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REPLY
Single Complete Compression Ultrasonography for Suspected Deep Venous Thrombosis: Ideal in Routine Clinical Practice?
Scott M. Stevens, MD, and
C. Gregory Elliott, MD
7 December 2004 | Volume 141 Issue 11 | Page 889
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 Büller'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.
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Author and Article Information
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From LDS Hospital and University of Utah, Salt Lake City, UT 84143.
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, Büller 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. Büller 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].
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