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Abstract

  1. Top of page
  2. Abstract
  3. Disclosure of Conflict of Interests
  4. References

See also Tan M, Velthuis SI, Westerbeek RE, van Rooden CJ, van der Meer FJ, Huisman MV. High percentage of non-diagnostic compression ultrasonography results and the diagnosis of ipsilateral recurrent proximal deep vein thrombosis. J Thromb Haemost 2010; 8: 848–50; Hassen S, Barrellier MT, Seinturier C, Bosson JL, Genty C, Long A, Pernod G. High percentage of non-diagnostic compression ultrasonography results and the diagnosis of ipsilateral recurrent proximal deep vein thrombosis: a rebuttal. This issue, pp 414–6.

Hassen et al. [1] propose a compression ultrasonography (CUS) protocol examining the proximal and distal veins in patients with an acute deep vein thrombosis (DVT), thereby improving the diagnostic management of acute ipsilateral recurrent DVT. The authors discuss a very relevant clinical dilemma and we agree with the authors that a standardized optimized CUS protocol is needed. However, the results of this study deserve some comments.

First, it could be questioned whether the distal veins should be included in this evaluation. The distal veins are small and the sensitivity of diagnosing the distal veins by CUS examination is 73% (95% confidence interval, 54–93%) [2]. Although Hassen et al. [1] show a good interobserver agreement we question whether this would be as good if an inexperienced physician performed the same examination. Furthermore, an increase of 4 mm in thrombus diameter is considered as a recurrent DVT event in patients with a previous proximal DVT. However, the incidence of residual thrombosis in the distal veins has never been reported and a 4-mm increase is more substantial in the small distal veins than in the proximal veins.

Also, this assessment should be performed not only in the acute DVT phase, but also at the end of anticoagulant therapy in all patients, thus providing the physician with a more reliable reference examination should a patient return with complaints in the same leg.

Finally, this protocol does not resolve the important diagnostic issue of the absence of previous (standardized) ultrasonography reports. If the previous US examination has not been reported in a standardized manner or if US reports are absent from the previous DVT episode, no proper interpretation of the US examination can be performed. We have earlier shown in a survey of patients that in 34% of the patients with an indefinite diagnosis no previous (standardized) reports were available [3]. In these patients an alternative technique is needed to establish a definite diagnosis. Contrast venography is currently advised; however, this technique is invasive and exposes the patient to radiation. Furthermore, also with this examination previous reports are necessary to fully interpret a filling defect. Therefore an alternative technique is needed. Magnetic resonance direct thrombus imaging (MRDTI) has been shown to be an accurate diagnostic tool for the diagnosis of a first DVT [4,5]. This technique depends on the high T1 signal due to methemoglobin, which is formed in the acute thrombus. A recent study showed that the high signal associated with acute thrombosis completely disappeared after 6 months [5], making this technique potentially valuable in distinguishing a residual thrombosis from an acute thrombosis without the need for previous CUS reports. A study evaluating this MRDTI technique for patients with a suspected ipsilateral recurrent DVT has been nearly completed in our institution.

In conclusion, the diagnostic management of clinically suspected ipsilateral recurrent DVT remains a challenge and the absence of previous (standardized) CUS reports remains a clinical dilemma. New techniques to overcome this clinical issue are urgently needed but await further publication.

Disclosure of Conflict of Interests

  1. Top of page
  2. Abstract
  3. Disclosure of Conflict of Interests
  4. References

The authors state that they have no conflict of interest.

References

  1. Top of page
  2. Abstract
  3. Disclosure of Conflict of Interests
  4. References
  • 1
    Hassen S, Barrellier MT, Seinturier C, Bosson JL, Genty C, Long A, Pernod G. Interobserver agreement on ultrasound diameter measurements of acute proximal and distal deep vein thrombosis: a rebuttal. J Thromb Haemost 2011; 9: 4146.
  • 2
    Kearon C, Julian JA, Newman TE, Ginsberg JS. Noninvasive diagnosis of deep venous thrombosis. Ann Intern Med 1998; 28: 66377.
  • 3
    Tan M, Velthuis SI, Westerbeek RE, van Rooden CJ, van der Meer FJ, Huisman MV. High percentage of non-diagnostic compression ultrasonography results and the diagnosis of ipsilateral recurrent proximal deep vein thrombosis. J Thromb Haemost 2010; 8: 84850.
  • 4
    Fraser DG, Moody AR, Morgan PS, Martel AL, Davidson I. Diagnosis of lower-limb deep venous thrombosis: a prospective blinded study of magnetic resonance direct thrombus imaging. Ann Intern Med 2002; 136: 8998.
  • 5
    Westerbeek RE, van Rooden CJ, Tan M, van Gils AP, Kok S, De Bats MJ, De Roos A, Huisman MV. Magnetic resonance direct thrombus imaging of the evolution of acute deep vein thrombosis of the leg. J Thromb Haemost 2008; 6: 108792.