Diagnosis of recurrent deep vein thrombosis

Summary

Deep vein thrombosis is a chronic disease with a continuing risk of recurrence. In a patient with recurrence long term prognosis and treatment are significantly altered both carrying their own risks not only in the acute phase but mainly in the long term perspective. Thus, accurate diagnosis of recurrence is of utmost importance for the fate of the patient. Diagnosis of a first DVT episode is well established and follows an algorithm including clinical prediction rules, D-Dimer testing and compression ultrasound. Due to the previous episode the efficiency of all three elements is impaired in a patient with suspected recurrence. This opens up areas of uncertainty which have to be filled by individual clinical judgement. Guidelines reflect this difficulty by providing mainly weak recommendations based on sparse data. The present review summarizes what is known about the performance of tools for DVT diagnosis, discusses recent guidelines, and finally gives personally weighed recommendations how to deal with this peculiar diagnostic situation. In conclusion, it will turn out that the well accepted diagnostic algorithm for a first DVT may be applied as well if the lower efficiency is regarded. Compression ultrasound largely benefits from a baseline assessment at the end of the previous episode. The order of tests may be discussed according to local and regional attitudes.

Zusammenfassung

Die tiefe Beinvenenthrombose ist eine chronische Erkrankung mit einem fortdauernden Risiko für ein Rezidiv. Tritt ein Rezidiv ein, sind Prognose und Behandlung des Patienten deutlich verändert, wobei beide ihre spezifischen Risiken nicht nur in der Akutphase, sondern besonders im Langzeitverlauf haben. Daher ist die korrekte Diagnose eines Rezidivs von größter Bedeutung. Die Diagnose einer ersten Episode folgt gut fundierten Algorithmen, deren Elemente die klinische Vortestwahrscheinlichkeit, der D-Dimer-Test und der Kompressionsultraschall der Beinvenen darstellen. Die Effizienz aller drei Elemente ist bei einem Patienten mit Verdacht auf Rezidiv durch die vorhergehende Episode verschlechtert. Dies gibt Raum für klinische Unsicherheiten, der nur mit persönlicher Einschätzung auf dem Boden von Erfahrung gefüllt werden kann. Die verfügbaren Leitlinien spiegeln diesen Umstand wider, indem sie überwiegend schwache Empfehlungen auf der Basis nur weniger Daten geben. Die vorliegende Übersicht fasst zusammen, was über die einzelnen diagnostischen Werkzeuge bekannt ist, diskutiert jüngste Leitlinien und gibt schließlich Empfehlungen aufgrund einer persönlichen Gewichtung. Es stellt sich heraus, dass der für eine erste Episode gültige Algorithmus auch bei der Diagnose des Rezidivs verwendet werden kann, wenn man sich der schlechteren Effizienz bewusst ist. Der Ultraschall profitiert wesentlich, wenn ein Vorbefund vom Behandlungsende der vorausgegangenen Episode vorliegt. Mit welchem der verfügbaren Werkzeuge man im Einzelfall beginnt, kann durchaus an lokale oder regionale Gewohnheiten angepasst werden.

Keywords

DVT diagnosis - recurrence - clinical prediction rule - D-dimer - compression ultrasound

Schlüsselwörter

TVT-Diagnose - Rezidiv - klinische Vortestwahrscheinlichkeit - D-Dimer-Test - Kompressionssonographie

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