Michiels J J, Kasbergen H, Oudega R, Van Der Graaf F, De Maeseneer M, Van Der Planken M, Schroyens W
Hemostasis and Thrombosis Research, Department of Hematology, University Hospital Antwerp, Belgium.
Int Angiol. 2002 Mar;21(1):9-19.
Phlebography is the reference gold standard for the diagnosis of deep vein thrombosis (DVT), but due to its invasive nature and associated side effects it has been replaced by compression ultrasonography (CUS). Patients suspected of DVT are subjected to leg vein CUS that actually confirms DVT in only 16 to 28% of outpatients in large prospective management studies. CUS has a high positive predictive value of more than 98% for proximal DVT but usually misses calf vein thrombosis. Its negative predictive value for proximal DVT is about 97-98%, on the basis of which repeated scanning at day 7 after a negative first CUS (serial CUS) in outpatients with a first suspicion of DVT is advocated. Serial ultrasonography is costly and can be simplified and improved by the addition of clinical score and D-dimer testing. The safe exclusion of DVT by a rapid sensitive D-dimer test in combination with clinical score and/or CUS requires a negative predictive value of >99%. The negative predictive value for DVT is determined by the sensitivity of the rapid ELISA D-dimer test and the prevalence of DVT in subgroups of outpatients suspected of the condition. The prevalence of DVT in outpatients with a low, moderate and high clinical score varies widely from 3-10%, 15-30% and >70%, respectively. The combination of a low clinical score (prevalence DVT 3-5%) and a negative rapid ELISA D-dimer alone test will have a very high negative predictive value of >99.9% to exclude DVT without the need of CUS testing. The combination of a negative CUS and a negative rapid ELISA D-dimer test safely excludes DVT in patients with suspected DVT irrespective of the clinical score. The combination of a negative CUS, a low clinical score and a positive ELISA D-dimer but <1000 ng/ml excludes DVT with a negative predictive value of >99% without the need to repeat CUS. Patients with a negative CUS, scan but a positive ELISA D-dimer, and a moderate or high clinical score are still at risk with a probability of DVT of 3-5% and 20-30%, respectively and are thus candidates for repeated ultrasound scanning. The rapid ELISA D-dimer first followed by risk-based no, single or repeated CUS will be the most cost-effective strategy.
静脉造影是诊断深静脉血栓形成（DVT）的参考金标准，但由于其侵入性及相关副作用，已被压迫超声检查（CUS）所取代。疑似DVT的患者需接受腿部静脉CUS检查，而在大型前瞻性管理研究中，实际上只有16%至28%的门诊患者通过该检查确诊为DVT。CUS对近端DVT具有超过98%的高阳性预测值，但通常会漏诊小腿静脉血栓形成。其对近端DVT的阴性预测值约为97% - 98%，基于此，对于首次怀疑DVT的门诊患者，在首次CUS检查结果为阴性后第7天进行重复扫描（连续CUS）是被提倡的。连续超声检查成本高昂，可通过增加临床评分和D - 二聚体检测来简化和改进。通过快速敏感的D - 二聚体检测结合临床评分和/或CUS安全排除DVT需要阴性预测值>99%。DVT的阴性预测值由快速ELISA D - 二聚体检测的敏感性以及疑似该疾病的门诊患者亚组中DVT的患病率决定。临床评分低、中、高的门诊患者中DVT的患病率差异很大，分别为3% - 10%、15% - 30%和>70%。低临床评分（DVT患病率3% - 5%）与快速ELISA D - 二聚体单项检测结果为阴性相结合，将具有>99.9%的极高阴性预测值，无需CUS检测即可排除DVT。阴性CUS结果与阴性快速ELISA D - 二聚体检测相结合，无论临床评分如何，均可安全排除疑似DVT患者的DVT。阴性CUS、低临床评分与ELISA D - 二聚体阳性但<1000 ng/ml相结合，可排除DVT，阴性预测值>99%，无需重复CUS。CUS扫描结果为阴性但ELISA D - 二聚体阳性且临床评分为中度或高度的患者仍有风险，DVT概率分别为3% - 5%和20% - 30%，因此是重复超声扫描的候选对象。先进行快速ELISA D - 二聚体检测，然后根据风险进行不检查、单次或重复CUS检查将是最具成本效益的策略。
