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Ann R Coll Surg Engl. 2009 May; 91(4): 355.
PMCID: PMC2749427

Another Nail in the Coffin for Role of D-Dimer in Diagnosis of Postoperative Deep Vein Thrombosis!

The authors must be commended on their elaborate effort to prove the futility of D-dimer testing in postoperative patients. Innumerable studies have been done to try and prove the usefulness of D-dimer testing along with pre-test probability score, all aimed at avoiding expensive imaging.13 The study could have been more meaningful if they had clarified the following issues:

  1. The specificity and sensitivity of D-dimer levels vary with the type of test-enzyme-linked immunofluorescence assay (ELFA), microplate enzyme-linked immunosorbent assay (ELISA) or latex quantitative assay; the authors have not mentioned which test type did they use.4
  2. In the historical controls, only 37% patients had deep vein thrombosis (DVT) on or before day 7 after joint replacement surgery. The assessment of D-dimers pre-operatively and on postoperative days 1, 3, 5, 7 and duplex imaging on day 7 would have missed out a major proportion of patients likely to develop DVT (up to 63%). Considering the fact that the authors first presented this work in 2005, follow-up data on these 78 patients, if available, could have made the present publication more meaningful.
  3. The value of day 1 D-dimer in the published abstracts5,6 of their presentations is 3.63 compared to 3.39 in the present article, without any obvious change in any other numbers, probably a typing error in the present article.

D-Dimer should remain as a screening test for proximal DVT and pulmonary embolism for out-patients with low clinical probability of DVT, where it obviates the need for a duplex ultrasound examination. Positive D-dimer, irrespective of its value, has little meaning when the probability of clinical DVT is high.

References

1. Yamaki T, Nozaki M, Sakurai H, Takeuchi M, Soejima K, Kono T. Uses of different D-dimer levels can reduce the need for venous duplex scanning to rule out deep vein thrombosis in patients with symptomatic pulmonary embolism. J Vasc Surg. 2007;46:526–32. [PubMed]
2. Wells PS, Owen C, Doucette S, Fergusson D, Tran H. Does this patient have deep vein thrombosis? JAMA. 2006;295:199–207. [PubMed]
3. Fancher TL, White RH, Kravitz RL. Combined use of rapid D-dimer testing and estimation of clinical probability in the diagnosis of deep vein thrombosis: systemic review. BMJ. 2004;329:821. [PMC free article] [PubMed]
4. Di Nisio M, Squizzato A, Rutjes AW, Buller HR, Zwinderman AH, Bossuyt PM. Diagnostic accuracy of D-dimer test for exclusion of venous thromboembolism: a systemic review. J Thromb Haemost. 2007;5:296–304. [PubMed]
5. Rafee A, McLauchlan GJ, Gilbert R, Herlikar D. Usefulness of plasma D-dimer levels in detecting DVT following total hip and knee arthroplasty. J Bone Joint Surg Br. 2006;88(Suppl I):181.
6. Rafee A, MacLauchlan GJ, Gilbert R, Herlikar D. Usefulness of plasma D-dimer levels in detecting DVT following total hip and knee arthroplasty. J Bone Joint Surg Br. 2006;88(Suppl II):235–6.

Articles from Annals of The Royal College of Surgeons of England are provided here courtesy of The Royal College of Surgeons of England