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EVALUATION OF SUSPECTEDEVALUATION OF SUSPECTEDVENOUSVENOUS

THROMBOEMBOLISM THROMBOEMBOLISM

PULMONARY EMBOLISMPULMONARY EMBOLISM

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VENOUS THROMBOEMBOLISMVENOUS THROMBOEMBOLISM(VTE)(VTE)

Represents numerous !sor ers o"Represents numerous !sor ers o"#emost$s!s most %ommon&' resu&t!n !n#emost$s!s most %ommon&' resu&t!n !n

eep *enous t#rom+os!s (DVT)eep *enous t#rom+os!s (DVT)pu&mon$r' em+o&!sm (PE)pu&mon$r' em+o&!sm (PE)

Mort$&!t' r$te "or t#ese !sor ers !s , -./Mort$&!t' r$te "or t#ese !sor ers !s , -./De$t# !s o"ten &!n0e 1!t# m!sse orDe$t# !s o"ten &!n0e 1!t# m!sse or

e&$'e !$ nos!s2 1#!%# po!nts to t#ee&$'e !$ nos!s2 1#!%# po!nts to t#e!mport$n%e o" %&!n!%$& susp!%!on !n!mport$n%e o" %&!n!%$& susp!%!on !nsu%%ess"u& m$n$ ement3su%%ess"u& m$n$ ement3

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Clinical PresentationClinical Presentation

DVT4DVT4Un!&$ter$& &eUn!&$ter$& &e

s1e&&!ns1e&&!nLe p$!n5ten ernessLe p$!n5ten erness

6 m$' !n%re$se 1!t#6 m$' !n%re$se 1!t#1$&0!n 2 st$n !n 2 or1$&0!n 2 st$n !n 2 ore7ert!on3e7ert!on3

1$rmt# !n t#e &e1$rmt# !n t#e &eB&u!s# or re !s#B&u!s# or re !s#s0!n !s%o&or$t!ons0!n !s%o&or$t!on

PE4PE4D'spne$5t$%#'pne$D'spne$5t$%#'pne$

T$%#'%$r !$ T$%#'%$r !$Fe*erFe*erCou #5#emopt's!sCou #5#emopt's!sH'potens!onH'potens!onS'n%opeS'n%ope

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RISK FACTORSRISK FACTORS

Tr$um$ Tr$um$H!stor' o" DVTH!stor' o" DVTA e 8 9:A e 8 9:Pro&on e Immo+!&!t'Pro&on e Immo+!&!t'CVACVACHFCHFSur er' (espe%!$&&'Sur er' (espe%!$&&'

ort#ope !% or pe&*!%)ort#ope !% or pe&*!%)Fr$%ture o" LE orFr$%ture o" LE orpe&*!spe&*!sVenous %$t#etersVenous %$t#eters

Compress!onCompress!on(!ntr!ns!% or e7tr!ns!%)(!ntr!ns!% or e7tr!ns!%)Pre n$n%' or re%entPre n$n%' or re%ent

e&!*er'e&!*er'O+es!t'O+es!t'Estro en T#er$p'Estro en T#er$p'In;$mm$tor'In;$mm$tor'

!sor ers (*$s%u&!t!s2!sor ers (*$s%u&!t!s2IBD2 SLE)IBD2 SLE)C$n%erC$n%er

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Virchow’s TriadVirchow’s Triad

H'per%o$ u&$+!&!tH'per%o$ u&$+!&!t''En ot#e&!$& !n>ur'En ot#e&!$& !n>ur'Venous ;o1Venous ;o1

!stur+$n%e!stur+$n%e(st$s!s or(st$s!s ortur+u&en%e)tur+u&en%e)

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Venous Thrombosis AfterVenous Thrombosis After

Lon !haul Fli htsLon !haul Fli hts ?? Lon 6#$u& ;! #ts o" @ #ours $nLon 6#$u& ;! #ts o" @ #ours $n&on er ou+&e t#e r!s0 "or !so&$te&on er ou+&e t#e r!s0 "or !so&$te%$&" mus%&e *enous t#rom+os!s !n%$&" mus%&e *enous t#rom+os!s !np$t!ents 1!t# ot#er r!s0 "$%tors3 ?p$t!ents 1!t# ot#er r!s0 "$%tors3 ?

