Diagnostic Value of Compression Ultrasonography and Fibrinogen-related Parameters for the Detection of Postoperative Deep Vein Thrombosis following Elective Hip Replacement: a Pilot Study

Summary

To determine their ability to diagnose postoperative deep vein thrombosis (DVT) D-dimer – by three methods – fibrinogen degradation products (FgDP) and fibrinogen levels were measured in 68 consecutive patients before elective surgery for hip replacement and on postoperative day 1, 3, 6, and 10. All patients received prophylaxis and underwent compression real-time B-mode ultrasonography (C-US) on postoperative day 5 and 9, and bilateral ascending venography on day 10. Twenty-two out of 68 patients developed asymptomatic postoperative DVT, which was limited to the calf veins in 14 and involved the proximal veins in 8 patients. C-US was negative in all patients on day 5. On day 9, C-US sensitivity and specificity for proximal DVT were 63% (95% confidence interval: 26%-90%) and 98% (89%-100%) respectively. Postoperative changes in the laboratory parameters evaluated were not different in patients with or without DVT until day 10. On day 10, mean D-dimer, FgDP and fibrinogen levels were significantly higher in patients with DVT than in those without DVT (p values between 0.006 and 0.032), but only D-dimer was higher with DVT involving two or more venous segments than with thrombosis involving one venous segment only (p <0.05). Stepwise logistic regression analysis identified D-dimer and fibrinogen on day 10 as predictors of postoperative DVT. In a receiver operator curve and after weighing for the coefficients generated by logistic regression analysis, the combination of a latex photometric immunoassay and of PT-derived fibrinogen yielded - at a cut-off value of 7.0 - a sensitivity of 100% (73%-100%) and a specificity of 58% (39%-75%) for DVT, with a negative predictive value of 100% (78%-100%), a positive predictive value of 52% (32%-71%) and an overall accuracy of 71% (55%-83%). These results suggest that two simple, fast and reproducible tests may permit the identification of patients at low risk of having postoperative DVT and that a combination of sensitive laboratory assays and of the highly specific C-US may select patients requiring anticoagulant treatment. Efficacy and cost-effectiveness of this approach should be evaluated in large clinical management studies.

