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Cited by 402Venous Thromboembolism Diagnosis and ManagementCerebral Venous Sinus ThrombosisPeripheral Artery Disease Management

Diagnosis and management of acute deep vein thrombosis: a joint consensus document from the European Society of Cardiology working groups of aorta and peripheral vascular diseases and pulmonary circulation and right ventricular function

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Mazzolai, Lucia, Aboyans, Victor, Ageno, Walter, Agnelli, Giancarlo, Alatri, Adriano, Bauersachs, Rupert, Brekelmans, Marjolein P A, Büller, Harry R +9 more·2018·European Heart Journal
DOI 10.1093/eurheartj/ehx003
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Abstract

Venous thromboembolism (VTE) incidence increases sharply with age (Figure1) and appears steady over the last 25 years, despite preventive strategies.1 Women are more often affected at younger ages; this ratio reverses in the elderly.2 Incidence is similar in Blacks but lower in Asians.3 Almost two-thirds of VTE cases are isolated deep vein thromboses (DVTs), and 80% are proximal.4 Venous thromboembolism incidence according to age group. Recent European population studies reported DVT incidence of 70–140 cases/100,000 person-year.5 Deep vein thrombosis are mostly secondary to predisposing factors common with pulmonary embolism (PE) (webtable 1).6 Distal (below knee) DVTs are more frequently related to transient situations while proximal ones to chronic conditions.7 In 25–50% of first DVT episodes, no predisposing factor is identified. In patients with DVT without PE, short-term mortality rates of 2–5% were reported, more frequent in proximal than distal DVT.7 Recurrence risk is high, especially within first 6 months.8 Early- and mid-term complications include thrombosis extension, and PE and DVT recurrence (see Supplementary material online, only section). Long-term complications include post-thrombotic syndrome (PTS), defined as chronic venous symptoms and/or signs secondary to DVT. It represents the most frequent chronic DVT complication, occurring in 30–50% of patients within 2 years after proximal DVT.9 In 5–10% of cases, PTS is severe.9 Previous ipsilateral DVT, proximal location (ilio-femoral > popliteal), and residual veins obstruction are most significant PTS risk factors. Obesity and poor INR control during the first 3-months treatment are additional independent risk factors.10 Villalta score is used for PTS diagnosis and treatment evaluation (Table1).11 Villalta score11 Points are summed into a total score (range 0–33). Post Thrombotic syndrome (PTS) is defined by a total score of ≥5 or the presence of a venous ulcer. PTS is classified as mild if Villalta score is 5–9, moderate if 10–14, and severe if ≥15 or venous ulcer is present. Villalta score11 Points are summed into a total score (range 0–33). Post Thrombotic syndrome (PTS) is defined by a total score of ≥5 or the presence of a venous ulcer. PTS is classified as mild if Villalta score is 5–9, moderate if 10–14, and severe if ≥15 or venous ulcer is present. Clinical signs and symptoms are highly variable and unspecific but remain the cornerstone of diagnostic strategy. Symptoms include pain, swelling, increased skin veins visibility, erythema, and cyanosis accompanied by unexplained fever. Pre-test probability assessment is the first step in the diagnostic algorithm of DVT suspicion (Figure2). Sensitivity and specificity of clinical symptoms are low when considered individually; however, their combination, using prediction rules, allows pre-test clinical probability classification into two- (DVT unlikely or likely) or three-categories (low-, intermediate-, or high-clinical probability) corresponding to increasing disease prevalence.12,13 Wells score has been widely validated and can be applied both to out- and inpatients (Table2). The experts’ panel favours the modified two-level pre-test probability as it is more straightforward.14 The Wells score12,13 The Wells score12,13 Proposed deep vein thrombosis diagnostic and management algorithm. AC, anticoagulation; DOAC, direct oral anticoagulant. Normal d-dimers render DVT unlikely,15 however, d-dimers have low specificity. Quantitative ELISA or ELISA-derived assays (>95% sensitivity) allow ruling out DVT in patients with DVT ‘unlikely’. Negative ELISA d-dimer can exclude DVT without further testing in 30% of patients,16 with 3-month thromboembolic risk <1% without treatment.13 Quantitative latex-derived and whole-blood agglutination assay have lower sensitivity (85–90%).17 In patients with ‘likely’ DVT, d-Dimer testing is not necessary: imaging is required. Therapeutic anticoagulation should be initiated, if not contraindicated, in patients with DVT ‘likely’ until imaging. Venous ultrasound (VUS) is the first line DVT imaging modality (other imaging: see Supplementary material online, only section). It is based on B-mode, combined or not with color-Doppler US, and power imaging techniques. DVT diagnostic criteria are cross-sectional vein incompressibility, direct thrombus imaging with vein enlargement, and abnormal spectral and color-Doppler flow. VUS can be performed by examining popliteal and common femoral veins only [2-point/2-region compression venous ultrasonography (CUS) or limited CUS], or by extended imaging of inferior vena cava, iliac and femoral veins, and calf veins (whole-leg VUS or complete VUS). There are controversies as to whether explore symptomatic leg only, or both.18,19 In clinically suspected DVT, VUS provides overall sensitivity of 94.2% for proximal, and 63.5% for isolated distal DVT, with an overall specificity of 93.8%.20 Combination with color-Doppler US increases sens

