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ISOLATED DISTAL DEEP VEIN THROMBOSIS IN SYMPTOMATIC AMBULATORY PATIENTS: A PROSPECTIVE DATA ANALYSIS AND THERAPEUTIC FEASIBILITY STUDY
[Thesis]. Manchester, UK: The University of Manchester; 2013.
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Abstract
Isolated distal deep vein thrombosis (IDDVT) is a condition recently suggested to be a different entity to that of proximal disease. There is currently little evidence defining the clinical importance of detection and treatment. International guidelines vary regarding management advice.An observational cohort study, prospective service evaluation and pilot randomised controlled trial were performed within a United Kingdom ambulatory thrombosis service. This project aimed to describe the burden of disease and explore three poorly researched aspects of IDDVT assessment and management: whole-leg compression ultrasound (CUS) performed by non-physicians within an ambulatory framework as a principal diagnostic modality; clinical presentation data and risk profile in comparison to that of proximal disease; the feasibility of further interventional randomised research and the risk/benefit profile of therapeutic anticoagulation.Within this ambulatory cohort, IDDVT accounted for 49.7% of acute thrombosis and differed significantly to proximal disease regarding provocation and symptomatology at clinical presentation. A negative whole-leg CUS excluded deep vein thrombosis with an adverse event rate (diagnosis of symptomatic venous thromboembolism during the 3 month follow up period) of 0.47% (95% CI 0.08 to 2.62). Future interventional research was proved feasible within an ambulatory setting.The randomised controlled trial conducted within this project is the largest to date comparing therapeutic anticoagulation against conservative strategy for the management of acute IDDVT. Patients allocated to therapeutic anticoagulation had significantly less overall propagation of thrombus (Absolute risk reduction [ARR] 25.7%, 95% Confidence interval 5.9 to 44.3 p<0.01), less short-term symptomatic progression (ARR 16.7%, 95% CI 2.6 to 32.1 p=0.05) and a result trending towards significance for reduction in serious thromboembolic complications (ARR 11.4%, 95% CI -1.5 to 26.7 p=0.11).IDDVT is a condition of equal prevalence to proximal venous thrombosis, which varies significantly regarding risk profile and clinical presentation. Using a single whole leg CUS reported by a non-physician within an emergency department pathway is associated with a low adverse event rate. This contemporary data also suggests that therapeutic anticoagulation is beneficial for reduction of short-term complications in IDDVT. The risk of false positive diagnosis and excess anticoagulation remains.This data can inform and direct future design of adequately powered randomised studies, in order to attempt external validation of these findings.