1076 Letters to the Editor
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tivity Task Force. J Am Coll Cardiol 2002; 39: 25765.
10 Sobki S, Khan S, Al Mofawaz T, Saadeddin S, Al Suliman M, Al
Khader A. Homocysteine in renal transplant recipients: association
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11 Perna A, Ingrosso D, Lombardi C, Cesare C, Acantora F, Satta E, De
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12 Hackam DG, Anand SS. Emerging risk factors for atherosclerotic
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13 Kerlin B, Cooley BC, Isermann BH, Hernandez I, Sood R, Zogg M,
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14 MonteroI,OrbeJ,VaroN,BeloquiO,MonrealJI,RodriguezJA,DiezJ,
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15 Blann AD. Plasma von Willebrand factor, thrombosis, and the
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16 Woo K, Chook P, Lolin Y, Sanderson J, Metreweli C, Celermajer D.
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17 Marcucci R. Vitamin supplementation reduces the progression of
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18 Doshi SN, McDowell IF, Moat SJ, Payne N, Durrant HJ, Lewis MJ,
Goodfellow J. Folic acid improves endothelial function in coronary
D-dimer as an adjunct to compression ultrasonography in
patients with suspected recurrent deep vein thrombosis
P . P R A N D O N I , D . T O R M E N E , F . D A L L A V A L L E , A . C O N C O L A T O and R . P E S A V E N T O
Department of Medical and Surgical Sciences, Thromboembolism Unit, University of Padua, Padua, Italy
To cite this article: Prandoni P, Tormene D, Dalla Valle F, Concolato A, Pesavento R. D-dimer as an adjunct to compression ultrasonography in
patients with suspected recurrent deep vein thrombosis. J Thromb Haemost 2007; 5: 10767.
Diagnosis of recurrent ipsilateral deep-vein thrombosis (DVT)
is difcult because of limitations in distinguishing acute from
old thrombi. Clinical diagnosis is indeed inaccurate, and all
diagnostic approaches have limitations in this context [14].
Among them, ultrasonography is by far the most widely
adopted strategy. According to the results of an investigation
conducted in the 1990s, patients presenting with new leg vein
incompressibility and those with an increased vein diameter of
more than 4 mm, as compared with earlier vein assessments,
are currently labeled as having a recurrent DVT, while all other
patients need further testing [4]. Recently, D-dimer was found
Correspondence: Paolo Prandoni, Department of Medical and
Surgical Sciences, Thromboembolism Unit, Via Ospedale Civile 105,
35128 Padua, Italy.
Tel.: +39 049 8212656; fax: +39 049 8218731; e-mail:
paoloprandoni@tin.it
Received 20 January 2007, accepted 13 February 2007
artery disease via mechanisms largely independent of homocysteine
lowering. Circulation 2002; 105: 226.
19 van Guldener C, Janssen M, Lambert J, ter Wee P, Jakobs C, Donker
A, Stehouwer C. No change in impaired endothelial function after
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RC, Nicholls K, Fraenkel M, Hutchison BG, Walker R, McNeil JJ.
Cardiovascular morbidity and mortality in the Atherosclerosis and Folic
Acid Supplementation Trial (ASFAST) in chronic renal failure: a multi-
center, randomized, controlled trial. J Am Coll Cardiol 2006; 47: 110816.
21 Rakhit DJ, Marwick TH, Armstrong KA, Johnson DW, Leano R,
Isbel NM. Eect of aggressive risk factor modication on cardiac
events and myocardial ischemia in patients with chronic kidney dis-
ease. Heart 2006; 92: 14028.
22 Toole J, Malinow M, Chambless L, Spence J, Pettigrew L, Howard V,
Sides E, Wang C, Stampfer M. Lowering homocysteine in patients
with ischemic stroke to prevent recurrent stroke, myocardial infarc-
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23 Lonn E, Yusuf S, Arnold MJ, Sheridan P, Pogue J, Micks M,
McQueen MJ, Probsteld J, Fodor G, Held C, Genest Jr J. Homo-
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24 Bonaa KH, Njolstad I, Ueland PM, Schirmer H, Tverdal A, Steigen T,
Wang H, Nordrehaug JE, Arnesen E, Rasmussen K. Homocysteine
lowering and cardiovascular events after acute myocardial infarction.
N Engl J Med 2006; 354: 157888.
to have a high negative predictive value in patients with
suspected recurrent DVT who did not receive objective tests [5].
