Skip to main content
SpringerLink
Log in

Controversies in the Diagnosis and Management of Distal Deep Vein Thrombosis

  • Chapter
  • First Online:
Current Management of Venous Diseases

  • 1969 Accesses

Abstract

Distal deep vein thrombosis (DVT), also known as calf DVT, is a frequent medical condition and represents around 50% of all lower limb DVTs in ultrasound series. Whereas the optimal management of acute proximal DVT and pulmonary embolism (PE) has been extensively studied and well standardized, the diagnostic and therapeutic management of distal DVT remains one of the most controversial subjects in the field of venous thromboembolism. Robust data arising from randomized studies remain scarce. Nevertheless, recent data suggest that the use of therapeutic anticoagulation may not be necessary in patients with distal DVT at low risk of extension.

This is a preview of subscription content, log in via an institution to check access.

Access this chapter

Log in via an institution

Institutional subscriptions

References

  1. Righini M. Is it worth diagnosing and treating distal deep vein thrombosis? No. J Thromb Haemost. 2007;5(Suppl 1):55–9.

    Article  PubMed  Google Scholar 

  2. Righini M, Paris S, Le Gal G, Laroche JP, Perrier A, Bounameaux H. Clinical relevance of distal deep vein thrombosis. Review of literature data. Thromb Haemost. 2006;95(1):56–64.

    CAS  PubMed  Google Scholar 

  3. Galanaud JP, Sevestre-Pietri MA, Bosson JL, Laroche JP, Righini M, Brisot D, et al. Comparative study on risk factors and early outcome of symptomatic distal versus proximal deep vein thrombosis: results from the OPTIMEV study. Thromb Haemost. 2009;102(3):493–500.

    CAS  PubMed  Google Scholar 

  4. Kearon C, Akl EA, Comerota AJ, Prandoni P, Bounameaux H, Goldhaber SZ, et al. Antithrombotic therapy for VTE disease: antithrombotic therapy and prevention of thrombosis, 9th ed: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines. Chest. 2012;141(2 Suppl):e419S–94S.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  5. Palareti G. How I treat isolated distal deep vein thrombosis (IDDVT). Blood. 2014;123(12):1802–9.

    Article  CAS  PubMed  Google Scholar 

  6. Schellong SM. Distal DVT: worth diagnosing? Yes. J Thromb Haemost. 2007;5(Suppl 1):51–4.

    Article  PubMed  Google Scholar 

  7. Almosni J, Meusy A, Frances P, Pontal D, Quere I, Galanaud JP. Practice variation in the management of distal deep vein thrombosis in primary vs. secondary cares: a clinical practice survey. Thromb Res. 2015;136(3):526–30.

    Article  CAS  PubMed  Google Scholar 

  8. Masuda EM, Kistner RL, Musikasinthorn C, Liquido F, Geling O, He Q. The controversy of managing calf vein thrombosis. J Vasc Surg. 2012;55(2):550–61.

    Article  PubMed  Google Scholar 

  9. Johnson SA, Stevens SM, Woller SC, Lake E, Donadini M, Cheng J, et al. Risk of deep vein thrombosis following a single negative whole-leg compression ultrasound: a systematic review and meta-analysis. JAMA. 2010;303(5):438–45.

    Article  CAS  PubMed  Google Scholar 

  10. Wells PS, Hirsh J, Anderson DR, Lensing AW, Foster G, Kearon C, et al. A simple clinical model for the diagnosis of deep-vein thrombosis combined with impedance plethysmography: potential for an improvement in the diagnostic process. J Intern Med. 1998;243(1):15–23.

    Article  CAS  PubMed  Google Scholar 

  11. Bernardi E, Camporese G, Buller HR, Siragusa S, Imberti D, Berchio A, et al. Serial 2-point ultrasonography plus D-dimer vs whole-leg color-coded Doppler ultrasonography for diagnosing suspected symptomatic deep vein thrombosis: a randomized controlled trial. JAMA. 2008;300(14):1653–9.

    Article  CAS  PubMed  Google Scholar 

  12. Gibson NS, Schellong SM, Kheir DY, Beyer-Westendorf J, Gallus AS, McRae S, et al. Safety and sensitivity of two ultrasound strategies in patients with clinically suspected deep venous thrombosis: a prospective management study. J Thromb Haemost. 2009;7(12):2035–41.

    Article  CAS  PubMed  Google Scholar 

  13. Galanaud JP, Sevestre MA, Genty C, Kahn SR, Pernod G, Rolland C, et al. Incidence and predictors of venous thromboembolism recurrence after a first isolated distal deep vein thrombosis. J Thromb Haemost. 2014;12(4):436–43.

