Acta Chir Belg
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The requirement for a safe diagnostic strategy should be based on an overall post-test incidence of venous thromboembolism (VTE) of less than 1% during 3 month follow-up. Compression ultrasonography (CUS) has a negative predictive value (NPV) of 97 to 98% indicating a post-CUS incidence of deep vein thrombosis (DVT) of 2 to 3%. A post-CUS DVT incidence of 3% implicates that 90 to 120 DVTs per 1 million inhabitants will be overlooked each year indicating the need to improve the diagnostic work-up of DVT as much as possible. ⋯ The rapid ELISA VIDAS D-dimer assay has a sensitivity and NPV of 98.6 and 99.5% in two management studies for the exclusion of DVT irrespective of clinical score. The combination of a normal ELISA VIDAS D-Dimer test with clinical score assessment will reduce the post-test DVT incidence of less than 0.5% and the need for CUS testing by 40 to 50%. It is concluded that the sequential use of a rapid quantitative D-dimer test, clinical score and CUS appears to be safe and the most cost-effective diagnostic work-up of DVT.
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Pulmonary angiography is the gold standard for segmental pulmonary embolism (PE) but no longer for subsegmental PE, because the inter-observer agreement for angiographically documented subsegmental PE is only 60%. Two non-invasive tools exclude PE with a negative predictive value of >99% : a normal perfusion lung scan and a normal rapid ELISA VIDAS D-dimer test. The positive predictive value is 85 to 88% for a high probability ventilation-perfusion lung scan (VP-scan) and >95% for helical spiral CT. ⋯ Single-slice helical CT as the primary diagnostic test in patients with suspected PE in three retrospective studies and in two prospective management study indicate that the negative predictive value of a normal helical spiral CT, a negative compression ultrasonography of the legs (CUS) together with a low or intermediate pre-test clinical probability is >99%. Therefore, helical spiral CT can replace both the VP-scan and pulmonary angiography to safely rule in and out PE. The combination of clinical assessment, a rapid ELISA VIDAS D-dimer followed by CUS will reduce the need for helical spiral CT by 40 to 50%.