. Johnson
  • Department of Radiology, Indiana University School of Medicine, Indiana University Hospital, Indianapolis, Indiana
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Publikationsdatum:
31. Dezember 2001 (online)

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ABSTRACT

Venous thromboembolic disease (VTD), comprising deep venous thrombosis (DVT) and pulmonary embolism (PE), is a major cause of morbidity and mortality throughout the world. Anticoagulation has been demonstrated to be beneficial in the treatment of VTD, but it is not without its risks. Thus, definitive diagnosis of DVT and PE should be obtained prior to initiation of anticoagulation. Because clinical examination is insufficient for the diagnosis of VTD, it must be supplemented by serologic or imaging studies, or both. D-Dimer assays, when negative, may help to exclude VTD. Doppler ultrasound examination may reliably diagnose femoropopliteal thrombus. The diagnosis of PE should be based on detailed clinical examination followed by appropriate studies, including chest radiography, electrocardiography, ventilation/perfusion (V/Q) lung scintigraphy, and, if those studies are inconclusive, pulmonary arteriography. The use of spiral computed tomography in the diagnosis of PE is undergoing evaluation and may prove useful in the diagnostic algorithm; however, its current sensitivity (approximately 85% for segmental and larger emboli) weighs against its widespread use as the final diagnostic modality. The current evaluation of VTD is discussed, and a diagnostic algorithm is proposed here.

KEYWORD

Deep vein thrombosis - pulmonary embolism - anticoagulation

REFERENCES

  • 1 Goldhaber S Z, Visani L, De Rosa M. Acute pulmonary embolism: clinical outcomes in the International Cooperative Pulmonary Embolism Registry (ICOPER).  Lancet . 1999;  353 1386-1389
    CrossrefPubMedSuche in Google Scholar
  • 2 Dalen J E, Alpert J S. Natural history of pulmonary embolism.  Prog Cardiovasc Dis . 1975;  17 257-270
    PubMedSuche in Google Scholar
  • 3 National Institutes of Health Consensus Conference. Prevention of venous thrombosis and pulmonary embolism.  JAMA . 1986;  256 744-749
    CrossrefPubMedSuche in Google Scholar
  • 4 Moser K M, Fedullo P F, Littejohn J K, Crawford R. Frequent asymptomatic pulmonary embolism in patients with deep venous thrombosis.  JAMA . 1994;  271 223-225
    CrossrefPubMedSuche in Google Scholar
  • 5 Anderson Jr A F, Wheeler H B, Goldberg R J. A population-based perspective of the hospital incidence and case-fatality rates of deep vein thrombosis and pulmonary embolism.  Arch Intern Med . 1991;  151 933-938
    CrossrefPubMedSuche in Google Scholar
  • 6 Silverstein M D, Heit J A, Mohr D N. Trends in the incidence of deep vein thrombosis and pulmonary embolism: a 25-year population-based study.  Arch Intern Med . 1998;  158 585-593
    CrossrefPubMedSuche in Google Scholar
  • 7 Douketis J D, Kearon C, Bates S, Duku E K, Ginsburg J S. Risk of fatal pulmonary embolism in patients with treated venous thromboembolism.  JAMA . 1998;  279 458-462
    CrossrefPubMedSuche in Google Scholar
  • 8 van Beek J E, Kuijer P M, Buller H R. The clinical course of patients with suspected pulmonary embolism.  Arch Intern Med . 1997;  157 2593-2598
    CrossrefPubMedSuche in Google Scholar
  • 9 Anand S S, Wells P S, Hunt D. Does this patient have deep vein thrombosis?.  JAMA . 1998;  279 1094-1096
