Review
Current Approaches and Controversial
Issues in the Diagnosis of Deep Vein
Thrombosis via Duplex Doppler Ultrasound
Diana Gaitini, MD
Unit of Ultrasound, Department of Medical Imaging, Rambam Medical Center, POB 9602, 31906, Haifa, Israel
Received 13 September 2005; accepted 28 February 2006
ABSTRACT: Duplex and color Doppler sonography
(DUS) is currently the technique of choice for the diag-
nosis of deep venous thrombosis (DVT) in symptomatic
patients, because it has proven safe and cost-effective,
with a very high sensitivity and specicity (96% and
98%, respectively) for the diagnosis of proximal DVT.
Several issues regarding its method and clinical indica-
tions remain controversial, however. Although isolated
calf vein thrombosis does not seem to have a signi-
cant adverse outcome in the short term, scanning the
calf only in patients with localized symptoms or signs
is cost-effective. Bilateral examination is indicated in
high-risk patients or when screening asymptomatic
patients. When negative, a complete DUS examination
of the proximal and distal veins, at least down to the
level of the popliteal trifurcation, allows withholding
anticoagulant therapy without the risk of major compli-
cations. This examination may be repeated if signs or
symptoms worsen. Some populations of asymptom-
atic patients at high risk of DVT may benet from DUS
screening. Bilateral DUS examination of lower limb
veins should be performed as the initial examination in
the workow of pulmonary embolism only in patients
with risk factors for DVT. Recurrent thrombosis is a
challenging diagnosis for all imaging modalities. A
diagnostic strategy combining clinical probability score
and D-dimer test may rene the selection of patients.
The pitfalls and limitations of venous DUS are related to
vein anatomy, ow changes, technical issues, and oper-
ator expertise. V C 2006 Wiley Periodicals, Inc. J Clin
Ultrasound 34:289297, 2006; Published online in
Wiley InterScience (www.interscience.wiley.com). DOI:
10.1002/jcu.20236
Keywords: duplex Doppler ultrasonography; color
Doppler ultrasonography; veins; extremities; venous
thrombosis; embolism; pulmonary
' 2006 Wiley Periodicals, Inc.
VOL. 34, NO. 6, JULY/AUGUST 2006DOI 10.1002/jcu
BACKGROUND
D eep venous thrombosis (DVT) of the lower
limb is a common and life-threatening condi-
tion. In the United States, its incidence is calcu-
lated at 70100,000 cases, with as many as
200,000 hospitalizations/year. It carries the risk
of pulmonary embolism (PE) and postthrombotic
syndrome. The incidence of PE is calculated
at 600,000 cases/year, 100,000 of them being
fatal.13 Early and accurate diagnosis of DVT is
therefore mandatory, yet clinical diagnosis is
unreliable: only 2030% of symptomatic patients
have proven DVT, and 90% of patients with fatal
PE are asymptomatic for DVT.4 Therefore, objec-
tive methods of examination are required to
reach an accurate and reliable diagnosis. There
is agreement that, in the current state-of-the-art,
duplex and color Doppler sonography (DUS) is
the main diagnostic tool for DVT diagnosis, while
ascending X ray venography is either abandoned or
reserved for patients with negative or equivocal
DUS results and a high clinical probability of DVT.2
Although venography is still the gold stand-
ard test, it relies on the variable and complex
anatomy of the venous system, lacks physiologic
information, is costly and invasive, and carries a
risk for contrast media reaction and postveno-
graphic phlebitis.5,6 Impedance plethysmogra-
phy, a noninvasive and functional test, fails to
detect nonocclusive proximal DVT, occlusive DVT
in a duplicated vein, and isolated calf DVT.7 The
only noninvasive technique that investigates
both the anatomy and physiology of the veins is
DUS.814 Among its advantages are its low cost,
availability, portability, and accuracy. It is required
as the primary instrumentation for peripheral
289
 GAITINI
venous testing according to the standards of the
Intersocietal Commission for the Accreditation of
Vascular Laboratories.15
The primary goal of DUS examination of the
veins is to diagnose the presence or absence of a
thrombus. Further information includes throm-
bus extent (mainly its upper limit) and character-
ization (fresh or organized, free-oating or
attached, and partially or totally occlusive). Its
ndings have some prognostic value as for the
development of postthrombotic syndrome and
the risk of PE. Patients with proximal DVT tend
to present a slower and incomplete resolution of
thrombus and to develop a more severe post-
thrombotic syndrome because of valve incompe-
tence.16 A free-oating thrombus seems to carry
an increased risk of PE, although it tends to attach
to the vein wall or resolve and does not warrant
any specic therapeutic procedure.17 When no
thrombosis is found, DUS may put forward alter-
native diagnoses (also known as pseudothrombo-
phlebitis) such as popliteal Bakers cyst, hema-
toma, popliteal aneurysm, pseudoaneurysm, lymph-
adenopathy, or other tumors. The incidence of these
alternative diagnoses is 1118%.18
The sensitivity and specicity of DUS for the
diagnosis of DVT in symptomatic patients are
very high. Compressibility under probe pressure
is the most accurate test. Compressibility under
probe pressure had reached a 97100% sensitiv-
ity and a 9899% specicity for the diagnosis of
proximal, femoral and popliteal DVT, but its sen-
sitivity dropped to 5070% and its specicity to
60% for the diagnosis of isolated calf DVT. The
visibility of the thrombus as a xed, echoic image
within the vein lumen had a sensitivity of ap-
proximately 50% for both proximal and calf DVT.