    Article  PubMed  Google Scholar 

  14. Righini MGJ, Guenneguez H, Brisot D, Diard A, Faisse P, Barrelier MT, et al. Anticoagulant therapy for symptomatic distal deep vein thrombosis: the cactus randomized placebo controlled trial. J Thromb Haemost. 2015;13(S2):50.

    Google Scholar 

  15. Anand SS, Wells PS, Hunt D, Brill-Edwards P, Cook D, Ginsberg JS. Does this patient have deep vein thrombosis? JAMA. 1998;279(14):1094–9.

    Article  CAS  PubMed  Google Scholar 

  16. Wells PS, Hirsh J, Anderson DR, Lensing AW, Foster G, Kearon C, et al. Accuracy of clinical assessment of deep-vein thrombosis. Lancet. 1995;345(8961):1326–30.

    Article  CAS  PubMed  Google Scholar 

  17. Cogo A, Lensing AW, Prandoni P, Hirsh J. Distribution of thrombosis in patients with symptomatic deep vein thrombosis. Implications for simplifying the diagnostic process with compression ultrasound. Arch Intern Med. 1993;153(24):2777–80.

    Article  CAS  PubMed  Google Scholar 

  18. Bressollette L, Nonent M, Oger E, Garcia JF, Larroche P, Guias B, et al. Diagnostic accuracy of compression ultrasonography for the detection of asymptomatic deep venous thrombosis in medical patients—the TADEUS project. Thromb Haemost. 2001;86(2):529–33.

    CAS  PubMed  Google Scholar 

  19. Oger E. Incidence of venous thromboembolism: a community-based study in Western France. EPI-GETBP Study Group. Groupe d’Etude de la Thrombose de Bretagne Occidentale. Thromb Haemost. 2000;83(5):657–60.

    CAS  PubMed  Google Scholar 

  20. Monreal M, Ruiz J, Olazabal A, Arias A, Roca J. Deep venous thrombosis and the risk of pulmonary embolism. A systematic study. Chest. 1992;102(3):677–81.

    CAS  PubMed  Google Scholar 

  21. Garry J, Duke A, Labropoulos N. Systematic review of the complications following isolated calf deep vein thrombosis. Br J Surg. 2016;103(7):789–96.

    Article  CAS  PubMed  Google Scholar 

  22. Birdwell BG, Raskob GE, Whitsett TL, Durica SS, Comp PC, George JN, et al. The clinical validity of normal compression ultrasonography in outpatients suspected of having deep venous thrombosis. Ann Intern Med. 1998;128(1):1–7.

    Article  CAS  PubMed  Google Scholar 

  23. Bernardi E, Prandoni P, Lensing AW, Agnelli G, Guazzaloca G, Scannapieco G, et al. D-dimer testing as an adjunct to ultrasonography in patients with clinically suspected deep vein thrombosis: prospective cohort study. The Multicentre Italian D-dimer Ultrasound Study Investigators Group. BMJ. 1998;317(7165):1037–40.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  24. Wells PS, Anderson DR, Bormanis J, Guy F, Mitchell M, Gray L, et al. Value of assessment of pretest probability of deep-vein thrombosis in clinical management. Lancet. 1997;350(9094):1795–8.

    Article  CAS  PubMed  Google Scholar 

  25. 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(9148):190–5.

    Article  CAS  PubMed  Google Scholar 

  26. 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(8):907–11.

    Article  PubMed  Google Scholar 

  27. Galanaud JP, Quenet S, Rivron-Guillot K, Quere I, Sanchez Munoz-Torrero JF, Tolosa C, et al. Comparison of the clinical history of symptomatic isolated distal deep-vein thrombosis vs. proximal deep vein thrombosis in 11 086 patients. J Thromb Haemost. 2009;7(12):2028–34.

    Article  CAS  PubMed  Google Scholar 

  28. Sartori M, Migliaccio L, Favaretto E, Palareti G, Cosmi B. Two years outcome of isolated distal deep vein thrombosis. Thromb Res. 2014;134(1):36–40.

    Article  CAS  PubMed  Google Scholar 

  29. Raghavendra BN, Horii SC, Hilton S, Subramanyam BR, Rosen RJ, Lam S. Deep venous thrombosis: detection by probe compression of veins. J Ultrasound Med. 1986;5(2):89–95.

    Article  CAS  PubMed  Google Scholar 

  30. Tapson VF, Carroll BA, Davidson BL, Elliott CG, Fedullo PF, Hales CA, et al. The diagnostic approach to acute venous thromboembolism. Clinical practice guideline. American Thoracic Society. Am J Respir Crit Care Med. 1999;160(3):1043–66.