• References

• 1 Harris WH, Athansoulis C, Waltman AC, Salzman EW. Cuff impedance plethysmography and¹²⁵I-fibrinogen leg scanning versus roentgenographic phlebography for diagnosis of thrombophlebitis following hip surgery. J Bone Joint Surg 1976; 58: 939-944
• 2 Hull RD, van Aken WG, Hirsh J, Gallus AS, Hoicka G, Turpie AG G, Walker I, Gent M. Impedance plethysmography using the occlusive cuff technique in the diagnosis of venous thrombosis. Circulation 1976; 53: 696-700
• 3 Lensing AW A, Levi MM, Büller H, Prandoni P, Vigo M, Agnelli G, Lupa-telli L, Huisman MV, ten Cate JW. Diagnosis of deep-vein thrombosis using an objective doppler method. Ann Intern Med 1990; 113: 9-13
• 4 Lensing AW A, Prandoni P, Brandjes D, Huisman PM, Vigo M, Toma-sella G, Krekt J, ten Cate JW, Huisman MV, Büller H. Detection of deep-vein thrombosis by real-time b-mode ultrasonography. N Eng J Med 1989; 320: 342-345
• 5 Cogo A, Lensing AW A, Prandoni P, Büller HA, Girolami A, ten Cate JW. Comparison of real-time B-mode ultrasonography and doppler ultrasound with contrast venography in the diagnosis of venous thrombosis in symptomatic outpatients. Thromb Haemost 1993; 70: 404-407
• 6 Cruickshank MK, Levine MN, Hirsh J, Turpie AG G, Powers P, Jay R, Gent M. An evaluation of impedance plethysmography and^l25I-fibrinogen leg scanning in patients following hip surgery. Thromb Haemost 1989; 62: 830-834
• 7 Jongbloets LM M, Lensing AW A, Koopman MW, Büller HR, ten Cate JW. Comparison of real-time B-mode ultrasonography and doppler ultrasound for the detection of symptomless postoperative deep vein thrombosis. Lancet 1994; 343: 1142-1144
• 8 Agnelli G, Volpato R, Radicchia S, Veschi F, Di Filippo P, Lupattelli L, Nenci GG. Detection of asymptomatic deep vein thrombosis by real-time B-mode ultrasonography in hip surgery patients. Thromb Haemost 1992; 68: 257-260
• 9 Büller HR, Lensing AW A, Hirsh J, ten Cate JW. Deep vein thrombosis: new non-invasive diagnostic tests. Thromb Haemost 1991; 66: 133-137
• 10 Kroneman R, Nieuwenhuizen W, Knot EA R. Monoclonal antibody-based plasma assays for fibrino(gen) and derivatives, and their clinical relevance. Blood Coag Fibrinol 1990; 1: 91-111
• 11 Bounameaux H, de Moerloose P, Perrier A, Reber G. Plasma measurement of D-Dimer as diagnostic aid in suspected venous thromboembolism: an overview. Thromb Haemost 1994; 71: 1-6
• 12 Bounamenux H, Kliahiri E, Huber O, Schneider PA, Didier D, de Moer-loose P, Keher G. Value of liquid crystal contact thermography and plasma level of D-dimer for screening of deep venous thrombosis following general abdominal surgery. Thromh Haemost 1992; 67: 603-606
• 13 Rowhotham BJ, Whitaker AN, Harrison J, Murtaugh P, Reasbeek I, Bowie EJ W. Measurement of crosslinked fibrin derivatives in patients undergoing abdominal surgery: use in the diagnosis of postoperative venous thrombosis. Blood Cong Eibrinol 1992; 3: 25-31
• 14 Dunn ID, Hui AC W, Triffit PD, Crozier AE C, Gregg PJ, Sinclair ME, Armstrong AL, Mitchell VE. Plasma D-Dimer as a marker of postoperative deep venous thrombosis. Thromb Haemost 1994; 72: 663-665
• 15 Kario K, Matsuo M, Kabayashi H, Matsuo M, Yamamoto K, Sakurai G, Baba M. Rapid quantitative evaluation of plasma D-Dimer levels in thrombotic states using an automated latex photometric immunoassay. Thromb Res 1992; 66: 179-189
• 16 Rabinov K, Paulin S. Roentgen diagnosis of venous thrombosis in the leg. ArchSurg 1972; 104: 134-144
• 17 Saekett D, Haynes R, Tugwell P. In: Clinical Hpidemiology a Basic Science for Clinical Medicine. Little, Brown and Company; Boston, IL: 1985. 1. ed pp 59-138
• 18 Metz CE. Basic principles of ROC analysis. Semin Nuel Med 1978; 8: 283-298
• 19 Planes A, Silsiguen M, Vochelle N. Elective hip surgery. In: Prevention of Venous Thromboembolism. Bergquist D, Camerota AJ, Nicolaides AN, Scurr JH. eds. Mcd-Orion; London: 1994. pp 271-280
• 20 Eriksson Bl, Kalebo P, Anthmyr B, Wadenvik H, Tengborn L, Risberg B. Prevention of deep vein thrombosis and pulmonary embolism after total hip replacement. J Bone Joint Surg 1991; 73 A 484
• 21 Heijboer H, Ginsberg JS, Büller HR, Lensing AW A, Colly LP, ten Cate JW. The use of D-Dimcr test in combination with non-invasive testing versus serial non-invasive testing alone for the diagnosis of deep-vein thrombosis. Thromb Haemost 1992; 65: 510-513
• 22 Bettman MA, Robbins A, Braun SD, Wetzner S, Dunnick NR, Finkelstein J. Contrast venography of the leg: diagnostic efficacy, tolerance and complication rates with ionic and non-ionic contrast media. Radiology 1987; 165: 113-116
• 23 Lensing AW A, Prandoni P, Duller HR, Cogo A, Casara D, ten Cate JW. Lower extremity venography with iohexol: results and complications. Radiology 1990; 77: 503-505
• 24 Bongard O, Wicky J, Peter R, Simonovska S, Vogel JJ, de Moerloose P, Reber G, Bounameaux H. D-Dimer plasma measurement in patients undergoing major hip surgery: use in the prediction and diagnosis of postoperative proximal vein thrombosis. Thromb Res 1994; 74: 487-493
• 25 Jørgensen LN, Lind B, Haueh O, Leffers A, Albrecht-Beste E, Konradsen LA G. Thrombin-antithrombin III-complex and fibrin degradation products in plasma: surgery and postoperative deep vein thrombosis. Thromb Res 1990; 59: 69-76
• 26 Milani E, Safa O, Mazzola G, Garlando A, Pattarini E, D’Angelo A. Turbidimetric quantitative determination of plasma D-Dimer: comparison with ELISA and qualitative methods. First International Winter Meeting on Coagulation – Basic, laboratory and clinical aspects of venous thromboembolism. 09.03.1994. Cortina D’Ampezzo, Italy; Volume of Abstracts p 49
• 27 Borris LC, Christiansen HM, Lassen MR, Olsen AD, Schott P. Comparison of real-time B-mode ultrasonography and bilateral ascending phlebography for detection of postoperative deep vein thrombosis following elective hip surgery. Thomb Haemost 1989; 61: 363-365
• 28 Woolson ST, McCrory DW, Walter JE, Maloney WJ, Watt JM, Cahill PD. B-Mode ultrasound scanning in the detection of proximal venous thrombosis after total hip replacement. J Bone Joint Surg 1990; 72 A 983-987