Diagnosis of DVT and PE?

[PharmlyDoc]

What is the GOLD standard diagnosis for DVT and for PE?

For diagnosis of DVT, most literature states contrast venography as gold standard, but other literature is mentioning compression ultrasonography?

For PE the literature states that pulmonary angiography is the gold standard for diagnosis?

Is there a medical association that has a consensus statement on the gold standard(s) for diagnosis of VTE?

Any help or guidance would be greatly appreciated.

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[CherryRedDracul]

The historic gold standard examination for diagnosing DVT is contrast venography. But that is different from being the practical and preferred imaging modality.

The preferred initial imaging modality for diagnosing DVT is compression ultrasonography as it is noninvasive, portable, and does not involve injecting intravenous contrast into the patient. Contrast venography is reserved for difficult and equivocal cases in which preferred imaging was not adequate.

That is the position of the American College of Radiology (ACR). They have the ACR Appropriateness Criteria published to help radiologists and non-radiologists understand preferred imaging for various conditions and their pros and cons.

https://acsearch.acr.org/docs/69416/Narrative/

 

[CaptainSSO]

I think with today’s multidetector CTs, CTA and CTV will be even better than catheter based angiogram/venogram for diagnosing thromboemboli. I think most radiologists would agree the clot is actually much easier to see on the CTA/CTV than on angio. There’s exceptions, like if you’re worried about venous thoracic outlet syndrome a catheter based venogram is good because you can abduct the arm to see if you can reproduce the obstruction. But generally you won’t do a real angiogram/venogram unless you want to try to lyse the clot.

But basically your first choice exams are CTPA for PE and ultrasound for DVT.

 

[colbgw02]

ultrasound for DVT. CTV has a role if the vein is noncompressible by virtue of its location, e.g. may-thurner syndrome. i'll add that timing the contrast for a CTV is problematic, although CTVs of the head work well for sinus thrombosis evaluation.

CTAs of the chest (CTPAs) have replaced conventional angiography for PE.

 

[PharmlyDoc]

Is there a different approach to the diagnosis of an arterial clot?

 

[colbgw02]

ultrasound is general first-line for the extremities and carotids, particularly in the setting of chronic symptoms. CTA is used for the head, torso, etc., if there's acute pathology (e.g. stroke, blue toe), or if endovascular intervention is pending.

 

[jdh71]

Good luck finding a radiologist who still remembers how to do a pulmonary angiogram!

 

[CherryRedDracul]

Good luck finding a radiologist who still remembers how to do a pulmonary angiogram!

I know an interventional radiologist who can. But he's been in practice for about 50 years or so.

 

[mimelim]

Good luck finding a radiologist who still remembers how to do a pulmonary angiogram!

I'm no radiologist, but I've done maybe 6 since the start of this month...

 

[jdh71]

I'm no radiologist, but I've done maybe 6 since the start of this month...

Noh wai?!

 

[nimbus]

Good luck finding a radiologist who still remembers how to do a pulmonary angiogram!

Shoot some dye through a pa catheter. Am I missing something??

 

[mimelim]

Noh wai?!

Been running a special on PEs. Two massive PEs, five sub-massives last week. We are fairly aggressive with our CDT, hence multiple pulmonary angios per patient. I guess technically those numbers include the weekend/tail end of June, but the point is, skill set is alive and well

 

[jdh71]

Shoot some dye through a pa catheter. Am I missing something??

I don't know.

 

[jdh71]

Been running a special on PEs. Two massive PEs, five sub-massives last week. We are fairly aggressive with our CDT, hence multiple pulmonary angios per patient. I guess technically those numbers include the weekend/tail end of June, but the point is, skill set is alive and well

Cool.