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Research Letter |

Whole-Arm Ultrasound to Rule Out Suspected Upper-Extremity Deep Venous Thrombosis in Outpatients FREE

Michelangelo Sartori, MD, PhD1; Ludovica Migliaccio, BSc1; Elisabetta Favaretto, MD1; Carlotta Brusi, MD1; Eleonora Conti, MD1; Giuseppina Rodorigo, MD1; Benilde Cosmi, MD, PhD1
[+] Author Affiliations
1Department of Angiology and Blood Coagulation, S. Orsola-Malpighi University Hospital, Bologna, Italy
JAMA Intern Med. 2015;175(7):1226-1227. doi:10.1001/jamainternmed.2015.1683.
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Published online

Upper-extremity deep venous thrombosis (UE-DVT) accounts for approximately 14% of all cases of DVT.1 Because UE-DVT may provoke pulmonary embolism (PE), prompt diagnosis is necessary to select the patients who require anticoagulation. This study aimed to evaluate the failure rate of ultrasonographic screening for UE-DVT.

Study Design

A prospective management study was conducted from January 1, 2011, through December 31, 2013, in the Angiology and Blood Coagulation Unit, University Hospital, Bologna, Italy, a tertiary care teaching hospital, in outpatients referred by general practice physicians to the vascular emergency department for suspected symptomatic DVT or superficial venous thrombosis (SVT) of the upper extremities. Exclusion criteria were age younger than 18 years, pregnancy or puerperium, PE symptoms, life expectancy of less than 3 months, and a need for anticoagulant therapy or anticoagulation lasting more than 48 hours. We enrolled eligible consecutive patients during business days. Patients with DVT or SVT received anticoagulants while patients with either negative or initially inconclusive findings from the ultrasonographic screening were not treated and were followed up for 3 months. The outcome was the cumulative 3-month incidence of objectively confirmed symptomatic PE and/or UE-DVT. All events were adjudicated by one of us (B.C.) who was not involved in patient enrollment or follow-up. Participants who were lost to follow-up were removed a priori from the analysis. This study was approved by the local Ethics Committee of Bologna University Hospital, Italy. Written informed consent was obtained for all patients.

Ultrasonography

Ultrasonography was performed according to the methods of Chin et al2: radial, ulnar, and brachial veins were scanned transversally, whereas axillary, subclavian, and internal jugular veins were scanned both transversally and longitudinally. The diagnostic criteria were the presence of intraluminal thrombus combined with a lack of vein compression and/or with an abnormal flow pattern in the segment of the vein distal to the thrombosis. Superficial venous thrombosis was diagnosed as previously described.3 If technical problems or anatomical barriers hampered visualization, findings from the ultrasonographic screening were considered indeterminate and it was repeated after 5 to 7 days.

The Table shows characteristics of the 483 study participants. The Figure shows the study flowchart. Findings from the ultrasonographic screening at enrollment were normal in 319 patients (66.0%) and inconclusive in 21 (4.3%), who repeated the test after 5 to 7 days. For those who repeated the test, findings from the ultrasonographic screening showed SVT in 1 patient (4.8%) and DVT in 2 patients (9.5%). Of the 337 patients with negative ultrasonographic findings, 5 were lost to follow-up, one 89-year-old man died of infection (the death was not related to PE), and 2 patients (0.60%; 95% CI, 0.16%-2.17%) developed DVT or SVT (1 ipsilateral DVT after 1 month and 1 SVT after peripheral vein infusion). No PE occurred (0.0%; 95% CI, 0.0%-1.0%). Overall, 1 diagnosis of DVT was missed, for a failure rate of 0.30% (95% CI, 0.05%-1.68%).

Table Graphic Jump LocationTable.  Characteristics of the 483 Study Participants
Place holder to copy figure label and caption
Figure.
Study Flowchart

Of the 483 patients who underwent whole-arm ultrasonography for suspected upper-extremity deep venous thrombosis (DVT), 319 patients had a normal result, of whom 5 were lost to follow-up. Twenty-one patients had an inconclusive test, which was repeated after 5 to 7 days, results of which revealed upper-extremity superficial venous thrombosis (SVT) in 1 patient and DVT in 2 patients. A total of 53 and 81 patients had abnormal results from testing for DVT and SVT, respectively, and 9 had abnormal results for both SVT and DVT. During the 3-month follow-up, 2 of the 337 patients with normal results on initial testing (0.60%; 95% CI, 0.16%-2.17%) had abnormal results for DVT or SVT.

Graphic Jump Location

Our study shows that, similar to that of the lower extremities, a completely normal finding on ultrasonography of the upper extremity can safely exclude DVT.4 Venography is the criterion standard for diagnosis of UE-DVT,5 but it has been largely replaced by ultrasonography in clinical practice. No prospective management study for suspected UE-DVT is available in which anticoagulation is withheld only on the basis of ultrasound.6 The proposed diagnostic algorithm for suspected UE-DVT with D-dimer in a recent study3 was designed to limit ultrasonographies, but 373 were performed in 402 patients because 14.3% patients repeated the ultrasonographic screening. Repeated testing involves greater resource use and more discomfort for patients, some of whom are not willing to return for a second test. With our approach, more initial ultrasonographies were performed, but they were repeated in only 4.3% of patients.

