Andrew Ryan¹, Mark Ferguson¹, Mohammed Hassan¹, Aaron Niblock^1,2

¹Antrim Area Hospital, N. Ireland

²Ulster University, School of Medicine, N. Ireland

Corresponding Author: Aaron Niblock, Haematology Department, Antrim Area Hospital, Northern Ireland; School of Medicine, Ulster University, Northern Ireland

Citation: Andrew Ryan, Mark Ferguson, Mohammed Hassan, Aaron Niblock (2023). Diagnostic Challenge of D-dimer Negative Upper Extremity DVT. World J Case Rep Clin Imag. 2023 November-December; 2(2)1-4.

Copyrights © 2023, Aaron Niblock, et al. This article is licensed under the Creative Commons Attribution-Non-Commercial-4.0-International-License-(CCBY-NC) (https://worldjournalofcasereports.org/blogpage/copyright-policy). Usage and distribution for commercial purposes require written permission.

Abstract

Studies suggest D-Dimer has a high sensitivity with negative predictive value for upper extremity DVT (UEDVT). Sensitivity is around 92% with a negative predictive value of 98%. UEDVT is an uncommon presentation with an incidence rate of 4-10%. Risk factors for UEDVT include thrombophilia, central venous catheters, malignancy, pacemakers and upper limb surgery and/or immobilisation. The use of scoring systems for assessing UEDVT risk is less well known and therefore poorly utilised. A scoring system similar to a Wells' score, known as Constans criteria, is a 2 level scoring system developed and first published in 2008. The Criteria considers, venous material in-situ, localised pain, unilateral oedema and plausibility of alternative cause. Score interpretation; -1 to 0 points (low probability of UEDVT 12%), 1 point (intermediate probability 20%), 2 to 3 points (high probability 70%).  Kleinjan, et al., sought further improved upon this scoring tool by incorporating D-dimer results in the stratification of intermediate risk patients, asserting that its use can safely and effectively exclude venous thrombosis of the upper extremity. This case series shows 2 patients diagnosed with UEDVT. both patients had a Constans score of 1 therefore prompting use of D-Dimer results to stratify risk. Irrespective of negative D-dimer results, ultrasound doppler scans where performed and appropriate treatment given. The authors of this case series reviewed the limitations/interference factors of HemosIL HS D-Dimer reagent, along with 2 other D-Dimer reagents and subsequently developed recommendations which may be useful in interpretation of D-Dimers in clinical practice. Additionally, recommendation for cautious intrepretation of D-Dimer results in conjunction the Constans scoring tool with scores of 1 or less.

Background

Studies suggest D-Dimer has a high sensitivity with negative predictive value for upper extremity DVT (UEDVT). Sensitivity is around 92% with a negative predictive value of 98%. UEDVT is an uncommon presentation with an incidence rate of 4-10%. Overall DVT has an incidence of 1 per 1000 per year [1]. Risk factors for UEDVT include thrombophilia, central venous catheters, malignancy, pacemakers and upper limb surgery and/or immobilisation. With or without these risk factors; Paget Schroetter Syndrome is a well-recognised form of UEDVT. Paget Schroetter Syndrome is thrombosis of the axillary and subclavian veins induced through mechanical effort compressing the subclavian vein at the thoracic outlet [2]. Though a 2 level Wells' Score is largely used for the assessment of lower limb DVT, use of scoring systems for assessing UEDVT risk is less well known and therefore poorly utilised [3].

A scoring system similar to a Wells' score, known as Constans score or Constans criteria, is a 2 level scoring system developed and first published in 2008. The Criteria considers, venous material insitu, localised pain, unilateral oedema and plausibility of alternative cause. Score interpretation; -1 to 0 points (low probability of UEDVT 12%), 1 point (intermediate probability 20%), 2 to 3 points (high probability 70%) [4]. Kleinjan, et al., sought further improved upon this scoring tool by incorporating D-dimer results in the stratification of intermediate risk patients, asserting that its use can safely and effectively exclude venous thrombosis of the upper extremity [8]. In both of the following cases presented the Constans score was 1 prompting the use of D-dimer to discriminate for probable UEDVT.