However, an incidence of symptomatic VTE as high as 6.0%
(95% CI, 2.611.4%) in the 3-month follow-up of patients who
were not treated because of negative D-dimer could not be
excluded. We hypothesized that a negative D-dimer would help
simplify the diagnostic approach by safely preventing further
testing in a substantial proportion of patients with stable or
slightly increased (up to 4 mm) vein diameter.
One hundred and forty-six consecutive patients, who had
received a clinical and echographic follow-up at our Institution
after their rst episode of acute DVT and had discontinued oral
anticoagulant therapy, presented with clinically suspected
recurrent ipsilateral DVT. Table 1 shows the main character-
istics of the study patients. They received the ultrasound
evaluation of the proximal vein system according to methods
described elsewhere [4]. Informed consent was obtained from all
participants. Briey, the vein diameter of the common femoral
and popliteal vein was measured under compression and
compared with earlier ultrasound results. Thirty-eight patients
 2007 International Society on Thrombosis and Haemostasis

Table 1 Characteristics of the patients included in the study
Patients (n)
Age (median, range)
Sex (M:F)
Ultrasound location of the rst
deep-vein thrombosis (DVT) episode
Popliteal vein
Common femoral vein
Both
Interval between the rst
DVT and the suspected recurrence
36 months
612 months
1224 months
Longer than 24 months
(26.0%) with new leg vein incompressibility or increased vein
diameter of more than 4 mm were labeled as having recurrent
DVT [4], and were treated accordingly. In the remaining 108
patients a D-dimer test was performed, using the Biopool
Autodimer (Trinity Biotech, Bray, Ireland), which was recently
found to be accurate in patients with suspected DVT [6].
The D-dimer test was positive in 31 of the 108 patients
(28.7%), and negative in the remaining 75. The 31 patients with
positive D-dimer had further testing (repeat leg vein ultraso-
nography within 1 week or ascending phlebography), which
showed ndings suggestive of recurrent DVT in six (26.1%).
The 75 patients with negative D-dimer were not treated with
anticoagulants and had a 3-month follow-up period, which was
uneventful in all (incidence of recurrent VTE, 0%; 95% CI, 0
4.8%).
Determination of pediatric norms for assessment of upper
venous system post-thrombotic syndrome
B . M . B O U L D E N , S . E . C R A R Y , G . R . B U C H A N A N and J . M . J O U R N E Y C A K E
Department of Pediatrics, University of Texas Southwestern Medical Center at Dallas, and the Hemophilia and Thrombosis Program in the Center
for Cancer and Blood Disorders, Childrens Medical Center Dallas, Dallas, TX, USA
To cite this article: Boulden BM, Crary SE, Buchanan GR, Journeycake JM. Determination of pediatric norms for assessment of upper venous system
post-thrombotic syndrome. J Thromb Haemost 2007; 5: 10779
Deep venous thrombosis (DVT) is increasingly prevalent in
children and adolescents [1]. One of the major long-term
complications of DVT is post-thrombotic syndrome (PTS),
dened as swelling, pain, collateral vessel formation, discolor-
Correspondence: Janna M. Journeycake, University of Texas
Southwestern Medical Center at Dallas, 5323 Harry Hines Blvd,
Dallas, TX 75390-9063, USA.
Tel.: +1 214 648 3896; fax: +1 214 648 3122; e-mail: janna.
journeycake@childrens.com
Received 1 February 2007, accepted 6 February 2007
 2007 International Society on Thrombosis and Haemostasis
Letters to the Editor 1077
We conclude that the D-dimer test has the potential to
146 simplify the diagnostic approach to patients with the clinical
66 (2487) suspicion of recurrent ipsilateral DVT. It is safe to withhold
77:69 anticoagulant treatment from patients with stable or slightly
increased (up to 4 mm) vein diameter and negative D-dimer. If
48
D-dimer is positive, patients should undergo further testing.
27
71
Disclosure of Conflict of Interests
The authors state that they have no conict of interest.
14 (9.6%)
18 (12.3%)
48 (32.8%) References
66 (45.2%)
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ation and dysfunction involving the affected limb which
develops weeks to months after diagnosis of DVT [2,3]. The
clinical criteria for PTS involving the lower extremity are well-
described in both children and adults [25], even although the
commonly used scales have not been validated [4,6]. However,
there are no specic diagnostic criteria for PTS involving the
upper extremity, which is the most frequent site of DVT in
children, primarily as a result of central venous catheter (CVC)
use [1]. There is growing interest in identifying long-term
sequelae of CVC use in children. For instance, a report of
hemophilia patients suggested that the arm ipsilateral to the
catheter site was longer and had a larger girth [7]. Additionally, a
recent study of children with prior CVC inserted in their jugular