This poor sensitivity has been attributed to the
low echogenicity of the fresh thrombus,1922
although there seems to be a continuum between
blood stasis, which is clearly hyperechoic, and th-
rombosis, whose echogenicity changes with time.
In a meta-analysis of 100 cohort studies that
compared duplex Doppler sonography with con-
trast X ray venography in patients with suspected
DVT, the sensitivity was 96.5% for proximal DVT
and 71.2% for distal DVT, with a 94.3% specicity.
Some earlier studies have reported a lower sensi-
tivity, which may be explained by less advanced
ultrasound technology, limitations in examination
technique, and operator expertise.23
DIFFICULT AND CONTROVERSIAL ISSUES
There are several controversial or difcult issues
regarding the diagnosis of DVT via DUS.24 Con-
290
troversial issues include the diagnosis of isolated
calf vein thrombosis, bilateral versus unilateral
examination, focused versus extensive examina-
tion, single versus serial scanning in patients
with initially negative DUS results, screening of
asymptomatic patients at high risk for DVT, sus-
pected PE, suspected recurrent DVT, urgent off-
hour DUS, and the need for a diagnostic strategy
to rene the selection of patients referred for ve-
nous sonography. Difcult issues include pitfalls
and limitations of the method for DVT diagnosis.
Isolated Calf Vein Thrombosis
The deep calf venous network comprises 3 paired
veinsposterior tibial, bular, and anterior tib-
ialand 2 nonpaired muscular veinssoleal and
gastrocnemialadjacent to the corresponding
arteries, except for the soleal vein. Supercial
veins such as the small saphenous vein (saphena
parva) may also be a source of thrombophlebitis
and pain. The prevalence of isolated calf vein
thrombosis (CVT) is low (512%) in symptomatic
patients25 but is higher in asymptomatic patients
at high risk of DVT: 15% after knee or hip sur-
gery and 45% after coronary artery bypass sur-
gery.2628
DUS remains inconclusive in 3255% of cases
of calf veins thrombosis, although power Doppler
sonography may help identify the paired calf
veins.29 Bucek et al30 tested sonographic contrast
infusion for the examination of the calf veins and
succeeded in reducing the rate of indeterminate
scans from 55% to 20%. Nevertheless, the use of
sonographic contrast media has not been ap-
proved by the US Food and Drug Administration.
On the other hand, technologic progresses may
overcome some limitations of DUS in the detec-
tion and examination of calf veins.
A comprehensive lower extremity examination
including all the paired and nonpaired veins has
been recommended by some authors to increase
DUS accuracy, and to avoid overlooking possible
thrombophilic disorders.31,32 In a meta-analysis
of the literature available before 1999, Gottlieb
et al33 found a wide (9.382.7%) variation in the
reported rate of indeterminate results of calf
DUS examinations. In their own study, these
authors observed no adverse outcome on a 3-
month follow-up of patients with DUS diagnosed
CVT who did not receive anticoagulation.34 In a
more recent prospective study, they were able to
see all segments of all the paired calf veins in less
than 40% of patients undergoing a protocol in
which the deep calf veins were evaluated either
systematically or only if local signs and symp-
JOURNAL OF CLINICAL ULTRASOUNDDOI 10.1002/jcu
 CONTROVERSIES IN US DIAGNOSIS OF DVT
toms were present. The rate of adverse outcomes
(ie, thrombus extension to the thigh or pulmo-
nary embolism) was not signicantly different
between these 2 groups.35 For calf vein evalua-
tion, special attention must be paid to the painful
areas. Proximal extension of isolated CVT may
occur in up to 20% of cases. Because many calf
thrombi do not progress to proximal veins or give
rise to PE, an aggressive, invasive approach via
X ray venography to diagnosing and treating
CVT may not be warranted,8 but a policy of DUS
scanning the calf in patients with localized symp-
toms or physical ndings is cost-effective. There
are also controversies regarding the need for
anticoagulant treatment in the presence of iso-
lated CVT. According to the American Society of
Chest Surgeons, anticoagulation is recommen-
ded in symptomatic patients, at least for 612
weeks.36 Other authors recommend anticoagula-
tion only in cases of proximal propagation diag-
nosed on follow-up examination.34 When not jus-
tied by clinical ndings, repeated DUS exami-
nation is questionable, because it yields positive
results in only 1.3% of cases.23
Bilateral versus Unilateral DUS
In symptomatic patients, the incidence of contra-
lateral, asymptomatic DVT is low (57%).37 A bilat-
eral examination is indicated when screening
asymptomatic patients at high risk of DVT, such
as after coronary bypass surgery, major neuro-
surgery, spinal cord injury, total hip arthroplasty,
and suspicion of PE.3739 The asymptomatic con-
tralateral leg of a patient with a history of DVT
can be examined to help distinguish recurrent
DVT from postthrombotic syndrome.40 In the clini-
cal routine, although diagnosing asymptomatic
contralateral thrombosis has implications in pre-
venting postthrombotic disorders, unilateral DUS
examination of the symptomatic leg is considered
the standard procedure39,41 in some countries,
whereas bilateral examination is the rule in others.
