Deep Venous Thrombosis in a Patient with a Moderate Pretest Probability and a Negative D-Dimer Test: A Review of the Diagnostic Algorithms

Abstract

Modern diagnostic strategies of venous thromboembolism (VTE) have been developed. In this review, the diagnostic algorithms for deep-vein thrombosis (DVT) and their parameters are discussed individually in the context of reporting a case of DVT in a 43-year-old Caucasian female with a moderate pretest probability stratified by Wells’ score and a negative high quality D-dimer test. The patient was on treatment with Xarelto (rivaroxaban), 20 mg PO daily at the time of presentation. The diagnosis was verified through a complete lower limb ultrasound (US). This case highlights the diagnostic challenges and pitfalls of the current algorithms, especially those seen in a subgroup of patients such as patients with cancer, pregnancy, recurrent VTE or are on anticoagulation therapy at the time of presentation. The diagnosis of DVT is less plausible in a patient who is on anticoagulation therapy, but physicians should be aware of such a possibility. Physicians should also know in advance the numerous clinically relevant limitations of D-dimer testing before interpreting the results. Unifying the current diagnostic strategies, modifying the current Wells’ score and using the protocol of a whole-leg compression US instead of the limited US protocol are among the several cautious suggestions that have been proposed based on this review to possibly decrease the incidence of missed DVT.

Keywords:

• compression ultrasound
• recurrent thrombosis
• rivaroxaban
• Wells’ score

Acknowledgment

The authors sincerely thank the patient for agreeing to publish anonymously this case in an attempt to contribute to the review of the current guidelines, and the two anonymous reviewers for their careful reading of the manuscript and insightful suggestions. The authors also thank the department of Cardiology at Nordsjælland (North Zealand) University Hospital for their financial support in completing the publication of the manuscript.

Ethics

The patient’s oral consent for publication of the case details was witnessed by documenting it in the patient’s official electronic system. No institutional approval was required to publish the case details.

Disclosure

The authors report no conflicts of interest in this work.

Additional information

Funding

This is a noncommercial research. The authors did not receive any form of funding for the presented review.