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Diagnosis of venous thrombosis during COVID-19

Diagnosis of venous thrombosis during COVID 19

How to suspect and diagnose venous thrombosis during the COVID-19 pandemic, according to the recommendations of the European Society of Vascular Surgeons - a detailed algorithm.

Thanks to the media, a situation is now emerging that resembles mass hysteria. Many patients who have had a COVID-19 infection and experience any discomfort in the lower extremities immediately take a coagulogram (or even more often the famous D-dimer) in order to be safe from deep vein thrombosis. During these times, it is especially important to maintain common sense and to assess the situation critically, and current clinical guidelines can help with this.

Looking ahead, there are several important things to note. First, there are special valid scales that assess the risk of venous thrombosis (low, medium or high) and determine the need for additional tests (Wells scale). Secondly, a slight increase in coagulogram indicators (for example, PT or INR) in the level of platelets in the general blood test, or the level of D-dimer is NOT a predictor of an increased risk of venous thrombosis, and should not be a cause for panic.

So in case of suspicion of deep vein thrombosis, the first step in the diagnostic algorithm should be to determine the risk according to the Wells scale (recommendation level I C). This is a simple clinical tool that includes 9 questions. Physicians can keep a link to this handy clinical calculator and use this tool in their routine: Wells Scale.

If, after calculating the points of this scale, a result of a moderate or high risk of thrombosis is obtained, then the patient must undergo an ULTRASONIC compression study, which has an extremely high level of specificity (97.8%) and sensitivity (96.5%) to exclude venous thrombosis of the proximal localization ( the most dangerous in relation to thromboembolic complications) - recommendation level I C.

If the risk is low or ultrasound is not available, a laboratory test such as D-dimer level may be considered. This analysis has a high negative predictive value, which means that if the indicators are within the normal range, then this, in fact, with 100% probability, gives the doctor the right to exclude the diagnosis of venous thrombosis. At the same time, this figure rises slightly in fact in most inflammatory and infectious diseases, including COVID-19. It is interesting to note an example of one of the studies in which in the case of D-dimer values ​​<2,000 ng / ml (or 2 FEU / ml) almost 4 times higher than the norm (!!!), not a single case of venous thrombosis was confirmed, because in most situations in the presence of an active thrombotic process, this indicator increases, if not tens, then hundreds of times! Therefore, if the D-dimer is elevated in this range (which is a normal situation after an acute COVID-19 infection), this should not be an urgent reason to sound the alarm, especially in the absence of symptoms and low risk on the Wells scale. But in the case of a positive test, an ultrasound examination is imperative.

In cases where ultrasound findings do not reveal signs of thrombosis, but clinical suspicion persists, it is possible to repeat the ultrasound after 5-7 days (recommendation level IIa C) or consider performing CT or MR venography (recommendation level IIa C).

The full text of the ESVS Clinical Guidelines can be found at ESVS Guideline 2021 Therefore, it is worth using evidence-based approaches for the diagnosis of venous thrombosis, stay critical thinking in these difficult times.

The Angiolife Vascular Center performs a full range of diagnostics (performing ultrasound duplex scanning of veins and prescribing additional examinations if necessary) of deep vein thrombosis, including those associated with coagulopathies in COVID-19 infection.

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