Focused Compression versus Continuous,
Full Lower Limb Examination
Some authors have proposed a limited, 2-point
examination technique using compression testing
on the common femoral and the popliteal veins,
claiming that it is able to detect approximately
99% of thrombi that extend above the knee. This
protocol is based on the fact that most sympto-
matic patients have a continuous clot involving
more than 1 single venous segment.4244 With
this technique, an isolated thrombus in the femo-
VOL. 34, NO. 6, JULY/AUGUST 2006DOI 10.1002/jcu
ral (wrongly but universally named the super-
cial femoral) vein or in calf veins will remain
unidentied. In a multicenter study performed
on symptomatic ambulatory patients, a complete
examination of proximal and distal veins was
performed, and the patients were followed up for
3 months after a negative sonographic examina-
tion. Neither proximal DVT nor pulmonary
embolism occurred, and distal DVT occurred in
only 0.5% of these patients. Although this ap-
proach may prove cost-effective in ambulatory
symptomatic patients, a complete examination of
the entire proximal venous system, including the
popliteal trifurcation in the proximal calf, re-
mains necessary in most patients and should be
the usual procedure when performing venous
DUS examinations.40
Single versus Serial Scanning in Patients
with Negative DUS
How dangerous is it to denitely rule out venous
thrombosis in a symptomatic patient with nega-
tive DUS examination? The incidence of PE at
3 months follow-up of patients with a negative
initial DUS examination was1.6% (1.3 % in out-
patients, and 10% in inpatients). The incidence
of PE in untreated CVT was 0.71.1%, similar to
PE in patients with normal X ray contrast venog-
raphy.35,45,46 Repeated sonography performed af-
ter 1 week in patients with intermediate or high
clinical probability for DVT and a negative rst
sonographic examination increased the percent-
age of patients with diagnosed DVT from 32.5%
to 33.5%. This diagnostic improvement was clearly
too small to justify repeated scanning as a routine
procedure.47 In their meta-analysis, Goodacre
et al23 identied no study that compared repeated
sonography with X ray venography in all patients.
Repeated sonography appears to have a positive
yield of 1.3%, 89% of these being conrmed via X
ray venography and the rest via clinical follow-
up.23 In a multicenter study, no proximal DVT or
PE developed at 3 months follow-up after a nega-
tive complete and bilateral DUS examination of
the lower limb veins. The authors concluded that
it is safe to withhold anticoagulant therapy in
patients with clinically suspected DVT after a sin-
gle, negative sonographic examination.48 Never-
theless, a repeated examination is warranted if
the clinical situation worsens.
Screening Asymptomatic Patients
with High Prevalence of DVT
Several studies have evaluated DUS as a screen-
ing test in asymptomatic patients after coronary
291
 GAITINI
artery bypass grafts,27 after admission in an in-
ternal medicine unit,37 after long-haul ights,49
and in patients with suspected pulmonary embo-
lism.38 We conducted a screening study using
bilateral DUS to detect asymptomatic DVT in 62
ambulatory cancer patients undergoing chemo-
therapy. Despite the known hypercoagulable
state of these patients, we found no DVT and con-
cluded that systematic DUS screening is not jus-
tied in this specic cancer population.50 In 1995,
Wells et al28 concluded from a meta-analysis of
studies with minimized bias that venous sono-
graphic imaging had a high specicity (97%) but
a low sensitivity (5470%), limiting the useful-
ness of DUS as a screening test. Quite logically,
the sensitivity of DUS is greater in populations
with a greater prevalence of DVT.23 From a
recent meta-analysis of studies comparing DUS
with X ray venography in asymptomatic patients,
it was concluded that DUS is accurate for the di-
agnosis of DVT in asymptomatic postoperative
orthopedic patients, whereas more research is
needed in other clinical settings.51
Although the specicity of DUS for the diagno-
sis of DVT in asymptomatic patients is high (86
100%), its overall sensitivity is only approxi-
mately 50%, probably because of the smaller size
and the nonocclusive character of the thrombus,
as well as a higher prevalence of isolated CVT.28,52
Therefore, venous DUS should be complete (in-
cluding calf veins) and bilateral when performed
in asymptomatic patients.53
Suspected PE
Bilateral lower extremities DUS is accepted as
an initial examination for patients with clinically
suspected PE.38 However, Fard et al54 reported
that even bilateral X ray contrast venography
revealed no DVT in approximately one third of
patients with proven PE. In this study, DUS was
positive in only 20% of patients who had proven
PE but were asymptomatic for DVT. DUS was
positive in 90% of patients with proven PE who
were symptomatic for DVT, and there was a
thrombus in the asymptomatic lower limb in 14%
of them.54 According to Sheiman and McArdle,
facing the low prevalence of DVT in patients that
are just suspected for PE but asymptomatic for
DVT (810%), bilateral lower extremities venous
US should be performed as the initial examina-
tion in the workow of PE only in patients with
risk factors for DVT. This policy would reduce the
number of examinations performed without a
decline in DVT detection.38 An US examination
limited to the popliteal and femoral veins is com-
292
monly performed to detect DVT in patients with
clinically suspected PE.55 According to Elias
et al,56 a complete lower limb sonographic exami-
nation of both proximal and distal veins has a
higher sensitivity but a slightly lower specicity.
