Key Points

  • The diagnosis of recurrent ipsilateral DVT is challenging because of persistent intravascular abnormalities after previous DVT.

  • The incidence of VTE recurrence after negative MRDTI was low, and MRDTI proved to be a feasible and reproducible diagnostic test.

Abstract

The diagnosis of recurrent ipsilateral deep vein thrombosis (DVT) is challenging, because persistent intravascular abnormalities after previous DVT often hinder a diagnosis by compression ultrasonography. Magnetic resonance direct thrombus imaging (MRDTI), a technique without intravenous contrast and with a 10-minute acquisition time, has been shown to accurately distinguish acute recurrent DVT from chronic thrombotic remains. We have evaluated the safety of MRDTI as the sole test for excluding recurrent ipsilateral DVT. The Theia Study was a prospective, international, multicenter, diagnostic management study involving patients with clinically suspected acute recurrent ipsilateral DVT. Treatment of the patients was managed according to the result of the MRDTI, performed within 24 hours of study inclusion. The primary outcome was the 3-month incidence of venous thromboembolism (VTE) after a MRDTI negative for DVT. The secondary outcome was the interobserver agreement on the MRDTI readings. An independent committee adjudicated all end points. Three hundred five patients were included. The baseline prevalence of recurrent DVT was 38%; superficial thrombophlebitis was diagnosed in 4.6%. The primary outcome occurred in 2 of 119 (1.7%; 95% confidence interval [CI], 0.20-5.9) patients with MRDTI negative for DVT and thrombophlebitis, who were not treated with any anticoagulant during follow-up; neither of these recurrences was fatal. The incidence of recurrent VTE in all patients with MRDTI negative for DVT was 1.1% (95% CI, 0.13%-3.8%). The agreement between initial local and post hoc central reading of the MRDTI images was excellent (κ statistic, 0.91). The incidence of VTE recurrence after negative MRDTI was low, and MRDTI proved to be a feasible and reproducible diagnostic test. This trial was registered at www.clinicaltrials.gov as #NCT02262052.

