Appropriate use criteria
ACR Appropriateness Criteria® Suspected Lower Extremity Deep Vein Thrombosis

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Abstract

Suspected lower extremity deep venous thrombosis is a common clinical scenario which providers seek a reliable test to guide management. The importance of confidently making this diagnosis lies in the 50% to 60% risk of pulmonary embolism with untreated deep vein thrombosis and subsequent mortality of 25% to 30%, balanced with the risks of anticoagulation. The ACR Appropriateness Criteria Expert Panel on Vascular Imaging reviews the current literature regarding lower extremity deep venous thrombosis and compared various imaging modalities including ultrasound, MR venography, CT venography, and catheter venography.

The American College of Radiology Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision include an extensive analysis of current medical literature from peer reviewed journals and the application of well-established methodologies (RAND/UCLA Appropriateness Method and Grading of Recommendations Assessment, Development, and Evaluation or GRADE) to rate the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances where evidence is lacking or equivocal, expert opinion may supplement the available evidence to recommend imaging or treatment.

Section snippets

Introduction/Background

Lower extremity deep venous thrombosis (DVT) has an estimated annual incidence of approximately 5 per 10,000 in the general population, with the incidence increasing with advancing age [1]. DVT typically starts distally below the knee but can extend proximally above the knee and potentially result in life-threatening pulmonary embolism. Pulmonary embolism can occur in 50% to 60% of patients with untreated DVT, with an associated mortality rate of 25% to 30% 2, 3. See the ACR Appropriateness

Catheter Venography Pelvis and Lower Extremity

Contrast catheter venography is the historic and de facto gold standard for diagnosing DVT 3, 6, 10, 11. With this technique, proximal compression tourniquets are applied, and a series of overlapping radiographs are obtained following an iodine-containing contrast medium injection into a dorsal vein in the foot. DVT is present if a distinct filling defect is present in a deep vein, typically in the calf or thigh, but it can often extend to or involve more proximal veins, such as those in the

Summary of Recommendations

  • Variant 1: US duplex doppler lower extremity is the recommended initial imaging examination for patients with suspected lower extremity DVT.

Summary of Evidence

Of the 28 references cited in the ACR Appropriateness Criteria® Suspected Lower Extremity Deep Vein Thrombosis document, 2 are categorized as therapeutic references including 1 well-designed study. Additionally, 24 references are categorized as diagnostic references including 5 good-quality studies, and 5 quality studies that may have design limitations. There are 15 references that may not be useful as primary evidence. There are 2 references that are meta-analysis studies.

The 28 references

Relative Radiation Level Information

Potential adverse health effects associated with radiation exposure are an important factor to consider when selecting the appropriate imaging procedure. Because there is a wide range of radiation exposures associated with different diagnostic procedures, a relative radiation level (RRL) indication has been included for each imaging examination. The RRLs are based on effective dose, which is a radiation dose quantity that is used to estimate population total radiation risk associated with an

Supporting Documents

For additional information on the Appropriateness Criteria methodology and other supporting documents go to www.acr.org/ac.

References (28)

  • American College of Radiology. ACR Appropriateness Criteria®: Suspected Pulmonary Embolism. Available at:...
  • R.H. White

    The epidemiology of venous thromboembolism

    Circulation

    (2003)
  • S. Goodacre et al.

    Measurement of the clinical and cost-effectiveness of non-invasive diagnostic testing strategies for deep vein thrombosis

    Health Technol Assess

    (2006)
  • R.H. Gottlieb 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)
  • Cited by (9)

    • Body and Extremity MR Venography: Technique, Clinical Applications, and Advances

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    • Prevalence of Asymptomatic Deep Vein Thrombosis in Preoperative State of Spine Surgeries

      2023, World Neurosurgery
      Citation Excerpt :

      Similarly, the Wells score24 was not utilized as a screening method in this study because it was designed to be used in patients with clinically suspected, not asymptomatic, DVTs. Conversely, LLVD has been recognized as the diagnostic modality of choice for lower limb DVT because it is noninvasive, low cost, safe, and widely available, with 97% specificity for above knee DVT and 94% specificity for calf DVTs.4,35 In a prospective multicenter clinical trial including 711 patients, computed tomography venography and lower extremity Duplex yield equivalent diagnostic results with 95.5% concordance.36

    • ACR Appropriateness Criteria® Suspected Pulmonary Embolism: 2022 Update

      2022, Journal of the American College of Radiology
      Citation Excerpt :

      PE also may occur without detectable DVT. For patients with suspected DVT, please refer to the ACR Appropriateness Criteria® topic on "Suspected Lower Extremity Deep Vein Thrombosis" for imaging guidelines [5]. Diagnosis of PE is challenging because of the nonspecific nature of the clinical presentation, with associated symptoms such as chest pain, shortness of breath, and tachycardia that may mimic other pulmonary or cardiac conditions.

    • Diagnosis of deep vein thrombosis

      2020, Revista Clinica Espanola
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    The American College of Radiology seeks and encourages collaboration with other organizations on the development of the ACR Appropriateness Criteria through society representation on expert panels. Participation by representatives from collaborating societies on the expert panel does not necessarily imply individual or society endorsement of the final document.

    Reprint requests to: [email protected].

    Dr. Chandra reports other from Abbott Vascular, and other from W.L. Gore, outside the submitted work. The other authors have no conflicts of interest related to the material discussed in this article.

    Disclaimer: The ACR Committee on Appropriateness Criteria and its expert panels have developed criteria for determining appropriate imaging examinations for diagnosis and treatment of specified medical condition(s). These criteria are intended to guide radiologists, radiation oncologists, and referring physicians in making decisions regarding radiologic imaging and treatment. Generally, the complexity and severity of a patient’s clinical condition should dictate the selection of appropriate imaging procedures or treatments. Only those examinations generally used for evaluation of the patient’s condition are ranked. Other imaging studies necessary to evaluate other co-existent diseases or other medical consequences of this condition are not considered in this document. The availability of equipment or personnel may influence the selection of appropriate imaging procedures or treatments. Imaging techniques classified as investigational by the FDA have not been considered in developing these criteria; however, study of new equipment and applications should be encouraged. The ultimate decision regarding the appropriateness of any specific radiologic examination or treatment must be made by the referring physician and radiologist in light of all the circumstances presented in an individual examination.

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