Schwarz Schwarz et3 A&32et3 A&32 Arch Intern Arch InternMed.Med. :: - 4 .G6 93:: - 4 .G6 93

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Predicti"e "alue of clinical criteriaPredicti"e "alue of clinical criteriafor the dia nosis of dee# "einfor the dia nosis of dee# "ein

thrombosis$thrombosis$ Criado E, Burnham CB. Surgery. 1997 Sep;122(3):578 83Criado E, Burnham CB. Surgery. 1997 Sep;122(3):578 83 $$

T#e %om+!n$t!on o" T#e %om+!n$t!on o"%$&" %!r%um"eren%e !s%rep$n%' o" &ess t#$n %$&" %!r%um"eren%e !s%rep$n%' o" &ess t#$n %m%m $+sen%e o" r!s0 "$%tors (re%ent oper$t!on2$+sen%e o" r!s0 "$%tors (re%ent oper$t!on2tr$um$2 m$&! n$n%'2 pre*!ous #!stor' o" DVT2tr$um$2 m$&! n$n%'2 pre*!ous #!stor' o" DVT2or #'per%o$ u&$+&e st$te)3or #'per%o$ u&$+&e st$te)3

pre !%te t#e $+sen%e o" DVT !n G / o"pre !%te t#e $+sen%e o" DVT !n G / o"

!np$t!ents $n G / o" outp$t!ents3!np$t!ents $n G / o" outp$t!ents3 C&!n!%$& s'mptoms2 r!s0 "$%tors2 $nC&!n!%$& s'mptoms2 r!s0 "$%tors2 $np#'s!%$& n !n s $re poor pre !%tors o" t#ep#'s!%$& n !n s $re poor pre !%tors o" t#epresen%e o" $%ute DVT3presen%e o" $%ute DVT3

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%uestion time&%uestion time&A '( )$o$ woman #resents with acute d)s#nea$ SheA '( )$o$ woman #resents with acute d)s#nea$ Shehas no h*o tra"el+ trauma+ or medications$ She ishas no h*o tra"el+ trauma+ or medications$ She is

otherwise health)+ does not smo,e+ and has ne"erotherwise health)+ does not smo,e+ and has ne"erused oral contrace#ti"es$ She had a -VT with herused oral contrace#ti"es$ She had a -VT with her.. stst #re nanc) at a e /0+ and a P1 after a#re nanc) at a e /0+ and a P1 after ah)sterectom) at a e 02$ 3er mother died suddenl)h)sterectom) at a e 02$ 3er mother died suddenl)at 4( )$o$ of un,nown causes$ She is found to ha"eat 4( )$o$ of un,nown causes$ She is found to ha"ea recurrent P$1$a recurrent P$1$

5hat is the most li,el) contributin factor65hat is the most li,el) contributin factor6

(A) F$%tor V Le! en mut$t!on(A) F$%tor V Le! en mut$t!on(B) Prote!n C e %!en%'(B) Prote!n C e %!en%'(C) O%%u&t m$&! n$nt tumor(C) O%%u&t m$&! n$nt tumor(D) Ant!p#osp#o&!p! $nt!+o '(D) Ant!p#osp#o&!p! $nt!+o '

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7A8 Factor V Leiden7A8 Factor V Leidenmutationmutation

Most %ommon "orm o" #ere !t$r' t#rom+op#!&!$Most %ommon "orm o" #ere !t$r' t#rom+op#!&!$6--/ pre*$&en%e !n t#e ener$& popu&$t!on6--/ pre*$&en%e !n t#e ener$& popu&$t!on

I ent! e !n :/ o" -I ent! e !n :/ o" - stst VTE2 $n .:/ o" re%urrent VTEVTE2 $n .:/ o" re%urrent VTE

De"e%tDe"e%t Pre*$&en%Pre*$&en%ee

T#rom+os!s T#rom+os!sr$ter$te

H'per#omo%'ste!nemH'per#omo%'ste!nem!$!$

-: 6 .:/-: 6 .:/ -: 6 :/-: 6 :/

F$%tor II : -:F$%tor II : -:mut$t!onmut$t!on

6 3./ 6 3./ 6 -@/ 6 -@/

Prote!n C e %!en%'Prote!n C e %!en%' :39/:39/ - 6 ./- 6 ./

Ant!t#rom+!nAnt!t#rom+!ne %!en%'e %!en%'

:3: 6:3: 6:3:./:3:./

- 6 /- 6 /

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PR1-ICTI9: T31PR1-ICTI9: T31

PRO;A;ILIT< OF P1PRO;A;ILIT< OF P1S5S o" DVTS5S o" DVT PTS PTSA&tern$t!*e 7 eeme &ess &!0e&' t#$n PEA&tern$t!*e 7 eeme &ess &!0e&' t#$n PE PTS PTSImmo+!&!t' or sur er' !n t#e pre*!ous 910sImmo+!&!t' or sur er' !n t#e pre*!ous 910s -3. PT-3. PT

HR 8-::HR 8-:: -3. PT-3. PTPre*3 DVT5PEPre*3 DVT5PE -3. PT-3. PTHemopt's!sHemopt's!s -3: PT -3: PTC$n%erC$n%er -3: PT-3: PT

Lo1 Pro+$+!&!t' 3:Lo1 Pro+$+!&!t' 3:Interme !$te 3:6 3:Interme !$te 3:6 3:

H! #H! # 8 3: 8 3:

Frost: Mayo Clin Proc, Volume 78 !!".#o$em%er &''(.!(8)*Frost: Mayo Clin Proc, Volume 78 !!".#o$em%er &''(.!(8)*!(+!!(+!