Of course, a negative DUS examination should
not be used to rule out the diagnosis of PE.54,56
Suspected Recurrent DVT
Venum venorum develop in thrombi over time, the
acute event being followed by clot retraction,
lumen recanalization and valve damage. After 69
months, complete vein recanalization occurs in
only 45% of patients, and valve immobility and/or
destruction remain in most cases. Reux from
deep to supercial vein systems develops with sub-
sequent enlargement of the saphenous and perfo-
rating veins, development of varicose veins in the
subcutaneous fat, and clinical manifestations of
the postthrombotic syndrome.5761 During the year
following acute thrombosis, 1 out of 3 patients will
exhibit symptoms of DVT, and recurrent DVT
occurs in 1 out of 3 of these symptomatic patients.
The annual likelihood of recurrence is 515%, with
a cumulative recurrence rate of approximately
25% after 4 years.62 Differentiating acute on
chronic thrombosis from postthrombotic syndrome
is a clinical and imaging challenge. Some DUS fea-
tures may help. A fresh thrombus (<710 days
old) is mostly hypoechoic, homogeneous, partially
compressible, and sometimes oating, and the vein
diameter is enlarged. Thrombolysis is successful in
90% of these cases. On the contrary, an older,
organized thrombus is hyperechoic, heterogene-
ous, uncompressible, and rmly adherent to the
vein walls, and moderate or no vein enlargement
is visible. Thrombolytic therapy may succeed in
only 12% of these cases.58 Acute on chronic DVT is
a difcult diagnosis for all diagnostic modalities,
enhancing the value of a baseline study for distin-
guishing old residual thrombus from superimposed
acute or chronic DVT.
Urgent, Off-Hours DUS
Is it justied to perform urgent DUS during off
hours? This is a concern for every resident and
sonographist, and places a high demand on vas-
cular labs. Langan et al63 tested a program in
which patients suspected of having DVT were ei-
ther sent home with a single prophylactic dose
(1 mg/kg) of low-molecular weight heparin, or
kept in observation when heparin was contrain-
dicated, then undergone DUS at 8 A.M. the next
day. There was no death, PE, or immediate com-
JOURNAL OF CLINICAL ULTRASOUNDDOI 10.1002/jcu
 CONTROVERSIES IN US DIAGNOSIS OF DVT

FIGURE 1. Algorithm for the diagnosis of DVT in symptomatic patients. Venous DUS examination should be performed in patients with a high
clinical probability score and/or a positive D-dimer test. The appropriate examination is compression DUS of the complete venous system (includ-
ing the distal veins when focal symptoms or signs are present) and bilateral examination in high-risk patients. Modied from Mantoni.65 DVT,
deep venous thrombosis; US, sonographic examination.

plication of anticoagulation, whereas an 89% re-
duction in after-hours DUS for DVT was achieved.
To reduce unnecessary hospitalization, the clinical
probability of DVT should be evaluated and/or a
D-dimer test should be used to identify low-risk
patients in which DUS may be delayed.40
Diagnostic Strategy for Symptomatic
Patients
The large number of patients referred for DUS
examination for clinically suspected DVT con-
trasts with the low prevalence of proven DVT and
led to a search for alternative strategies that
would offer the possibility of rening the selec-
tion of patients for imaging. The proposed diag-
nostic strategies combine the clinical probability
score with D-dimer test and compression sonog-
raphy.6472
The clinical risk assessment score is based on
patient history, symptoms and physical examina-
tion. A history of malignancy, previous DVT,
recent immobilization, recent surgery, and differ-
ence in calf diameter were the most useful crite-
ria for assessing the clinical probability of DVT.73
Wells et als clinical score stratied patients into
groups with high, intermediate, and low probabil-
ity of DVT and was proven effective in decreasing
the number of unnecessary DUS examinations.74
The D-dimer test is the biochemical assay of a
brin degradation product. It has a high negative
predictive value for the diagnosis of DVT.6971 A
VOL. 34, NO. 6, JULY/AUGUST 2006DOI 10.1002/jcu
D-dimer test at a cutoff level of 1
g/ml had a sen-
sitivity of 9598% and a negative predictive value
of 9698%, whereas its specicity and positive
predictive value were only 55% and 48%, respec-
tively.67,72 Because concentrations rise in inam-
matory states, recent surgery, or cancer, the use-
fulness of the D-dimer test is limited by the high
rate of false positive results in these populations,
particularly in hospitalized patients. Michiels
et al75 found a sensitivity and negative predictive
value of 98.6% and 99.5%, respectively, for the
rapid ELISA VIDAS D-dimer assay. In patients
suspected of DVT with a normal D-dimer test and
a low clinical probability score, the prevalence of
DVT was less than 0.5%, and the need for com-
pression sonographic testing was reduced by 40
