Deep vein thrombosis

By Dr. Pascal Bafteh · last updated 09/2026

Overview

Clinical Signs

• Payr: Pain with flexion / pressure on the medial sole of the foot
• Meyer (= Mayr): Pain with pressure on the calf
• Homans: Pain medial sole of the foot / calf with dorsiflexion
• Local: warm, edematous, livid leg, prominent collateral veins

Wells Score (DVT)

• Assessment: ≥ 2 → DVT likely → Duplex ultrasound ± D-dimer. If < 2 + neg. D-dimer → DVT unlikely.
• Surgery time window (common pitfall!): In the original Wells score, major surgery < 12 weeks counts as +1 point — not "< 4 weeks", as is often incorrectly taught.

D-dimer — for exclusion only, never for proof

• The D-dimer test has high sensitivity and low specificity. It is therefore useful only to exclude DVT when pre-test probability is low — a positive value proves nothing, a negative value with Wells < 2 practically rules DVT out.
• Age-adjusted cut-off from 50 years on: instead of the fixed 500 µg/l FEU cut-off, use age × 10 µg/l — so 800 µg/l in an 80-year-old. This markedly reduces unnecessary ultrasound scans without missing thromboses.
• False positives occur in pregnancy, cancer, inflammation, recent surgery, trauma and old age — that is, in nearly every patient in whom it gets ordered.

Compression Ultrasonography (CUS) — the standard test for DVT

• Principle: A patent vein can be fully compressed with gentle probe pressure in the transverse plane (the lumen disappears and only the pulsating artery remains); a thrombosed vein is not or only incompletely compressible — non-compressibility is the decisive criterion, not echogenicity.
• Procedure: in the transverse plane from proximal to distal in 1–2 cm steps: common femoral vein including the saphenofemoral junction (crosse) → femoral vein → adductor canal → popliteal vein (patient seated or prone) → calf veins (posterior tibial and fibular veins). Colour duplex and flow manoeuvres (Valsalva, distal compression) are added to assess residual lumen and reflux. Whole-leg compression ultrasound covers the entire limb, whereas two-point compression ultrasound examines only groin and popliteal fossa — with a negative result and persisting suspicion a repeat scan after 5–7 days is required.
• Vein wall structure: three layers as in the artery — tunica intima, tunica media, tunica adventitia. Compared with the artery the media is far less muscular and much thinner — which is why a vein is compressible at all; from medium calibre upwards veins additionally carry valves (intimal duplications).
• Thrombus age from echogenicity: A fresh thrombus is hypoechoic to almost anechoic and is therefore easily missed — it betrays itself only by the loss of compressibility and the distended vein lumen. With increasing age the thrombus becomes more echogenic, shrinks and adheres to the wall; a mural, echogenic residue indicates a post-thrombotic residual finding rather than fresh thrombosis.

Differential diagnoses

• Great saphenous vein varicosity
• Telangiectasias (spider veins) and reticular veins
• Corona phlebectatica paraplantaris
• Purpura jaune d’ocre
• Atrophie blanche
• Lipodermatosclerosis

Sources (selection)

1. Wells 2003 NEJM D-Dimer DVT
2. Plewig 2018 Braun-Falco p.1221
3. Linnemann B, et al. Diagnostik und Therapie der Venenthrombose und der Lungenembolie. S2k-Leitlinie, AWMF-Register-Nr. 065/002. Stand: September 2023.

More vascular skin disorders

• Erythromelalgia
• Leukocytoclastic vasculitis
• Lichen aureus
• Superficial thrombophlebitis
• Great saphenous vein varicosity

Note: This page is intended for medical education and does not replace diagnosis or treatment decisions in individual cases. Treatment and follow-up content is available in the app.