Diagnosis of deep vein thrombosis, and prevention of deep vein thrombosis recurrence and the post-thrombotic syndrome in the primary care medicine setting anno 2014

Abstract

The requirement for a safe diagnostic strategy of deep vein thrombosis (DVT) should be based on an overall objective post incidence of venous thromboembolism (VTE) of less than 1% during 3 mo follow-up. Compression ultrasonography (CUS) of the leg veins has a negative predictive value (NPV) of 97%-98% indicating the need of repeated CUS testing within one week. A negative ELISA VIDAS safely excludes DVT and VTE with a NPV between 99% and 100% at a low clinical score of zero. The combination of low clinical score and a less sensitive D-dimer test (Simplify) is not sensitive enough to exclude DVT and VTE in routine daily practice. From prospective clinical research studies it may be concluded that complete recanalization within 3 mo and no reflux is associated with a low or no risk of PTS obviating the need of MECS 6 mo after DVT. Partial and complete recanalization after 3 to more than 6 mo is usually complicated by reflux due to valve destruction and symptomatic PTS. Reflux seems to be a main determinant for PTS and DVT recurrence, the latter as a main contributing factor in worsening PTS. This hypothesis is supported by the relation between the persistent residual vein thrombosis (RVT = partial recanalization) and the risk of VTE recurrence in prospective studies. Absence of RVT at 3 mo post-DVT and no reflux is predicted to be associated with no recurrence of DVT (1.2%) during follow-up obviating the need of wearing medical elastic stockings and anticoagulation at 6 mo post-DVT. The presence or absence of RVT but with reflux at 3 to 6 mo post-DVT is associated with both symptomatic PTS and an increased risk of VTE recurrence in about one third in the post-DVT period after regular discontinuation of anticoagulant treatment. To test this hypothesis we designed a prospective DVT and postthrombotic syndrome (PTS) Bridging the Gap Study by addressing at least four unanswered questions in the treatment of DVT and PTS. Which DVT patient has a clear indication for long-term compression stocking therapy to prevent PTS after the initial anticoagulant treatment in the acute phase of DVT? Is 3 mo the appropriate point in time to determine candidates at risk to develop DVT recurrence and PTS? Which high risk symptomatic PTS patients need extended anticoagulant treatment?

Keywords: Deep Venous thrombosis; Ultrasonography; Post-thrombotic syndrome; ELISA VIDAS D-dimer; Medical elastic stockings; Anticoagulation

Core tip: A novel clinical concept for the assessment of acute deep vein thrombosis (DVT) and the post-thrombotic syndrome (PTS) by DUS in routine clinical practice at 1, 3 to 6 mo and at one year post-DVT will separates post-DVT patients in 4 groups: Group 1: rapid complete recanalization within 3 mo, no reflux at 6 mo post-DVT, and no PTS for which anticoagulation and medical elastic compression stockings (MECS) can be discontinued at 6 mo post-DVT. Group 2, no PTS with reflux of the deep venous system and no PTS at 6 months post-DVT when when wearing MECS for which anticoagulation should be continued until re-evaluation at 1 year post DVT. Group 3 and 4 PTS with reflux and incomplete recanalization or obstruction at 6-12 mo post-DVT are candidates for long-term anticoagulation and MECS for at least 2 years or even longer to prevent DVT recurrence to prevent progression of PTS. A large scale prospective study is warranted to fine-tune and prove this concept.