    CrossrefPubMedSuche in Google Scholar
  • 10 Bounameaux H, de Moerloose P, Perrier A, Reger G. Plasma measurement of D-dimer as diagnostic aid in suspected venous thromboembolism: an overview.  Thromb Haemost . 1994;  71 1-6
    Thieme ConnectPubMedSuche in Google Scholar
  • 11 Janssen M CH, Wollersheim H, Verbruggen B, Novakonva I RO. Rapid D-dimer assays to exclude deep venous thrombosis and pulmonary embolism: current status and new developments.  Semin Thromb Hemost . 1998;  24 393-400
    PubMedSuche in Google Scholar
  • 12 Raimondi P, Bongard O, de Moerloose P. D-dimer plasma concentration in various clinical conditions: implication for the use of this test in the diagnostic approach of venous thromboembolism.  Thromb Res . 1993;  69 125-130
    CrossrefPubMedSuche in Google Scholar
  • 13 ACCP Consensus Committee on Pulmonary Embolism. Opinions regarding the diagnosis and management of venous thromboembolic disease.  Chest . 1998;  113 499-504
    PubMedSuche in Google Scholar
  • 14 Tapson V F, Carroll B A, Davidson B L. The diagnostic approach to acute venous thromboembolism. Clinical practice guideline. American Thoracic Society.  Am J Respir Crit Care Med . 1999;  160 1043-1066
    PubMedSuche in Google Scholar
  • 15 Kearon C, Ginsberg J S, Hirsh J. The role of venous ultrasonography in the diagnosis of suspected deep venous thrombosis and pulmonary embolism.  Ann Intern Med . 1998;  129 1044-1049
    Suche in Google Scholar
  • 16 Gottlieb R H, Widjaja J, Mehra S, Robinette W B. Clinically important pulmonary emboli: does calf vein US alter outcomes?.  Radiology . 1999;  211 25-29
    PubMedSuche in Google Scholar
  • 17 Wells P S, Anderson D R, Bormanis J. Value of assessment of pretest probability of deep-vein thrombosis in clinical management.  Lancet . 1997;  350 1795-1798
    Suche in Google Scholar
  • 18 Wells P S, Hirsh J, Anderson D R. Accuracy of clinical assessment of deep-vein thrombosis.  Lancet . 1995;  345 1326-1330
    CrossrefPubMedSuche in Google Scholar
  • 19 Prandoni P, Cogo A, Bernardi E. A simple ultrasound approach for detection of recurrent proximal-vein thrombosis.  Circulation . 1993;  88 1730-1735
    CrossrefPubMedSuche in Google Scholar
  • 20 Kearon C, Julian J A, Newman T E, Ginsberg J S. Noninvasive diagnosis of deep venous thrombosis. McMaster Diagnostic Imaging Practice Guidelines Initiative.  Ann Intern Med . 1998;  128 663-677
    Suche in Google Scholar
  • 21 Turkstra F, Kuijer P M, van Beek J E. Diagnostic utility of ultrasonography of leg veins in patients suspected of having pulmonary embolism.  Ann Intern Med . 1997;  126 775-781
    CrossrefPubMedSuche in Google Scholar
  • 22 Perrier A, Bounameaux H, Morabia A. Diagnosis of pulmonary embolism by a decision analysis-based strategy including clinical probability, D-dimer levels, and ultrasonography: a management study.  Arch Intern Med . 1996;  156 531-536
    CrossrefPubMedSuche in Google Scholar
  • 23 Meyerovitz M F, Mannting F, Polak J F, Goldhaber S Z. Frequency of pulmonary embolism in patients with low-probability lung scan and negative lower extremity venous ultrasound.  Chest . 1999;  115 980-982
    CrossrefPubMedSuche in Google Scholar
  • 24 Stein P D, Henry J W. Clinical characteristics of patients with acute pulmonary embolism stratified according to their presenting syndromes.  Chest . 1997;  112 974-979
