title: Emergency Department Management of Suspected Calf-Vein Deep Venous Thrombosis: A Diagnostic Algorithm.
abstract: BACKGROUND
  Unilateral leg swelling with suspicion of deep venous thrombosis (DVT) is a common emergency department (ED) presentation. Proximal DVT (thrombus in the popliteal or femoral veins) can usually be diagnosed and treated at the initial ED encounter. When proximal DVT has been ruled out, isolated calf-vein deep venous thrombosis (IC-DVT) often remains a consideration. The current standard for the diagnosis of IC-DVT is whole-leg vascular duplex ultrasonography (WLUS), a test that is unavailable in many hospitals outside normal business hours. When WLUS is not available from the ED, recommendations for managing suspected IC-DVT vary. The objectives of the study is to use current evidence and recommendations to (1) propose a diagnostic algorithm for IC-DVT when definitive testing (WLUS) is unavailable; and (2) summarize the controversy surrounding IC-DVT treatment.
  
  
  CONCLUSIONS
  The Figure combines D-dimer testing with serial CUS or a single deferred FLUS for the diagnosis of IC-DVT. Such an algorithm has the potential to safely direct the management of suspected IC-DVT when definitive testing is unavailable. Whether or not to treat diagnosed IC-DVT remains widely debated and awaiting further evidence.
  
  
  CONCLUSIONS
  When IC-DVT is not ruled out in the ED, the suggested algorithm, although not prospectively validated by a controlled study, offers an approach to diagnosis that is consistent with current data and recommendations. When IC-DVT is diagnosed, current references suggest that a decision between anticoagulation and continued follow-up outpatient testing can be based on shared decision-making. The risks of proximal progression and life-threatening embolization should be balanced against the generally more benign natural history of such thrombi, and an individual patient's risk factors for both thrombus propagation and complications of anticoagulation.
authors.affiliation: Naval Medical Center Portsmouth, Emergency Department, Portsmouth, Virginia.
authors.forename: Levi
authors.initials: L
authors.lastname: Kitchen
authors.affiliation: Naval Medical Center Portsmouth, Emergency Department, Portsmouth, Virginia.
authors.forename: Matthew
authors.initials: M
authors.lastname: Lawrence
authors.affiliation: Naval Medical Center Portsmouth, Emergency Department, Portsmouth, Virginia.
authors.forename: Matthew
authors.initials: M
authors.lastname: Speicher
authors.affiliation: Naval Medical Center Portsmouth, Emergency Department, Portsmouth, Virginia.
authors.forename: Kenneth
authors.initials: K
authors.lastname: Frumkin
mesh_terms: D000465:Algorithms; D000925:Anticoagulants / Q000627:therapeutic use; D004636:Emergency Service, Hospital; D019317:Evidence-Based Medicine; D005338:Fibrin Fibrinogen Degradation Products / Q000627:therapeutic use; D006297:Health Services Accessibility; D006801:Humans; D007866:Leg / Q000098:blood supply*; D017410:Practice Guidelines as Topic; D011237:Predictive Value of Tests; D016896:Treatment Outcome; D018616:Ultrasonography, Doppler, Duplex / Q000706:statistics & numerical data; D020246:Venous Thrombosis / Q000175:diagnosis* / Q000503:physiopathology / Q000628:therapy
chemical_list: D000925:Anticoagulants; D005338:Fibrin Fibrinogen Degradation Products; C036309:fibrin fragment D