50%. A randomized multicenter trial demon-
strated that the use of D-dimer testing can
reduce the need for repeated sonography in out-
patients with normal results on initial sono-
graphic examination of the proximal veins.66
Based on clinical and biochemical parameters,
the use of DUS may be restricted to patients with
a high clinical probability score and/or a positive
D-dimer test. This strategy proved to be safe and
feasible in an emergency department setting.76
Facing a normal DUS examination in patients
with a high clinical probability score and a posi-
tive D-dimer test, an additional procedure such as
X ray venography or repeated DUS should be per-
formed (Figure 1). This combination appears safe
293
 GAITINI
and seems to be the most cost-effective diagnostic
workup for suspected DVT. Nevertheless, X ray
contrast venography is no longer performed in
many centers. The optimal strategy in a given
institution depends on local equipment, expertise,
and cost.77 Therefore, potential approaches to lim-
iting the use of sonography by adding D-dimer
tests in the evaluation of possible DVT are still or-
ganization-specic.78
Limitations and Pitfalls of DUS
for the Diagnosis of DVT
Anatomic limitations are associated with dif-
culty in imaging the iliac veins (which are deep
in the pelvis), the femoral vein at the level of the
Hunter canal (an aponeurotic adductor hiatus,
which is poorly compressible), and the calf veins
(which are numerous, small, and variable). DUS
with ow augmentation maneuvers may be use-
ful for these sites. A possible pitfall is vein dupli-
cation, which occurs in up to 20% of the femoral
and 35% of the popliteal veins, because one vein
may be normal while the other contains a throm-
bus.77 Other issues are related to technical limi-
tations, such as: a poorly compressible vein due
to obesity or edema; an echogenic lumen due to
low velocity blood ow as in low cardiac output;
and vein distention due to congestive heart fail-
ure. Blood ow echogenicity resulting from blood
stasis and erythrocyte aggregation may be a sig-
nicant source of false positive results. In these
situations, dynamic tests (ow augmentation pro-
duced by passive limb raising or upstream muscle
compression) may ensure a correct diagnosis. Fur-
thermore, there are limitations due to lack of
standard in the performance of vein DUS among
vascular laboratories, varying from unilateral to
bilateral, limited to complete, compression only to
DUS examination.79 Better training and improved
experience of sonographers, as well as technologic
progresses, have led to a higher sensitivity of DUS
in recent studies.23
CONCLUSION
DUS is currently the technique of choice for the
diagnosis of DVT in symptomatic patients. It is a
highly accurate, widely available, and noninva-
sive technique that does not entail ionizing radia-
tion and contrast media injection. Furthermore,
it is safe and cost-effective. When results are neg-
ative for DVT, it may help provide an alternative
diagnosis. DUS should be performed as a screen-
ing method for asymptomatic patients at high
294
risk of DVT. Several issues regarding the
methodas well as clinical indicationsremain
difcult or controversial. The presence or absence
of isolated CVT should be determined in patients
with localized symptoms and, bilaterally, in
asymptomatic patients with a high risk of DVT.
When the results are negative, complete com-
pression and DUS examination of the proximal
and distal veins at least down to the level of the
popliteal trifurcationincluding the more distal
veins when focal symptoms or signs are pres-
entallows withholding anticoagulant therapy.
Repeat examination is warranted if clinical dete-
rioration occurs. Applying a diagnostic strategy
that combines clinical probability score and a D-
dimer test may signicantly reduce the number
of required DUS examinations and additional
investigations in a minority of cases. Operator ex-
pertise, technologic developments, improved se-
lection of patients, and optimization of protocols
will ensure better diagnostic accuracy.
REFERENCES
1. Anderson FA, Wheeler HB, Goldberg RT, et al. A
population-based perspective of the hospital inci-
dence and case facility rates of deep vein thrombo-
sis and pulmonary embolism. The Worcester DVT
Study. Arch Intern Med 1991;151:933.
2. Weinmann EE, Salzman EW. Deep vein thrombo-
sis. N Engl J Med 1994;331:1630.
3. Kyrle PA, Eichinger S. Deep vein thrombosis. Lan-
cet 2005;365:1163.
4. Wells PS, Hirsh J, Anderson DR, et al. Accuracy of
clinical assessment of deep vein thrombosis. Lan-
cet 1995;345:1326.
5. Hull R, Hirsh J, Sackett DL, et al. Cost-effective-
ness of clinical diagnosis, venography and nonin-
vasive testing in patients with symptomatic deep-
vein thrombosis. N Engl J Med 1981;304:1561.
6. Flanigan DP, Goodreau JJ, Burnham S, et al. Vasc-
ular-laboratory diagnosis of clinically suspected
acute deep vein thrombosis. Lancet 1978;2:331.