    CrossrefPubMedSuche in Google Scholar
  • 25 Grifoni S, Olivotto I, Cecchini P. Utility of an integrated clinical, echocardiographic, and venous ultrasonographic approach for triage of patients with suspected pulmonary embolism.  Am J Cardiol . 1998;  82 1230-1235
    CrossrefPubMedSuche in Google Scholar
  • 26 Perrier A, Tamm C, Unger P F, Lerch R, Sztajzel J. Diagnostic accuracy of Doppler-echocardiography in unselected patients with suspected pulmonary embolism.  Int J Cardiol . 1998;  65 101-109
    CrossrefPubMedSuche in Google Scholar
  • 27 The PIOPED Investigators. Value of the ventilation/ perfusion scan in acute pulmonary embolism. Results of the Prospective Investigation of Pulmonary Embolism Diagnosis (PIOPED).  JAMA . 1990;  263 2753-2759
    Suche in Google Scholar
  • 28 Lesser B A, Leeper Jr U K, Stein P D. The diagnosis of acute pulmonary embolus in patients with chronic obstructive pulmonary disease.  Chest . 1992;  102 17-22
    CrossrefPubMedSuche in Google Scholar
  • 29 Ferretti G R, Bosson J L, Buffaz P D. Acute pulmonary embolism: role of helical CT in 164 patients with intermediate probability at ventilation-perfusion scintigraphy and normal results at duplex US of the legs.  Radiology . 1997;  205 453-458
    PubMedSuche in Google Scholar
  • 30 Mayo J R, Remy-Jardin M, Muller N L. Pulmonary embolism: prospective comparison of spiral CT with ventilation-perfusion scintigraphy.  Radiology . 1997;  205 447-452
    PubMedSuche in Google Scholar
  • 31 Cross J JL, Kemp P M, Walsh C G, Flower C D, Dixon A K. A randomized trial of spiral CT and ventilation perfusion scintigraphy for the diagnosis of pulmonary embolism.  Clin Radiol . 1998;  53 177-182
    PubMedSuche in Google Scholar
  • 32 van Rossum B A, Pattynama P M, Mallens W M, Hermans J, Heijerman H G. Can helical CT replace scintigraphy in the diagnostic process in suspected pulmonary embolism?.  <~>A retrolective-prolective cohort study focusing on total diagnostic yield. Eur Radiol . 1998;  8 90-96
    CrossrefPubMedSuche in Google Scholar
  • 33 Garg K, Welsh C H, Feyerabend A J. Pulmonary embolism: diagnosis with spiral CT and ventilation-perfusion scanning-correlation with pulmonary angiographic results or clinical outcome.  Radiology . 1998;  208 201-208
    PubMedSuche in Google Scholar
  • 34 Drucker E A, Rivitz S M, Shepard J A. Acute pulmonary embolism: assessment of helical CT for diagnosis.  Radiology . 1998;  209 235-241
    PubMedSuche in Google Scholar
  • 35 Kim K I, Muller N L, Mayo J R. Clinically suspected pulmonary embolism: utility of spiral CT.  Radiology . 1999;  210 693-697
    CrossrefPubMedSuche in Google Scholar
  • 36 Brink J A, Woodard P K, Horesh L. Depiction of pulmonary emboli with spiral CT: optimization of display window settings in a porcine model.  Radiology . 1997;  204 703-708
    PubMedSuche in Google Scholar
  • 37 Schlueter F J, Zuckerman D A, Horesh L. Digital subtraction versus film-screen angiography for detecting acute pulmonary emboli: evaluation in a porcine model.  J Vasc Interv Radiol . 1997;  8 1015-1024
    PubMedSuche in Google Scholar
  • 38 Amundsen T, Kvaerness J, Jones R A. Pulmonary embolism: detection with MR perfusion imaging of lung-a feasibility study.  Radiology . 1997;  203 181-185
    PubMedSuche in Google Scholar
  • 39 Moody A R, Liddicoat A, Krarup K. Magnetic resonance pulmonary angiography and direct imaging of embolus for the detection of pulmonary emboli.  Invest Radiol . 1997;  32 431-440