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The wor,!u#&The wor,!u#&

Venous Dup&e7 USVenous Dup&e7 USC#est J6R$'C#est J6R$'E&e%tro%$r !o r$mE&e%tro%$r !o r$mArter!$& B&oo

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=LTRASO=9-=LTRASO=9-7Com#ression+ -u#le>+ or7Com#ression+ -u#le>+ or

-o##ler8-o##ler8Pro s

Ku!%02 %#e$p2 $n non6!n*$s!*e

Con s#! #&' oper$tor epen ent

%$nnot +e use to ru&e out VTE%$nnot +e use to ru&e out VTEne $t!*e !n -:6 :/ o" r$n om p$t!entsne $t!*e !n -:6 :/ o" r$n om p$t!entspos !n .:/ o" p$t!ents 1!t# pro*en VTEpos !n .:/ o" p$t!ents 1!t# pro*en VTE

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Chest ?!Ra)Chest ?!Ra)

Common r$ !o r$p#!% n !n s 6 nonspe%! %$te&e%t$s!s

p&eur$& e us!onpu&mon$r' !n &tr$tes

e&e*$t!on o" $ #em! !$p#r$ m

C&$ss!% n !n s 6 su est!*e +ut !n"re=uent 3H$mpton s #ump (pu&mon$r' !n"$r%t!on)

esterm$r0 s s! n ( e%re$se *$s%u&$r!t')

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Chest ?!Ra)Chest ?!Ra)

T#e m$>or!t' o" p$t!ents 1!t# PE#$*e $n $+norm$& +ut nonspe%! %

%#est r$ !o r$p#3A norm$& %#est J6R$'J6R$' !n t#e sett!no" se*ere 'spne$ $n #'po7em!$

1!t#out e*! en%e o" +ron%#osp$smor $n$tom!% %$r !$% s#unt !sstron &' su est!*e o" PE3

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A;:A;:

H'po7em!$ $n e&e*$te A6$H'po7em!$ $n e&e*$te A6$r$ !ent m$' +e present2 +ut P$Or$ !ent m$' +e present2 +ut P$O

$n A6$ r$ !ent m$' +e norm$&2$n A6$ r$ !ent m$' +e norm$&2espe%!$&&' !n 'oun p$t!ents 1!t#espe%!$&&' !n 'oun p$t!ents 1!t#norm$& pu&mon$r' "un%t!on3 Innorm$& pu&mon$r' "un%t!on3 Inpro*en PE4pro*en PE4

P$O 8 @:mmH !n G/ un er 9: '3o3P$O 8 @:mmH !n G/ un er 9: '3o3A6$ r$ !ent !n%re$se :mmH !n -9/A6$ r$ !ent !n%re$se :mmH !n -9/un er 9: '3o3un er 9: '3o3

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1K:1K:

Nonspe%! %Nonspe%! %per UPETper UPET 2 @ / sens5 / spe%! %2 @ / sens5 / spe%! %

S- K T p$tternr! #t +un &e +r$n%# +&o%0P61$*e pu&mon$&e

r! #t $7!s e*!$t!on T I !n V - 6V9

Uro0!n$se !n PE Tr!$&

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1C: chan es inacute #ulmonar) embolism

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-!-I@1R-!-I@1R

F!+r!n De r$ $t!on Pro u%tF!+r!n De r$ $t!on Pro u%tH! #&' sens!t!*e2 +ut $ nonspe%! %H! #&' sens!t!*e2 +ut $ nonspe%! %

s%reen!n test "or DVTs%reen!n test "or DVTC$n +e e&e*$te !n pre n$n%'2C$n +e e&e*$te !n pre n$n%'2!n;$mm$t!on2 $ *$n%e $ e2 tr$um$2!n;$mm$t!on2 $ *$n%e $ e2 tr$um$2

post6op per!o 2 $n %$n%erpost6op per!o 2 $n %$n%erD6D!mer !s on&' spe%! % !" !t !s ne $t!*eD6D!mer !s on&' spe%! % !" !t !s ne $t!*eG.6GG/ ne pre !%t!*e *$&ue (ELISA)G.6GG/ ne pre !%t!*e *$&ue (ELISA)