7. Hull TD, van Aken WG, Hirsh J, et al. Impedance
plethysmography using the occlusive cuff tech-
nique in the diagnosis of venous thrombosis. Circu-
lation 1976;53:696.
8. Kearon C, Julian JA, Math M, et al. Noninvasive
diagnosis of deep vein thrombosis. Mc Master Di-
agnostic Imaging Practice Guidelines Initiative.
Ann Intern Med 1998;128:663.
9. Birdwell BG, Raskob GE, Whitsett TL, et al. The
clinical validity of normal compression ultrasonog-
raphy in outpatients suspected of having deep vein
thrombosis. Ann Intern Med 1998;128:1.
10. Wells PS, Hirsh J, Anderson DR, et al. Comparison
of the accuracy of impedance plethysmography
and compression ultrasonography in outpatients
JOURNAL OF CLINICAL ULTRASOUNDDOI 10.1002/jcu
 CONTROVERSIES IN US DIAGNOSIS OF DVT
with clinically suspected deep vein thrombosis. A
two centre paired-design prospective trial. Thromb
Haemost 1995;74:1423.
11. Lensing AWA, Prandoni P, Brandjes D, et al.
Detection of deep vein thrombosis by real time
B-mode ultrasonograpy. N Engl J Med 1989;320:
342.
12. White RH, McGahan JP, Daschbach MM, et al. Di-
agnosis of deep vein thrombosis using duplex ultra-
sound. Ann Intern Med 1989;111:297.
13. Polak JF, Cutler SS, OLeary DH. Deep veins of
the calf: assessment with color Doppler ow imaging.
Radiology 1989;171:481.
14. Gaitini D, Kaftori JK, Pery M, et al. High resolu-
tion real-time ultrasonography in the diagnosis of
deep vein thrombosis. Rofo 1988;149:26.
15. ICAVL standards for accreditation in noninvasive
vascular testing. Part II. Vascular laboratory
operationsperipheral venous testing. 200:18.
Available at: http://www.intersocietal.org/icavl/pdfs/
venous2005.pdf.
16. Asbeutah AM, Riha AZ, Cameron JD, et al. Five-
year outcome study of deep vein thrombosis in the
lower limbs. J Vasc Surg 2004;40:1184.
17. Voet D, Afschrift M. Floating thrombi: diagnosis
and follow-up by duplex ultrasound. Br J Radiol 1991;
64:1010.
18. Langsfeld M, Matteson B, Johnson W, et al.
Bakers cysts mimicking the symptoms of deep vein
thrombosis: diagnosis with venous duplex scanning.
J Vasc Surg 1997;25:658.
19. Theodorou SJ, Theodorou DJ, Kakitsubata Y.
Sonography and venography of the lower extrem-
ities for diagnosing deep vein thrombosis in symp-
tomatic patients. Clin Imaging 2003;27:180.
20. Baxter GM. The role of ultrasound in deep venous
thrombosis. Clin Radiol 1997;52:1.
21. Mussurakis S, Papaioannou S, Voros D, et al. Com-
pression ultrasonography as a reliable imaging
monitor in deep venous thrombosis. Surg Gynecol
Obstet 1990;171:233.
22. Cogo A, Lensing AW, Koopman MM, et al. Com-
pression ultrasonography for diagnostic manage-
ment of patients with clinically suspected deep vein
thrombosis: prospective cohort study. BMJ 1998;
316:17.
23. Goodacre S, Sampson F, Thomas S, et al. System-
atic review and meta-analysis of the diagnostic ac-
curacy of ultrasonography for deep vein thrombo-
sis. BMC Med Imaging 2005;5:6.
24. Dauzat M, Laroche JP, Deklunder G, et al. Diagno-
sis of acute lower limb deep venous thrombosis
with ultrasound: trends and controversies. J Clin
Ultrasound 1997;25:343.
25. Gottlieb RH, Widjaja J, Tian L, et al. Calf sonogra-
phy for detecting deep venous thrombosis in symp-
tomatic patients: experience and review of the lit-
erature. J Clin Ultrasound 1999;27:415.
26. Oishi CS, Grady-Benson JC, Otis SM, et al. The
clinical course of distal deep venous thrombosis
after total hip and total knee arthroplasty, as
VOL. 34, NO. 6, JULY/AUGUST 2006DOI 10.1002/jcu
determined with duplex ultrasonography. J Bone
Joint Surg Am 1994;76:1658.
27. Reis SE, Polak JF, Hirsch DR, et al. Frequency of
deep venous thrombosis in asymptomatic patients
with coronary artery bypass grafts. Am Heart J 1991;
122:478.
28. Wells PS, Lensing AW, Davidson BL, et al. Accu-
racy of ultrasound for the diagnosis of deep venous
thrombosis in asymptomatic patients after orthope-
dic surgery: a meta-analysis. Ann Intern Med 1995;
122:47.
29. Forbes K, Stevenson AJ. The use of power Doppler
ultrasound in the diagnosis of isolated deep venous
thrombosis of the calf. Clin Radiol 1998;53:752.