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Authors
Mazzolai, L., Aboyans, V., Ageno, W., Agnelli, G., Alatri, A., Bauersachs, R., Brekelmans, M. P. A., Büller, H. R., Elias, A., Farge, D., Konstantinides, S., Palareti, G., Prandoni, P., Righini, M., Torbicki, A., Vlachopoulos, C., & Brodmann, M.
Affiliations
  • Centre Hospitalier Universitaire Vaudois (CH)
  • Inserm (FR)
  • University of Insubria (IT)
  • University of Perugia (IT)
  • University Medical Center of the Johannes Gutenberg University Mainz (DE)
  • Amsterdam UMC Location University of Amsterdam (NL)
  • Department of Vascular Medicine, Academic Medical Center, Meibergdreef 9, AZ, Amsterdam, The Netherlands
  • Cardiology and Vascular Medicine, Toulon Hospital Centre, 54 Rue Henri Sainte-Claire Deville, Toulon, France
  • Sorbonne Paris Cité (FR)
  • Democritus University of Thrace (GR)
  • University of Bologna (IT)
  • University of Padua (IT)
  • University Hospital of Geneva (CH)
  • Department of Pulmonary Circulation and Thromboembolic Diseases, Medical Center for Postgraduate Education, ul Plocka 26, Warszawa, Otwock, Poland
  • Department of Cardiology, Athens Medical School, Profiti elia 24, Athens, Greece
  • University of Graz (AT)
Corresponding author
Mazzolai, Lucia
ORCID
Venue
European Heart Journal
Publisher
Oxford University Press (OUP)
Published
2017-02-17
Volume
39
Issue
47
Pages
4208-4218
ISSN
  • 0195-668X (ISSN-L)
  • 1522-9645
DOI
10.1093/eurheartj/ehx003
OpenAlex
W2590995222
Cited by
402
References
123
Citations by year
2026: 13 · 2025: 29 · 2024: 49 · 2023: 47 · 2022: 76 · 2021: 66 · 2020: 57 · 2019: 37 · 2018: 24 · 2017: 3 · 2015: 1
FWCI
35.05
Type
journal article
Language
en
Open access
Licence
Locations
  • European Heart Journal (publishedVersion)
  • PubMed (publishedVersion)
  • Archive ouverte UNIGE (University of Geneva) (publishedVersion)
  • Data Archiving and Networked Services (DANS) (submittedVersion)
  • HAL (submittedVersion)
  • IrInSubria (University of Insubria) (submittedVersion)
  • IRIS (submittedVersion)
  • Pure Amsterdam UMC (submittedVersion, other-oa)
  • SERVAL (Université de Lausanne) (submittedVersion)
  • Archive ouverte UNIGE (University of Geneva) (submittedVersion, cc-by)
  • Padua Research Archive (University of Padova) (submittedVersion)
Topics
  • Health Sciences › Medicine › Internal Medicine › Venous Thromboembolism Diagnosis and Management
  • Health Sciences › Medicine › Neurology › Cerebral Venous Sinus Thrombosis
  • Health Sciences › Medicine › Surgery › Peripheral Artery Disease Management
Keywords
acute deep vein thrombosis, venous thromboembolism, pulmonary embolism, post-thrombotic syndrome, Villalta score, DVT recurrence, DVT risk factors, DVT diagnosis, anticoagulation, compression therapy, venous ulcers, DVT incidence
MeSH terms
Cardiology, Europe, Humans, Societies, Medical, Thrombolytic Therapy, Ventricular Function, Right, Thrombectomy, Ultrasonography, Doppler, Color, Disease Management, Venous Thrombosis, Consensus

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