    Article  CAS  PubMed  Google Scholar 

  31. Guanella R, Righini M. Serial limited versus single complete compression ultrasonography for the diagnosis of lower extremity deep vein thrombosis. Semin Respir Crit Care Med. 2012;33(2):144–50.

    Article  PubMed  Google Scholar 

  32. Cronan JJ, Dorfman GS. Advances in ultrasound imaging of venous thrombosis. Semin Nucl Med. 1991;21(4):297–312.

    Article  CAS  PubMed  Google Scholar 

  33. Kearon C, Julian JA, Newman TE, Ginsberg JS. Noninvasive diagnosis of deep venous thrombosis. McMaster diagnostic imaging practice guidelines initiative. Ann Intern Med. 1998;128(8):663–77.

    Article  CAS  PubMed  Google Scholar 

  34. Schellong SM. Complete compression ultrasound for the diagnosis of venous thromboembolism. Curr Opin Pulm Med. 2004;10(5):350–5.

    Article  PubMed  Google Scholar 

  35. Lensing AW, Prandoni P, Brandjes D, Huisman PM, Vigo M, Tomasella G, et al. Detection of deep-vein thrombosis by real-time B-mode ultrasonography. N Engl J Med. 1989;320(6):342–5.

    Article  CAS  PubMed  Google Scholar 

  36. 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(7124):17–20.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  37. Elias A, Mallard L, Elias M, Alquier C, Guidolin F, Gauthier B, et al. A single complete ultrasound investigation of the venous network for the diagnostic management of patients with a clinically suspected first episode of deep venous thrombosis of the lower limbs. Thromb Haemost. 2003;89(2):221–7.

    CAS  PubMed  Google Scholar 

  38. 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(2):228–34.

    CAS  PubMed  Google Scholar 

  39. 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(12):985–91.

    Article  PubMed  Google Scholar 

  40. Subramaniam RM, Heath R, Chou T, Cox K, Davis G, Swarbrick M. Deep venous thrombosis: withholding anticoagulation therapy after negative complete lower limb US findings. Radiology. 2005;237(1):348–52.

    Article  PubMed  Google Scholar 

  41. Sevestre MA, Labarere J, Casez P, Bressollette L, Taiar M, Pernod G, et al. Accuracy of complete compression ultrasound in ruling out suspected deep venous thrombosis in the ambulatory setting. A prospective cohort study. Thromb Haemost. 2009;102(1):166–72.

    CAS  PubMed  Google Scholar 

  42. Sevestre MA, Labarere J, Casez P, Bressollette L, Haddouche M, Pernod G, et al. Outcomes for inpatients with normal findings on whole-leg ultrasonography: a prospective study. Am J Med. 2010;123(2):158–65.

    Article  PubMed  Google Scholar 

  43. Kearon C, Ginsberg JS, Hirsh J. The role of venous ultrasonography in the diagnosis of suspected deep venous thrombosis and pulmonary embolism. Ann Intern Med. 1998;129(12):1044–9.

    Article  CAS  PubMed  Google Scholar 

  44. Brandjes DP, Heijboer H, Buller HR, de Rijk M, Jagt H, ten Cate JW. Acenocoumarol and heparin compared with acenocoumarol alone in the initial treatment of proximal-vein thrombosis. N Engl J Med. 1992;327(21):1485–9.

    Article  CAS  PubMed  Google Scholar 

  45. Goodacre S, Sampson F, Thomas S, van Beek E, Sutton A. Systematic review and meta-analysis of the diagnostic accuracy of ultrasonography for deep vein thrombosis. BMC Med Imaging. 2005;5:6.

    Article  PubMed  PubMed Central  Google Scholar 

  46. Rose SC, Zwiebel WJ, Nelson BD, Priest DL, Knighton RA, Brown JW, et al. Symptomatic lower extremity deep venous thrombosis: accuracy, limitations, and role of color duplex flow imaging in diagnosis. Radiology. 1990;175(3):639–44.

    Article  CAS  PubMed  Google Scholar 

  47. Simons GR, Skibo LK, Polak JF, Creager MA, Klapec-Fay JM, Goldhaber SZ. Utility of leg ultrasonography in suspected symptomatic isolated calf deep venous thrombosis. Am J Med. 1995;99(1):43–7.

    Article  CAS  PubMed  Google Scholar 

  48. Atri M, Herba MJ, Reinhold C, Leclerc J, Ye S, Illescas FF, et al. Accuracy of sonography in the evaluation of calf deep vein thrombosis in both postoperative surveillance and symptomatic patients. AJR Am J Roentgenol. 1996;166(6):1361–7.