    CrossrefPubMedSuche in Google Scholar
  • 40 Meaney J F, Weg J G, Chenevert T L. Diagnosis of pulmonary embolism with magnetic resonance angiography.  N Engl J Med . 1997;  336 1422-1427
    CrossrefPubMedSuche in Google Scholar
  • 41 Gupta A, Frazer C K, Ferguson J M. Acute pulmonary embolism: diagnosis with MR angiography.  Radiology . 1999;  210 353-359
    PubMedSuche in Google Scholar
  • 42 Hurst D R, Kazerooni E A, Stafford-Johnson D. Diagnosis of pulmonary embolism: comparison of CT angiography and MR angiography in canines.  J Vasc Interv Radiol . 1999;  10 309-318
    PubMedSuche in Google Scholar
  • 43 Cooper T J, Hayward M WJ, Hartog M. Survey on the use of pulmonary scintigraphy and angiography for suspected pulmonary thromboembolism in the UK.  Clin Radiol . 1991;  43 243-245
    CrossrefPubMedSuche in Google Scholar
  • 44 Sostman H D, Ravin C R, Sullivan D C. Use of pulmonary angiography for suspected pulmonary embolism: influence of scintigraphic diagnosis.  AJR Am J Roentgenol . 1982;  139 673-677
    PubMedSuche in Google Scholar
  • 45 Henschke C I, Mateescu I, Yankelevitz D F. Changing practice patterns in the workup of pulmonary embolism.  Chest . 1995;  107 940-945
    PubMedSuche in Google Scholar
  • 46 Goodman L R, Lipchik R J. Diagnosis of acute pulmonary embolism: time for a new approach.  Radiology . 1996;  199 25-27
    PubMedSuche in Google Scholar
  • 47 Rajendran J G, Jacobson A F. Review of 6-month mortality following low-probability lung scans.  Arch Intern Med . 1999;  159 349-352
    CrossrefPubMedSuche in Google Scholar
  • 48 Lomis N N, Yoon H C, Moran A G, Miller F J. Clinical outcomes of patients after a negative spiral CT pulmonary arteriogram in the evaluation of acute pulmonary embolism.  J Vasc Interv Radiol . 1999;  10 707-712
    PubMedSuche in Google Scholar
  • 49 Morpurgo M, Marzegalli M. Death in pulmonary embolism. In: Morpurgo M, ed. Pulmonary embolism New York: Dekker 1994: 107-114
    Suche in Google Scholar
  • 50 Stein P D, Henry J W. Prevalence of acute pulmonary embolism in central and subsegmental pulmonary arteries and relation to probability interpretation of ventilation/perfusion lung scans.  Chest . 1997;  111 1246-1248
    PubMedSuche in Google Scholar
  • 51 Oser R F, Zuckerman D A, Gutierrez F R, Brink J A. Anatomic distribution of pulmonary emboli at pulmonary angiography: implications for cross-sectional imaging.  Radiology . 1996;  199 31-35
    PubMedSuche in Google Scholar
  • 52 Quinn M F, Lundell C J, Klotz T A. Reliability of selective pulmonary arteriography in the diagnosis of pulmonary embolism.  Am J Roentgenol . 1987;  149 469-471
    PubMedSuche in Google Scholar
  • 53 Stein P D, Athanasoulis C, Alavi A. Complications and validity of pulmonary angiography in acute pulmonary embolism.  Circulation . 1992;  85 462-468
    PubMedSuche in Google Scholar
  • 54 Diffin D C, Leyendecker J R, Johnson S P, Zucker R J, Grebe P J. Effect of anatomic distribution of pulmonary emboli on interobserver agreement in the interpretation of pulmonary angiography.  Am J Roentgenol . 1998;  171 1085-1089
    CrossrefPubMedSuche in Google Scholar
  • 55 van Beek J R E, Bakker A J, Reekers J A. Pulmonary embolism: interobserver agreement in the interpretation of conventional angiographic and DSA images in patients with non-diagnostic lung scan results.  Radiology . 1996;  198 721-724