30. Bucek RA, Kos T, Schober E, et al. Ultrasound
with Levovist in the diagnosis of suspected calf
vein thrombosis. Ultrasound Med Biol 2001;27:
455.
31. Labropoulos N, Webb KM, Kang SS, et al. Patterns
and distribution of isolated calf deep vein thrombo-
sis. J Vasc Surg 1999;30:787.
32. Badgett DK, Comerota MC, Khan MN, et al.
Duplex venous imaging: role for a comprehensive
lower extremity examination. Ann Vasc Surg 2000;
14:73.
33. Gottlieb RH, Widjaja J, Mehra S, et al. Clinically
important pulmonary emboli: does calf vein US
alter outcomes? Radiology 1999;211:25.
34. Gottlieb RH, Widjaja J. Clinical outcomes of un-
treated symptomatic patients with negative nd-
ings on sonography of the thigh for deep vein
thrombosis: our experience and a review of the lit-
erature Am J Roentgenol 1999;172:1601.
35. Gottlieb RH, Voci SL, Syed L, et al. Randomized
prospective study comparing routine versus selec-
tive use of sonography of the complete calf in
patients with suspected deep venous thrombosis.
Am J Roentgenol 2003;180:241.
36. Geerts WH, Heit JA, Clagett GP, et al. Prevention
of venous thromboembolism Chest 2004;126:338S.
37. Bressollette L, Nonent M, Oger E, et al. Diagnostic
accuracy of compression ultrasonography for the
detection of asymptomatic deep venous thrombosis
in medical patients. The TADEUS project. Thromb
Haemost 2001;86:529.
38. Sheiman RG, McArdle CR. Clinicaly suspected
pulmonary embolism: use of bilateral lower ex-
tremity US as the initial examinationa prospec-
tive study. Radiology 1999;212:75.
39. Cronan JJ. Deep venous thrombosis: one leg or
both legs? Radiology 1996;200:323.
40. Fraser JD, Anderson DR. Deep venous thrombosis:
recent advances and optimal investigation with
US. Radiology 1999;211:9.
41. Giess CS, Bach AM, Hann LE. Lower extremity
venous sonography in the high risk cancer popula-
tion: one leg or two? Am J Roentgenol 2001;176:
1049.
42. Perzullo JA, Perkins AB, Cronan JJ. Symptomatic
deep vein thrombosis: diagnosis with limited com-
pression US. Radiology 1996;198:67.
295
 GAITINI
43. Cogo A, Lensing AWA, Koopman MM, et al. Com-
pression ultrasonography for diagnostic manage-
ment of patients with clinically suspected deep vein
thrombosis: prospective cohort study. BMJ 1998;
316:17.
44. Elias E, Mallard L, Elias M, et al. A single com-
plete ultrasound investigation of the venous net-
work for the diagnostic management of patients
with a clinically suspected rst episode of deep
venous thrombosis of the lower limbs. Thromb
Haemost 2003;89:221.
45. Sluzewski M, Koopman MM, Schuur KH, et al.
Inuence of negative ultrasound ndings on the
management of in and outpatients with suspected
deep vein thrombosis. Eur J Radiol 1991;13:174.
46. Wolf B, Nichols DM, Duncan JL. Safety of a single
duplex scan to exclude deep venous thrombosis. Br
J Surg 2000;87:1525.
47. Friera A, Gimenez NR, Caballer P, et al. Deep vein
thrombosis: can a second sonographic examination
be avoided? AJR Am J Roentgenol 2002;178:1001.
48. Elias A, Mallard L, Elias M, et al. A single com-
plete ultrasound investigation of the venous net-
work for the diagnostic management of patients
with a clinically suspected rst episode of deep ve-
nous thrombosis of the lower limbs. Thromb Hae-
most 2003;89:221.
49. Scurr JH, Machin SJ, Bailey-King S, et al. Fre-
quency and prevention of symptomless deep vein
thrombosis in long-haul ights: a randomized trial.
Lancet 2001;357:1485.
50. Berenstein R, Haim N, Brenner B, et al. Venous
sonography for the diagnosis of asymptomatic deep
vein thrombosis in patients with cancer under-
going chemotherapy. J Ultrasound Med 2004;23:
655.
51. Kassai B, Boissel JP, Cucherat M, et al. A system-
atic review of the accuracy of ultrasound in the di-
agnosis of deep venous thrombosis in asymptom-
atic patients. Thromb Haemost 2004;91:655.
52. Agnelli G, Radicchia S, Nenci GG. Diagnosis of
deep vein thrombosis in asymptomatic high-risk
patients. Haemostasis 1995;25:40.
53. Elias A, Cadene A, Elias M, et al. Extended lower
limb venous ultrasound for the diagnosis of proxi-
mal and distal vein thrombosis in asymptomatic
patients after total hip replacement. Eur J Vasc
Endovas Surg 2004;27:438.
54. Fard MN, Mostaan M, Anaraki MR. Utility of
lower extremity duplex sonography in patients
with venous thromboembolism. J Clin Ultrasound
2001;29:92.