    Article  CAS  PubMed  Google Scholar 

  49. Gottlieb RH, Widjaja J, Tian L, Rubens DJ, Voci SL. Calf sonography for detecting deep venous thrombosis in symptomatic patients: experience and review of the literature. J Clin Ultrasound. 1999;27(8):415–20.

    Article  CAS  PubMed  Google Scholar 

  50. Hull R, Hirsh J, Sackett DL, Taylor DW, Carter C, Turpie AG, et al. Clinical validity of a negative venogram in patients with clinically suspected venous thrombosis. Circulation. 1981;64(3):622–5.

    Article  CAS  PubMed  Google Scholar 

  51. Gottlieb RH, Voci SL, Syed L, Shyu C, Fultz PJ, Rubens DJ, et al. Randomized prospective study comparing routine versus selective use of sonography of the complete calf in patients with suspected deep venous thrombosis. AJR Am J Roentgenol. 2003;180(1):241–5.

    Article  PubMed  Google Scholar 

  52. Ageno W, Camporese G, Riva N, Iotti M, Bucherini E, Righini M, et al. Analysis of an algorithm incorporating limited and whole-leg assessment of the deep venous system in symptomatic outpatients with suspected deep-vein thrombosis (PALLADIO): a prospective, multicentre, cohort study. Lancet Haematol. 2015;2(11):e474–80.

    Article  PubMed  Google Scholar 

  53. Leroyer C, Escoffre M, Le Moigne E, Grimaux M, Cagnioncle O, Oger E, et al. Diagnostic value of a new sensitive membrane based technique for instantaneous D-dimer evaluation in patients with clinically suspected deep venous thrombosis. Thromb Haemost. 1997;77(4):637–40.

    CAS  PubMed  Google Scholar 

  54. Wells PS, Brill-Edwards P, Stevens P, Panju A, Patel A, Douketis J, et al. A novel and rapid whole-blood assay for D-dimer in patients with clinically suspected deep vein thrombosis. Circulation. 1995;91(8):2184–7.

    Article  CAS  PubMed  Google Scholar 

  55. Jennersjo CM, Fagerberg IH, Karlander SG, Lindahl TL. Normal D-dimer concentration is a common finding in symptomatic outpatients with distal deep vein thrombosis. Blood Coagul Fibrinolysis. 2005;16(7):517–23.

    Article  PubMed  Google Scholar 

  56. Lindahl TL, Lundahl TH, Fransson SG. Evaluation of an automated micro-latex D-dimer assay (Tina-quant on Hitachi 911 analyser) in symptomatic outpatients with suspected DVT. Thromb Haemost. 1999;82(6):1772–3.

    CAS  PubMed  Google Scholar 

  57. Lindahl TL, Lundahl TH, Ranby M, Fransson SG. Clinical evaluation of a diagnostic strategy for deep venous thrombosis with exclusion by low plasma levels of fibrin degradation product D-dimer. Scand J Clin Lab Invest. 1998;58(4):307–16.

    Article  CAS  PubMed  Google Scholar 

  58. Goodacre S, Sampson FC, Sutton AJ, Mason S, Morris F. Variation in the diagnostic performance of D-dimer for suspected deep vein thrombosis. QJM. 2005;98(7):513–27.

    Article  CAS  PubMed  Google Scholar 

  59. Sartori M, Cosmi B, Legnani C, Favaretto E, Valdre L, Guazzaloca G, et al. The Wells rule and D-dimer for the diagnosis of isolated distal deep vein thrombosis. J Thromb Haemost. 2012;10(11):2264–9.

    Article  CAS  PubMed  Google Scholar 

  60. Carrier M, Righini M, Djurabi RK, Huisman MV, Perrier A, Wells PS, et al. VIDAS D-dimer in combination with clinical pre-test probability to rule out pulmonary embolism. A systematic review of management outcome studies. Thromb Haemost. 2009;101(5):886–92.

    CAS  PubMed  Google Scholar 

  61. Sijens PE, van Ingen HE, van Beek EJ, Berghout A, Oudkerk M. Rapid ELISA assay for plasma D-dimer in the diagnosis of segmental and subsegmental pulmonary embolism. A comparison with pulmonary angiography. Thromb Haemost. 2000;84(2):156–9.

    CAS  PubMed  Google Scholar 

  62. Horner D, Hogg K, Body R, Nash MJ, Baglin T, Mackway-Jones K. The anticoagulation of calf thrombosis (ACT) project: results from the randomized controlled external pilot trial. Chest. 2014;146(6):1468–77.

