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Northwest Bill,

Larry (I believe *Dr.* Needleman?) this response is awesome, and thank you
for posting it.  I am a long-standing advocate of "groin to ankle" venous
exams, or perhaps "ankle to groin"?  I always start distally.  I admit
anguish when I find venous thrombosis in the distal veins without symptoms
of PE, and the dilemma we put to the referring physician.

I would never want to be in their place, making those decisions that might
heal but might cause death as well.  I think you are a "reasonable person"
and I do not have a stopwatch.  I have been privileged to work at places
that did not hold "through-put" above accuracy.

I always told my employers; "I am slow, but it is because I am careful"
although, to my mind it because I have so much to learn.

You do address the issue of looking below the knee.  What we find there may
not be important, but I support the idea that we should look.  I only hope
the folks we report our findings to understand what those findings mean as
well as you obviously do.

I thank you, sincerely, for your post, and just as sincerely hope my fellow
Flownetters consider your posting carefully.  There are so many issues you
present that we all should consider. And I so much appreciate the fact that
you cite references.




On Sun, Oct 28, 2012 at 8:24 AM, Larry Needleman <[log in to unmask]> wrote:

> Let me preface this by saying I work with both the IAC and Radiology
> standards and my own lab scans from thigh to ankle.  Medical staff, not
> administrators (or anyone with a stop watch), should determine how medical
> testing gets performed.
>
> But not everyone who scans to the knee (and not below it) is jeopardizing
> patients or even doing a bad job.
>
> BTW, the AIUM-ACR standard DOES recommend scanning below the knee
> when the study does not explain the patient's symptoms, e.g. calf pain
> with a
> negative femoropopliteal study.
> "Symptomatic areas such as the calf generally require additional evaluation
> and additional images if the cause of the symptoms is not readily
> elucidated
> by the standard examination."
> "The patient presentation, clinical indication, or clinical management
> pathways
> may require protocol adjustments such as more detailed evaluation of the
> superficial venous system, evaluation of the deep calf veins, or a
> bilateral
> study."
>
> While it is true that many DVT are totally or in part below the knee,
> there are
> reasonable people who think scanning below the knee is NOT necessary for
> all
> patients.
>
> Many centers, especially Europeans and North American internal medicine
> groups, use 2 thigh to knee ultrasounds a week apart. This requires two
> scans
> for moderate to high risk groups and no further scanning for low risk
> groups
> or those with negative d-dimer (I recognize how few patients get good
> evaluation before coming to a lab and this is one reason while I personally
> support the complete examination). This approach is well researched and is
> safe.
>
> The current anticoagulation guidelines from the Chest Physicians support
> this.
> The chapters are hundreds of pages long and have a VERY long chapter on
> diagnosing DVT. The guidelines do not recommend treating everyone with calf
> DVT and support tailoring imaging to diagnose treatable conditions rather
> than
> all DVT (i.e. calf DVT)
>
> How did they come to this conclusion.
> 1) Very few people evaluated have DVT, they have something else.
> 2) The minority of patients with calf DVT will propagate to above the knee
> (about 20%).
> 3) Larger veins are more likely to cause symptomatic PE, calf veins not at
> all
> or only rarely.
> 4) There is weak evidence that treating calf DVT affects the rate of
> chronic
> venous insufficiency or recurrent DVT. (Obviously more work needs to be
> done
> since it makes some sense that treating a disease earlier should help).
> 5) The risks of anticoagulation are real and the risks of overtreating
> insignificant calf DVT may outweigh the benefit of treating calf DVTs which
> have a more aggressive natural history.
>
> 1.      Guyatt GH, Akl EA, Crowther M, Gutterman DD, Schuunemann HJ, for
> the American College of Chest Physicians Antithrombotic Therapy and
> Prevention of Thrombosis Panel. Executive Summary: Antithrombotic Therapy
> and Prevention of Thrombosis, 9th ed: American College of Chest Physicians
> Evidence-Based Clinical Practice Guidelines. Chest. 2012Feb.6;141(2
> suppl):7S47S.
> 2.      Bates SM, Jaeschke R, Stevens SM, Goodacre S, Wells PS, Stevenson
> MD, et al. Diagnosis of DVT: Antithrombotic Therapy and Prevention of
> Thrombosis, 9th ed: American College of Chest Physicians Evidence-Based
> Clinical Practice Guidelines. Chest. 2012Feb.6;141(2 suppl):e351Se418S.
>
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