7 December 2004 Annals of Internal Medicine Volume 141 • Number 11
Single Complete Compression Ultrasonography for Suspected Deep Venous Thrombosis:
Ideal in Routine Clinical Practice?
TO THE EDITOR: Stevens and colleagues (1) reported that single complete lower-limb compression
ultrasonography (that is, including the calf veins) is safe for excluding deep venous thrombosis (DVT). It is interesting to
note that previous studies using proximal (that is, not studying the calf veins), serial (2, 3), or single proximal compression
ultrasonography associated with clinical probability and D-dimer tests (4) showed similar low 3-month thromboembolic
risks. Using a single ultrasonographic examination without clinical probability assessment or D-dimer dosage may be very
practical in an outpatient setting. However, even if this kind of strategy has the great advantage of avoiding repeated
compression ultrasonography, it requires that ultrasonography be performed in every patient. This may not be particularly
cost-effective. D-Dimer measurement may rule out DVT without further testing in a substantial proportion of outpatients
(30%), a strategy that is highly cost-effective (5). We are also very concerned by the potential problem of overdiagnosis
and overtreatment of distal DVT, as stated in the excellent editorial by El Kheir and Bu¨ller (6). Previous studies limited to
proximal vein compression ultrasonography showed a very low 3-month thromboembolic risk (2, 3), suggesting that most
cases of distal DVT do not need anticoagulant treatment. In the study by Stevens and colleagues, distal DVT accounted
for 31% of all DVT, and this proportion was even higher, reaching 50% or more, in previous studies (7). This is a crucial
issue because many patients may receive anticoagulation unnecessarily. Therefore, there is an absolute
need for properly designed studies to assess whether anticoagulant treatment is warranted in distal DVT.
Admittedly, complete leg ultrasonography may be useful in everyday clinical practice because it can help diagnose
other conditions, such as calf hematoma, partial muscle rupture, and popliteal cyst. However, its advantage in diagnosing
venous thromboembolism in clinical practice appears to be at least debatable.
Marc Righini, MD
Henri Bounameaux, MD
Geneva University Hospital
1211 Geneva 14, Switzerland
Gre´goire Le Gal, MD
Brest University Hospital
29629 Brest, France
References
1. Stevens SM, Elliott CG, Chan KJ, Egger MJ, Ahmed KM. Withholding anticoagulation after a negative result on duplex ultrasonography
for suspected symptomatic deep venous thrombosis. Ann Intern Med. 2004;140:985-91. [PMID: 15197015]
2. Cogo A, Lensing AW, Koopman MM, Piovella F, Siragusa S, Wells PS, et al. Compression ultrasonography for diagnostic management
of patients with clinically suspected deep vein thrombosis: prospective cohort study. BMJ. 1998;316:17-20. [PMID: 9451260]
3. Kraaijenhagen RA, Piovella F, Bernardi E, Verlato F, Beckers EA, Koopman MM, et al. Simplification of the diagnostic management of
suspected deep vein thrombosis. Arch Intern Med. 2002;162:907-11. [PMID: 11966342]
4. Perrier A, Desmarais S, Miron MJ, de Moerloose P, Lepage R, Slosman D, et al. Non-invasive diagnosis of venous thromboembolism
in outpatients. Lancet. 1999;353: 190-5. [PMID: 9923874]
5. Perone N, Bounameaux H, Perrier A. Comparison of four strategies for diagnosing deep vein thrombosis: a cost-effectiveness analysis.
Am J Med. 2001;110:33-40. [PMID: 11152863]
6. El Kheir D, Bu¨ller H. One-time comprehensive ultrasonography to diagnose deep venous thrombosis: is that the solution? [Editorial]
Ann Intern Med. 2004;140:1052-3. [PMID: 15197023]
7. Schellong SM, Schwarz T, Halbritter K, Beyer J, Siegert G, Oettler W, et al. Complete compression ultrasonography of the leg veins as
a single test for the diagnosis of deep vein thrombosis. Thromb Haemost. 2003;89:228-34. [PMID: 12574800]
IN RESPONSE: We appreciate the insights of Drs. Righini, Bounameaux, and Le Gal into the ramifications of use of
single comprehensive duplex ultrasonography for suspected symptomatic DVT of the legs. We studied single
comprehensive duplex ultrasonography because it is efficient and convenient compared with routine repeated simplified
compression ultrasonography. We recognize that validated strategies use a sensitive D-dimer assay and clinical score to
reduce the number of simplified compression ultrasonography studies used for suspected DVT (1), and we do not believe
that our findings decrease the attractiveness of such strategies. We agree with El Kheir and Bu¨ller’s recommendation (2)
that comprehensive duplex ultrasonography should be studied in conjunction with clinical scoring and sensitive D-dimer
assay. The identification of isolated calf DVT does indeed provide an additional challenge for the treating clinician. While
outcome data on this diagnosis are limited, it is worth noting that clinicians may opt for serial duplex ultrasonography in
lieu of therapeutic anticoagulation in this clinical situation, prescribing anticoagulation only for patients in whom thrombus
propagates to involve the popliteal or more proximal deep veins (3). Additional therapeutic strategies have been offered in
various guidelines (4, 5). Employing a strategy of repeated imaging raises the obvious criticism that serial duplex
ultrasonography would then be performed, undermining the value of our results. However, isolated calf DVT was found in
only a small proportion of the total patients in our study (4.3%), and we noted more than 20 negative initial results on
comprehensive ultrasonography for every instance of isolated calf DVT detected. Even if a repeated testing strategy is
chosen for isolated calf DVT, there would still be a significant reduction in the total number of ultrasonography tests
compared with the strategy of routine serial simplified compression ultrasonography. We very much agree that the natural
history, risks, and optimal management of isolated calf DVT should be the subject of further clinical study.
Scott M. Stevens, MD
C. Gregory Elliott, MD
LDS Hospital and University of Utah
Salt Lake City, UT 84143
References
1. Bates SM, Kearon C, Crowther M, Linkins L, O’Donnell M, Douketis J, et al. A diagnostic strategy involving a quantitative latex D-dimer
assay reliably excludes deep venous thrombosis. Ann Intern Med. 2003;138:787-94. [PMID: 12755550]
2. El Kheir D, Bu¨ller H. One-time comprehensive ultrasonography to diagnose deep venous thrombosis: is that the solution? [Editorial]
Ann Intern Med. 2004;140:1052-3. [PMID: 15197023]
3. Hyers TM, Agnelli G, Hull RD, Morris TA, Samama M, Tapson V, et al. Antithrombotic therapy for venous thromboembolic disease.
Chest. 2001;119:176S-193S. [PMID: 11157648]
4. Kearon C. Long-term management of patients after venous thromboembolism. Circulation. 2004;110:I10-8. [PMID: 15339876]
5. Bu¨ller HR, Agnelli G, Hull RD, Hyers TM, Prins MH, Raskob GE. Antithrombotic therapy for venous thromboembolic disease: the
Seventh ACCP Conference on Antithrombotic and Thrombolytic Therapy. Chest. 2004;126:401S-428S. [PMID: 15383479]