    Article  PubMed  Google Scholar 

  63. Lagerstedt CI, Olsson CG, Fagher BO, Oqvist BW, Albrechtsson U. Need for long-term anticoagulant treatment in symptomatic calf-vein thrombosis. Lancet. 1985;2(8454):515–8.

    Article  CAS  PubMed  Google Scholar 

  64. Pinede L, Ninet J, Duhaut P, Chabaud S, Demolombe-Rague S, Durieu I, et al. Comparison of 3 and 6 months of oral anticoagulant therapy after a first episode of proximal deep vein thrombosis or pulmonary embolism and comparison of 6 and 12 weeks of therapy after isolated calf deep vein thrombosis. Circulation. 2001;103(20):2453–60.

    Article  CAS  PubMed  Google Scholar 

  65. Schwarz T, Buschmann L, Beyer J, Halbritter K, Rastan A, Schellong S. Therapy of isolated calf muscle vein thrombosis: a randomized, controlled study. J Vasc Surg. 2010;52(5):1246–50.

    Article  PubMed  Google Scholar 

  66. Kearon C, Kahn SR, Agnelli G, Goldhaber S, Raskob GE, Comerota AJ, et al. Antithrombotic therapy for venous thromboembolic disease: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines (8th edition). Chest. 2008;133(6 Suppl):454S–545S.

    Article  CAS  PubMed  Google Scholar 

  67. Palareti G, Cosmi B, Lessiani G, Rodorigo G, Guazzaloca G, Brusi C, et al. Evolution of untreated calf deep-vein thrombosis in high risk symptomatic outpatients: the blind, prospective CALTHRO study. Thromb Haemost. 2010;104(5):1063–70.

    Article  CAS  PubMed  Google Scholar 

  68. Parisi R, Visona A, Camporese G, Verlato F, Lessiani G, Antignani PL, et al. Isolated distal deep vein thrombosis: efficacy and safety of a protocol of treatment. Treatment of Isolated Calf Thrombosis (TICT) Study. Int Angiol. 2009;28(1):68–72.

    CAS  PubMed  Google Scholar 

  69. Kearon C, Akl EA, Ornelas J, Blaivas A, Jimenez D, Bounameaux H, et al. Antithrombotic therapy for VTE disease: CHEST guideline and expert panel report. Chest. 2016;149(2):315–52.

    Article  PubMed  Google Scholar 

  70. Utter GH, Dhillon TS, Salcedo ES, Shouldice DJ, Reynolds CL, Humphries MD, et al. Therapeutic anticoagulation for isolated calf deep vein thrombosis. JAMA Surg. 2016;151(9):e161770.

    Article  PubMed  Google Scholar 

  71. Decousus H, Prandoni P, Mismetti P, Bauersachs RM, Boda Z, Brenner B, et al. Fondaparinux for the treatment of superficial-vein thrombosis in the legs. N Engl J Med. 2010;363(13):1222–32.

    Article  CAS  PubMed  Google Scholar 

Download references

Author information

Authors and Affiliations

  1. Division of Angiology and Hemostasis, Department of Medical Specialties, Geneva University Hospitals and Faculty of Medicine, 4, rue Gabrielle-Perret-Gentil, 1205, Geneva, Switzerland

    Helia Robert-Ebadi MD & Marc Righini MD

Authors
  1. Helia Robert-Ebadi MD
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. Marc Righini MD
    View author publications

    You can also search for this author in PubMed Google Scholar

Corresponding author

Correspondence to Helia Robert-Ebadi MD .

Editor information

Editors and Affiliations

  1. Section of Vascular Surgery, Department of Surgery, Yale School of Medicine, New Haven, Connecticut, USA

    Cassius Iyad Ochoa Chaar

Rights and permissions

Reprints and permissions

Copyright information

© 2018 Springer International Publishing AG

About this chapter

Check for updates. Verify currency and authenticity via CrossMark

Cite this chapter

Robert-Ebadi, H., Righini, M. (2018). Controversies in the Diagnosis and Management of Distal Deep Vein Thrombosis. In: Chaar, C. (eds) Current Management of Venous Diseases . Springer, Cham. https://doi.org/10.1007/978-3-319-65226-9_24

Download citation

  • DOI: https://doi.org/10.1007/978-3-319-65226-9_24

  • Published:

  • Publisher Name: Springer, Cham

  • Print ISBN: 978-3-319-65225-2

  • Online ISBN: 978-3-319-65226-9

  • eBook Packages: MedicineMedicine (R0)

Publish with us

Policies and ethics

Search

Navigation