55. Eze AR, Comerota AJ, Kerr RP, et al. Is venous
duplex imaging an appropriate initial screening
test for patients with suspected pulmonary embo-
lism? Ann Vasc Surg 1996;10:220.
56. Elias A, Colombier D, Victor G, et al. Diagnostic
performance of complete lower limb venous ultra-
sound in patients with clinically suspected acute
pulmonary embolism. Thromb Haemost 2004;91:
187.
296
57. Cronan JJ, Leen V. Recurrent deep venous throm-
bosis: limitations of US. Radiology 1989;170:739.
58. Meissner MH. Venous duplex scanning. In: Ruth-
erford RB, editor. Vascular surgery. Philadelphia:
Saunders; 2000. p 214.
59. Gaitini D, Kaftori JK, Pery M, et al. Late changes
in veins after deep venous thrombosis: ultrasono-
graphic ndings. Rofo 1990;153:68.
60. Haenen JH, Janssen MC, van Langen H, et al.
Duplex ultrasound in the hemodynamic evaluation
of the late sequelae of deep venous thrombosis.
J Vasc Surg 1998;27:472.
61. Baud JM, Stephas L, Ribadeau-Dumas C, et al.
Short and medium term duplex sonography follow-
up of deep venous thrombosis of the lower limbs.
J Clin Ultrasound 1998;26:7.
62. Prandoni P, Lensing AW, Cogo A, et al. The long-
term clinical course of acute deep venous thrombo-
sis. Ann Intern Med 1996;125:1.
63. Langan EM 3rd, Coffey CB, Taylor SM, et al. The
impact of the development of a program to reduce
urgent (off-hours) venous duplex ultrasound scan
studies. J Vasc Surg 2002;36:132.
64. Tick LW, Ton E, van Voorthuizen T, et al. Practical
diagnostic management of patients with clinically
suspected deep vein thrombosis by clinical probabil-
ity test, compression ultrasonography and D-dimer
test. Am J Med 2002;113:630.
65. Mantoni M. Ultrasound of limb veins. Eur Radiol
2001;11:1557.
66. Kearon C, Ginsberg JS, Douketis J, et al. A
randomized trial of diagnostic strategies after nor-
mal proximal vein ultrasonography for suspected
deep venous thrombosis: D-dimer testing com-
pared with repeated ultrasonography. Ann Intern
Med 2005;142:490.
67. Ruiz-Gimenez N, Friera A, Artieda P, et al. Rapid
D-dimer test combined a clinical model for deep
vein thrombosis. Validation with ultrasonography
and clinical follow-up in 383 patients. Thromb
Haemost 2004;91:1237.
68. Hull RD, Stein PD, Ghali WA, et al. Diagnostic
algorithms for deep vein thrombosis: work in pro-
gress. Am J Med 2002;113:687.
69. Brenner B, Pery M, Lanir N, et al. Application of a
bedside whole blood D-dimer assay in the diagno-
sis of deep vein thrombosis. Blood Coagul Fibrino-
lysis 1995;6:219.
70. Wells PS, Brill-Edwards P, Stevens P, et al. A novel
and rapid whole-blood assay for D-dimer in
patients with clinically suspected deep vein throm-
bosis. Circulation 1995;91:2184.
71. Akman MN, Cetin N, Bayramoglu M, et al. Value
of the D-dimer test in diagnosing deep vein throm-
bosis in rehabilitation inpatients. Arch Phys Med
Rehabil 2004;85:1091.
72. Heim SW, Schectman JM, Siadaty MS, et al. D-
dimer testing for deep venous thrombosis: a meta-
analysis. Clin Chem 2004;50:1136.
73. Goodacre S, Sutton AJ, Sampson FC. Meta-analy-
sis: the value of clinical assessment in the diagnosis
JOURNAL OF CLINICAL ULTRASOUNDDOI 10.1002/jcu
 CONTROVERSIES IN US DIAGNOSIS OF DVT
of deep venous thrombosis. Ann Intern Med 2005;
143:129.
74. Wells PS, Hirsh J, Anderson DR, et al. Accuracy of
clinical assessment of deep-vein thrombosis. Lancet
1995;345:1326.
75. Michiels JJ, Gadisseur A, van der Planken M,
et al. Diagnosis of deep vein thrombosis: how many
tests do we need? Acta Chir Belg 2005;105:16.
76. Anderson DR, Kovacs MJ, Stiell I, et al. Combined
use of clinical assessment and D-dimer to improve
the management of patients presenting to the
VOL. 34, NO. 6, JULY/AUGUST 2006DOI 10.1002/jcu
emergency department with suspected deep vein
thrombosis (the EDITED study). J Thromb Haemost
2003;1:635.
77. McRae SJ, Ginsberg JS. The diagnostic evaluation
of deep vein thrombosis. Am Heart Hosp J 2004;2:205.
78. Zierler BK. Ultrasonography and diagnosis of
venous thromboembolism. Circulation 2004;109
(12 Suppl 1):I9.
79. Zierler BK. Screening for acute DVT: optimal utili-
zation of the vascular diagnostic laboratory. Semin
Vasc Surg 2001;14:206.
297