    PubMedSuche in Google Scholar
  • 56 Johnson M S, Stine S B, Shah H. Possible pulmonary embolus: evaluation with digital subtraction versus cut-film angiography-prospective study in 80 patients.  Radiology . 1998;  207 131-138
    PubMedSuche in Google Scholar
  • 57 Hagspiel K D, Polak J F, Grassi C J. Pulmonary embolism: comparison of cut-film and digital pulmonary angiography.  Radiology . 1998;  207 139-145
    PubMedSuche in Google Scholar
  • 58 Mills S R, Jackson D C, Older R A, Heaston D K, Moore A V. The incidence, etiologies, and avoidance of complications of pulmonary angiography in a large series.  Radiology . 1980;  136 295-299
    PubMedSuche in Google Scholar
  • 59 Perlmutt L M, Braun S D, Newman G E, Oke E J, Dunnick N R. Pulmonary arteriography in the high-risk patient.  Radiology . 1987;  162 187-189
    PubMedSuche in Google Scholar
  • 60 Zuckerman D A, Sterling K M, Oser R F. Safety of pulmonary angiography in the 1990s.  J Vasc Interv Radiol . 1996;  7 199-205
    PubMedSuche in Google Scholar
  • 61 Hudson E R, Smith T P, McDermott V G. Pulmonary angiography performed with iopamidol: complications in 1434 patients.  Radiology . 1996;  198 61-65
    PubMedSuche in Google Scholar
  • 62 Smith T P, Lee V S, Hudson E R. Prospective evaluation of pulmonary artery pressures during pulmonary angiography performed with low-osmolar nonionic contrast media.  J Vasc Interv Radiol . 1996;  7 207-212
    PubMedSuche in Google Scholar
  • 63 Smith D C, Lois J F, Gomes A S, Maloney M D, Yahiku P Y. Pulmonary arteriography: comparison of cough stimulation effects of diatrizoate and ioxaglate.  Radiology . 1987;  162 617-618
    PubMedSuche in Google Scholar
  • 64 Henschke C I, Yankelevitz D F, Sicherman N. Evaluation of algorithms for the diagnosis of pulmonary embolism.  Semin Ultrasound CT MR . 1997;  18 376-382
    CrossrefPubMedSuche in Google Scholar
  • 65 Contraindications to pulmonary angiography. Interventional radiologist at work.  J Vasc Interv Radiol . 1996;  7 713-715
    PubMedSuche in Google Scholar
  • 66 Davey N C, Smith T P, Hanson M W. Ventilation-perfusion lung scintigraphy as a guide for pulmonary angiography in the localization of pulmonary emboli.  Radiology . 1999;  213 51-57
    PubMedSuche in Google Scholar
  • 67 Miniati M, Prediletto R, Formichi B. Accuracy of clinical assessment in the diagnosis of pulmonary embolism.  Am J Respir Crit Care Med . 1999;  159 864-871
    CrossrefPubMedSuche in Google Scholar
  • 68 Wells P S, Ginsberg J S, Anderson D R. Use of a clinical model for safe management of patients with suspected pulmonary embolism.  Ann Intern Med . 1998;  129 997-1005
    Suche in Google Scholar
  • 69 Sheiman R G, McArdle C R. Clinically suspected pulmonary embolism: use of bilateral lower extremity US as the initial examination-a prospective study.  Radiology . 1999;  212 75-78
    PubMedSuche in Google Scholar
  • 70 Auger W R, Fedullo P F, Moser K M, Buchbinder M, Peterson K L. Chronic major vessel thromboembolic pulmonary artery obstruction: appearance at angiography.  Radiology . 1992;  182 393-398
    PubMedSuche in Google Scholar
  • 71 Bergin C J, Sirlin C B, Hauschildt J P. Chronic thromboembolism: diagnosis with helical CT and MR imaging with angiographic and surgical correlation.  Radiology . 1997;  204 695-702
    PubMedSuche in Google Scholar