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Suspected proximal deep vein thrombosis — MSRA MCQ

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Moderateall topics relevant for this examSuspected proximal deep vein thrombosisMSRA

A 45-year-old woman presents with 3 days of left calf pain and swelling after a 6-hour coach journey. She has no previous venous thromboembolism, active cancer, recent surgery, paralysis or immobilisation. She has no chest pain, breathlessness or haemoptysis. Examination shows localised tenderness along the deep venous system, pitting oedema confined to the left leg, and a calf circumference 4 cm greater than the right when measured 10 cm below the tibial tuberosity. There is no cellulitis, muscle injury or Baker's cyst to provide an alternative diagnosis at least as likely as deep vein thrombosis. She is haemodynamically stable and has no contraindication to anticoagulation. The local urgent DVT pathway confirms that a proximal leg vein ultrasound result cannot be obtained for 16 hours. A D-dimer result will be available within 2 hours. What is the most appropriate management now?

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Correct answer: B — Take a D-dimer sample, start interim therapeutic anticoagulation, and arrange proximal leg vein ultrasound with a result within 24 hours

Her two-level DVT Wells score is 3: localised tenderness along the deep venous system, calf swelling greater than 3 cm, and pitting oedema confined to the symptomatic leg. DVT is therefore likely (Wells score 2 or more). NICE recommends proximal leg vein ultrasound with a result within 4 hours where possible. If this cannot be achieved, a D-dimer sample should be taken, interim therapeutic anticoagulation started, and proximal ultrasound arranged with a result within 24 hours. A is the pathway for DVT unlikely when a timely D-dimer result is available. B omits required interim anticoagulation while diagnostic imaging is delayed. C appropriately starts interim treatment but allows an excessive delay to imaging and omits D-dimer testing. E incorrectly makes interim anticoagulation conditional on the D-dimer result; in a likely DVT with delayed imaging, anticoagulation should start after the sample is taken, without awaiting the result. Long-term anticoagulation should not be committed to unless DVT is confirmed.

Reference: NICE NG158: Venous thromboembolic diseases: diagnosis, management and thrombophilia testing — Recommendations (Last updated 2 August 2023) — https://www.nice.org.uk/guidance/ng158/chapter/Recommendations