REFERENCES

REFERENCES
1.
Dronkers
CE
,
Klok
FA
,
Huisman
MV
.
Current and future perspectives in imaging of venous thromboembolism
.
J Thromb Haemost
.
2016
;
14
(
9
):
1696
-
1710
.
2.
Huisman
MV
,
Klok
FA
.
Current challenges in diagnostic imaging of venous thromboembolism
.
Blood
.
2015
;
126
(
21
):
2376
-
2382
.
3.
Tan
M
,
Velthuis
SI
,
Westerbeek
RE
,
van Rooden
CJ
,
van der Meer
FJ
,
Huisman
MV
.
High percentage of non-diagnostic compression ultrasonography results and the diagnosis of ipsilateral recurrent proximal deep vein thrombosis
.
J Thromb Haemost
.
2010
;
8
(
4
):
848
-
850
.
4.
Piovella
F
,
Crippa
L
,
Barone
M
, et al
.
Normalization rates of compression ultrasonography in patients with a first episode of deep vein thrombosis of the lower limbs: association with recurrence and new thrombosis
.
Haematologica
.
2002
;
87
(
5
):
515
-
522
.
5.
Barco
S
,
Konstantinides
S
,
Huisman
MV
,
Klok
FA
.
Diagnosis of recurrent venous thromboembolism
.
Thromb Res
.
2018
;
163
:
229
-
235
.
6.
Prandoni
P
,
Cogo
A
,
Bernardi
E
, et al
.
A simple ultrasound approach for detection of recurrent proximal-vein thrombosis
.
Circulation
.
1993
;
88
(
4, pt 1
):
1730
-
1735
.
7.
Prandoni
P
,
Lensing
AW
,
Bernardi
E
,
Villalta
S
,
Bagatella
P
,
Girolami
A
;
DERECUS Investigators Group
.
The diagnostic value of compression ultrasonography in patients with suspected recurrent deep vein thrombosis
.
Thromb Haemost
.
2002
;
88
(
3
):
402
-
406
.
8.
Le Gal
G
,
Kovacs
MJ
,
Carrier
M
, et al
.
Validation of a diagnostic approach to exclude recurrent venous thromboembolism
.
J Thromb Haemost
.
2009
;
7
(
5
):
752
-
759
.
9.
Bates
SM
,
Jaeschke
R
,
Stevens
SM
, et al
.
Diagnosis of DVT: antithrombotic therapy and prevention of thrombosis, 9th ed: American College of Chest Physicians evidence-based clinical practice guidelines
.
Chest
.
2012
;
141
(
suppl 2
):
e351S
-
e418S
.
10.
Linkins
LA
,
Stretton
R
,
Probyn
L
,
Kearon
C
.
Interobserver agreement on ultrasound measurements of residual vein diameter, thrombus echogenicity and Doppler venous flow in patients with previous venous thrombosis
.
Thromb Res
.
2006
;
117
(
3
):
241
-
247
.
11.
Moody
AR
.
Magnetic resonance direct thrombus imaging
.
J Thromb Haemost
.
2003
;
1
(
7
):
1403
-
1409
.
12.
Fraser
DG
,
Moody
AR
,
Morgan
PS
,
Martel
AL
,
Davidson
I
.
Diagnosis of lower-limb deep venous thrombosis: a prospective blinded study of magnetic resonance direct thrombus imaging
.
Ann Intern Med
.
2002
;
136
(
2
):
89
-
98
.
13.
Tan
M
,
Mol
GC
,
van Rooden
CJ
, et al
.
Magnetic resonance direct thrombus imaging differentiates acute recurrent ipsilateral deep vein thrombosis from residual thrombosis
.
Blood
.
2014
;
124
(
4
):
623
-
627
.
14.
Klok
FA
,
Tan
M
,
Huisman
MV
.
Letter by Klok et al regarding article, “18F-fluorodeoxyglucose positron emission tomography/computed tomography enables the detection of recurrent same-site deep vein thrombosis by illuminating recently formed, neutrophil-rich thrombus” [letter]
.
Circulation
.
2015
;
131
(
24
):
e530
.
15.
Westerbeek
RE
,
Van Rooden
CJ
,
Tan
M
, et al
.
Magnetic resonance direct thrombus imaging of the evolution of acute deep vein thrombosis of the leg
.
J Thromb Haemost
.
2008
;
6
(
7
):
1087
-
1092
.
16.
Konstantinides
SV
,
Torbicki
A
,
Agnelli
G
, et al
.
2014 ESC guidelines on the diagnosis and management of acute pulmonary embolism
.
Eur Heart J
.
2014
;
35
(
43
):
3033
-
3069
, 3069a-3069k.
17.
Dronkers
CEA
,
Klok
FA
,
van Langevelde
K
, et al
.
Diagnosing recurrent DVT of the leg by two different non-contrast-enhanced magnetic resonance direct thrombus imaging techniques: a pilot study
.
TH Open
.
2019
;
3
(
1
):
e37
-
e44
.
18.
Huisman
MV
,
Klok
FA
.
Diagnostic management of acute deep vein thrombosis and pulmonary embolism
.
J Thromb Haemost
.
2013
;
11
(
3
):
412
-
422
.
19.
van der Hulle
T
,
Cheung
WY
,
Kooij
S
, et al;
YEARS study group
.
Simplified diagnostic management of suspected pulmonary embolism (the YEARS study): a prospective, multicentre, cohort study [published correction appears Lancet. 2017;390(10091)230]
.
Lancet
.
2017
;
390
(
10091
):
289
-
297
.
20.
van der Pol
LM
,
Tromeur
C
,
Bistervels
IM
, et al;
Artemis Study Investigators
.
Pregnancy-adapted YEARS algorithm for diagnosis of suspected pulmonary embolism
.
N Engl J Med
.
2019
;
380
(
12
):
1139
-
1149
.
21.
Cohen
J
.
Weighted kappa: nominal scale agreement with provision for scaled disagreement or partial credit
.
Psychol Bull
.
1968
;
70
(
4
):
213
-
220
.
22.
Klok
FA
,
Pruefer
D
,
Rolf
A
,
Konstantinides
SV
.
Magnetic resonance direct thrombus imaging for pre-operative assessment of acute thrombosis in chronic thromboembolic pulmonary hypertension
.
Eur Heart J
.
2019
;
40
(
11
):
944
.
23.
Rodger
MA
,
Le Gal
G
,
Anderson
DR
, et al;
REVERSE II Study Investigators
.
Validating the HERDOO2 rule to guide treatment duration for women with unprovoked venous thrombosis: multinational prospective cohort management study
.
BMJ
.
2017
;
356
:
j1065
.
24.
Tan
M
,
Mos
IC
,
Klok
FA
,
Huisman
MV
.
Residual venous thrombosis as predictive factor for recurrent venous thromboembolism in patients with proximal deep vein thrombosis: a sytematic review
.
Br J Haematol
.
2011
;
153
(
2
):
168
-
178
.
25.
Kahn
SR
,
Comerota
AJ
,
Cushman
M
, et al;
American Heart Association Council on Peripheral Vascular Disease, Council on Clinical Cardiology, and Council on Cardiovascular and Stroke Nursing
.
The postthrombotic syndrome: evidence-based prevention, diagnosis, and treatment strategies: a scientific statement from the American Heart Association [published correction appears in Circulation. 2015;131(8):e359]
.
Circulation
.
2014
;
130
(
18
):
1636
-
1661
.
26.
Dronkers
CEA
,
Klok
FA
,
van Haren
GR
, et al
.
Diagnosing upper extremity deep vein thrombosis with non-contrast-enhanced magnetic resonance direct thrombus imaging: a pilot study
.
Thromb Res
.
2018
;
163
:
47
-
50
.
27.
Dronkers
CE
,
Sramek
A
,
Huisman
MV
,
Klok
FA
.
Accurate diagnosis of iliac vein thrombosis in pregnancy with magnetic resonance direct thrombus imaging (MRDTI)
.
BMJ Case Rep
.
2016
;218091.
28.
Yang
Q
,
Duan
J
,
Fan
Z
, et al
.
Early detection and quantification of cerebral venous thrombosis by magnetic resonance black-blood thrombus imaging [published correction appears in Stroke. 2016;47(2):e39]
.
Stroke
.
2016
;
47
(
2
):
404
-
409
.
29.
Dronkers
CEA
,
Ende-Verhaar
YM
,
Kyrle
PA
, et al;
Subcommittee on Predictive and Diagnostic Variables in Thrombotic Disease
.
Disease prevalence dependent failure rate in diagnostic management studies on suspected deep vein thrombosis: communication from the SSC of the ISTH
.
J Thromb Haemost
.
2017
;
15
(
11
):
2270
-
2273
.
You do not currently have access to this content.