Our study was performed in a single center, with enrollment limited to business hours, and 5 patients (1.5%) with normal ultrasonographic findings were lost to follow-up. The electronic medical record was consulted for these 5 patients at the end of the follow-up period and no hospitalizations for PE and/or DVT were found.

Our data suggest that anticoagulation can be safely withheld on the basis of ultrasonographic screening for suspected UE-DVT.

Corresponding Author: Michelangelo Sartori, MD, PhD, Department of Angiology and Blood Coagulation, S. Orsola-Malpighi University Hospital, Via Albertoni, 15, 40138 Bologna, Italy (michelangelo.sartori@aosp.bo.it).

Published Online: May 11, 2015. doi:10.1001/jamainternmed.2015.1683.

Author Contributions: Drs Sartori and Cosmi had full access to all the data in the study and take responsibility for the integrity of the data and the accuracy of the data analysis.

Study concept and design: Sartori, Favaretto, Cosmi.

Acquisition, analysis, or interpretation of data: Sartori, Migliaccio, Favaretto, Brusi, Conti, Rodorigo.

Drafting of the manuscript: Sartori, Favaretto, Cosmi.

Critical revision of the manuscript for important intellectual content: Sartori, Migliaccio, Brusi, Conti, Rodorigo.

Statistical analysis: Sartori.

Administrative, technical, or material support: Migliaccio, Rodorigo.

Study supervision: Sartori, Favaretto, Conti, Cosmi.

Conflict of Interest Disclosures: None reported.

Spencer  FA, Emery  C, Lessard  D, Goldberg  RJ; Worcester Venous Thromboembolism Study.  Upper extremity deep vein thrombosis: a community-based perspective. Am J Med. 2007;120(8):678-684.
PubMed   |  Link to Article
Chin  EE, Zimmerman  PT, Grant  EG.  Sonographic evaluation of upper extremity deep venous thrombosis. J Ultrasound Med. 2005;24(6):829-840.
PubMed
Kleinjan  A, Di Nisio  M, Beyer-Westendorf  J,  et al.  Safety and feasibility of a diagnostic algorithm combining clinical probability, d-dimer testing, and ultrasonography for suspected upper extremity deep venous thrombosis: a prospective management study. Ann Intern Med. 2014;160(7):451-457.
PubMed   |  Link to Article
Bernardi  E, Camporese  G, Büller  HR,  et al; Erasmus Study Group.  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):1653-1659.
PubMed   |  Link to Article
Bates  SM, Jaeschke  R, Stevens  SM,  et al; American College of Chest Physicians.  Diagnosis of DVT: antithrombotic therapy and prevention of thrombosis, 9th ed: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines. Chest. 2012;141(2)(suppl):e351S-e418S.
PubMed
Mustafa  BO, Rathbun  SW, Whitsett  TL, Raskob  GE.  Sensitivity and specificity of ultrasonography in the diagnosis of upper extremity deep vein thrombosis: a systematic review. Arch Intern Med. 2002;162(4):401-404.
PubMed   |  Link to Article

Figures

Place holder to copy figure label and caption
Figure.
Study Flowchart

Of the 483 patients who underwent whole-arm ultrasonography for suspected upper-extremity deep venous thrombosis (DVT), 319 patients had a normal result, of whom 5 were lost to follow-up. Twenty-one patients had an inconclusive test, which was repeated after 5 to 7 days, results of which revealed upper-extremity superficial venous thrombosis (SVT) in 1 patient and DVT in 2 patients. A total of 53 and 81 patients had abnormal results from testing for DVT and SVT, respectively, and 9 had abnormal results for both SVT and DVT. During the 3-month follow-up, 2 of the 337 patients with normal results on initial testing (0.60%; 95% CI, 0.16%-2.17%) had abnormal results for DVT or SVT.

Graphic Jump Location

Tables

Table Graphic Jump LocationTable.  Characteristics of the 483 Study Participants

References

Spencer  FA, Emery  C, Lessard  D, Goldberg  RJ; Worcester Venous Thromboembolism Study.  Upper extremity deep vein thrombosis: a community-based perspective. Am J Med. 2007;120(8):678-684.
PubMed   |  Link to Article
Chin  EE, Zimmerman  PT, Grant  EG.  Sonographic evaluation of upper extremity deep venous thrombosis. J Ultrasound Med. 2005;24(6):829-840.
PubMed
Kleinjan  A, Di Nisio  M, Beyer-Westendorf  J,  et al.  Safety and feasibility of a diagnostic algorithm combining clinical probability, d-dimer testing, and ultrasonography for suspected upper extremity deep venous thrombosis: a prospective management study. Ann Intern Med. 2014;160(7):451-457.
PubMed   |  Link to Article
Bernardi  E, Camporese  G, Büller  HR,  et al; Erasmus Study Group.  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):1653-1659.
PubMed   |  Link to Article
Bates  SM, Jaeschke  R, Stevens  SM,  et al; American College of Chest Physicians.  Diagnosis of DVT: antithrombotic therapy and prevention of thrombosis, 9th ed: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines. Chest. 2012;141(2)(suppl):e351S-e418S.
PubMed
Mustafa  BO, Rathbun  SW, Whitsett  TL, Raskob  GE.  Sensitivity and specificity of ultrasonography in the diagnosis of upper extremity deep vein thrombosis: a systematic review. Arch Intern Med. 2002;162(4):401-404.
PubMed   |  Link to Article

Correspondence

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