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Background: The widespread use of ultrasonography for the diagnosis of deep vein thrombosis (DVT) has led to the overuse of ultrasonography with low diagnostic yield. We conducted this study to investigate the predictive value of clinical features in the diagnosis of DVT and their potential value as clinical guidelines for the use of ultrasonographic testing in the diagnosis of DVT., Methods: The results of lower-extremity duplex ultrasonographic studies and clinical surveys prospectively obtained in 1526 patients suspected of having DVT were analyzed., Results: There were 916 inpatients and 610 outpatients. Acute DVT was found in 16% of the inpatient duplex scans, and in 12% of the outpatient studies (p < 0.05). The incidence of acute DVT was not different between men and women in inpatient or outpatient populations. Acute DVT was found in the left leg in 60% of the outpatient studies, significantly more often (p < 0.001) than in the inpatients (35%). Bilateral DVT was more common (p < 0.05) in the inpatient population (35%) compared with the outpatient population (20%). No difference in the anatomic distribution of thrombosis was found between inpatients and outpatients. The presence of leg symptoms was associated with a significantly higher rate (p < 0.05) of positive studies compared with those patients without leg symptoms in both the inpatient and the outpatient populations. Individual symptoms, risk factors, and physical findings had low positive predictive value and sensitivity for the presence of acute DVT on duplex scan. A calf circumference discrepancy of less than 2 cm predicted the absence of DVT in 93% of inpatients and 85% of outpatients. The combination of a calf circumference discrepancy of less than 2 cm with the absence of recent operation, trauma, malignancy, previous history of DVT, or hypercoagulable state predicted the absence of DVT in 92% of the inpatients and 97% of the outpatients., Conclusions: Clinical symptoms, risk factors, and physical findings are poor predictors of the presence of acute DVT on duplex scan. However, the absence of a combination of objective clinical factors has high predictive value for the absence of acute DVT on duplex scan. These criteria may be used to establish clinical guidelines to reduce the use of duplex scanning for the diagnosis of DVT.

Background: The purpose of this study was to review our experience with central vascular reconstruction for innominate artery occlusive disease. Eighteen patients underwent central reconstruction for innominate artery (IA) occlusive disease during an 8-year period (1986 to 1994). Mean age was 59 years (range, 36 to 77 years). Women outnumbered men 12 to 6. All patients had symptoms including amaurosis fugax 55%, transient ischemic attacks 44%, vertebrobasilar insufficiency 44%, and arm claudication 33%. The IA was occluded in three patients and stenotic in 15. Three patients underwent previous extrathoracic bypass procedures for IA lesions that failed., Methods: Operations performed through a median sternotomy included aortocarotid bypass with reimplantation of the subclavian (n = 10) and aortoinnominate bypass (n = 7). Transection and oversewing of the IA was performed in all but one patient, in whom ligation of the IA was performed. One patient with severe chronic obstructive pulmonary disease and previous coronary artery bypass grafting underwent retrograde-transluminal IA angioplasty with endovascular stent placement via a carotid approach. Four patients underwent concomitant carotid endarterectomy). Two patients underwent concomitant coronary artery bypass grafting at the time of IA reconstruction., Results: There was one operative death from myocardial infarction. Perioperative morbidity included dysrrhythmia (three), respiratory insufficiency (three), subendocardial myocardial infarction (two), cerebrovascular accident with complete recovery (two), hemorrhage (one), and acute graft occlusion (one). All grafts remained patient at a mean follow-up of 21 months (range, 8 to 60 months). The only patient who underwent ligation of the IA required a subsequent revision of the IA to transection and oversewing for an embolic event at 4 months status-post aortocarotid bypass. The patient who underwent angioplasty remained asymptomatic with a patient IA at 12 months. Average length of stay for transthoracic repair was 14 days and for transluminal angioplasty 2 days., Conclusions: Innominate artery bypass based on the ascending aorta is effective in providing relief of symptoms and has a high patency rate. Because of the significant morbidity, these procedures should be reserved for patients with symptoms. The IA should be transected and oversewn to prevent recurrent embolism. Transcarotid, retrograde angioplasty provides an alternative approach to stenotic lesions located in the IA or proximal common carotid artery. An aggressive approach directed at defining coronary artery disease is an invaluable adjunct to the proper treatment of this patient population.