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V*% SCA9V*% SCA9

D!$ nos!s +$se on pre6testD!$ nos!s +$se on pre6testpro+$+!&!t'pro+$+!&!t'

R$re&' !$ nost!% (!3e3 #! # orR$re&' !$ nost!% (!3e3 #! # or!nterme !$te pro+$+!&!t')!nterme !$te pro+$+!&!t')Unre&!$+&eUnre&!$+&e !n t#e sett!n o"

%on%om!t$nt &un !se$se (e3 3(e3 3pneumon!$2 %$n%er2 sur er'2 COPD)pneumon!$2 %$n%er2 sur er'2 COPD)or s! n! %$nt %$r !$% !se$se3or s! n! %$nt %$r !$% !se$se3

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V*% SCA9V*% SCA9

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SP1CIALSP1CIAL

CIRC=@STA9C1SCIRC=@STA9C1SPre6e7!st!n &un !se$sePre6e7!st!n &un !se$se V5K s%$n !s o" V5K s%$n !s o"&!m!te use"u&ness2 !n!t!$&&' us!n $ CT s%$n&!m!te use"u&ness2 !n!t!$&&' us!n $ CT s%$n1ou& +e $ppropr!$te1ou& +e $ppropr!$te

H!stor' o" PEH!stor' o" PE !t !s un%ert$!n 1#et#er !t !s un%ert$!n 1#et#er$+norm$&!t!es ete%te +' V5K s%$n $n CT$+norm$&!t!es ete%te +' V5K s%$n $n CTs%$n represent res! u$& o" t#e !n!t!$& e*ent ors%$n represent res! u$& o" t#e !n!t!$& e*ent orre%urrent t#rom+oem+o&!sm An !o r$mre%urrent t#rom+oem+o&!sm An !o r$m1ou& +e t#e test o" %#o!%e !n t#!s !nst$n%e1ou& +e t#e test o" %#o!%e !n t#!s !nst$n%e

Pre n$n%'Pre n$n%' Venous Dopp&ers s#ou& +e t#e Venous Dopp&ers s#ou& +e t#e!n!t!$& test o" %#o!%e3 I" t#e pro+$+&!t' o" $n!n!t!$& test o" %#o!%e3 I" t#e pro+$+&!t' o" $nem+o&!sm !s #! # e*en t#ou # opp&ers $reem+o&!sm !s #! # e*en t#ou # opp&ers $rene $t!*e2 V5K S%$n or CT S%$n 1ou& "o&&o13ne $t!*e2 V5K S%$n or CT S%$n 1ou& "o&&o13

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3i h!Res CT SCA93i h!Res CT SCA9

Ku!%02 $%%ur$te2 $*$!&$+&e2 $nKu!%02 $%%ur$te2 $*$!&$+&e2 $nre&$t!*e&' non6!n*$s!*e3re&$t!*e&' non6!n*$s!*e3

Sens!t!*!t' r$n es "rom . 6-::/ ( G/ $*e3)Sens!t!*!t' r$n es "rom . 6-::/ ( G/ $*e3)Spe%! %!t' r$n es "rom @6-::/ (G-/ $*e3)Spe%! %!t' r$n es "rom @6-::/ (G-/ $*e3)

He&p"u& 1!t# ot#er e&ements o" t#eHe&p"u& 1!t# ot#er e&ements o" t#eD 7D 7

V$&! on&' "or m$!n2 &o+$r2 orV$&! on&' "or m$!n2 &o+$r2 orse ment$& $rter' o%%&us!ons3se ment$& $rter' o%%&us!ons3Not $n opt!on !n ren$& !nsuQ%!en%'3Not $n opt!on !n ren$& !nsuQ%!en%'3

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A9:IO:RAP3< A9:IO:RAP3<

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APPROACHAPPROACH TO TO

TESTIN< TESTIN

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7C8 Pulmonar)7C8 Pulmonar)an io ra#h)an io ra#h)

In t#e sett!n o" $n !n eterm!n$te V6In t#e sett!n o" $n !n eterm!n$te V6K s%$n2 "urt#er test!n must +e oneK s%$n2 "urt#er test!n must +e one

to >ust!"' &on 6term $nt!%o$ u&$t!onto >ust!"' &on 6term $nt!%o$ u&$t!on#!&e prom!s!n 2 CT $n MRI o not#!&e prom!s!n 2 CT $n MRI o not

#$*e enou # e*! en%e !n t#e!r "$*or#$*e enou # e*! en%e !n t#e!r "$*or

I" !n ou+t2 o 1!t# t#eI" !n ou+t2 o 1!t# t#e

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