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Case presentation
The patient was placed on IV heparin. He had a CT scan of his chest, abdomen, and
pelvis that revealed no abnormalities besides the thrombus. He was switched to
oral rivaroxaban and discharged home 2 days later. He received anticoagulation for
a total of 6 months.
Background
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extremity DVT, upper-extremity DVT patients are typically younger, thinner, more
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likely to have a diagnosis of cancer, and less likely to have thrombophilia (1).
Cancer is found in up to 40% of patients with upper-extremity DVT (6).
Presentation
This condition can present with arm swelling, pain, and functional impairment;
however, asymptomatic cases have been reported. Other clinical features such as
visible collateral veins at the shoulder girdle or jugular distention are less frequent
(1). Fewer than 50% of symptomatic patients have objectively confirmed upper-
extremity DVT.
Complications
Etiology
The other 80% of upper-extremity DVT cases are secondary, with causes including
catheters; cancer; surgery, trauma, or immobilization by plaster casts; pregnancy;
oral contraceptives; and estrogen. The most important risk factor is the presence of
an indwelling central venous catheter (2, 6). About 50% of upper-extremity DVT
patients have a central catheter present (10). Cancer patients with indwelling
catheters are at particularly increased risk (11). Patients with implantation of
permanent pacemaker leads and inherited thrombophilic disorders have been
shown to also have an increased riskADVERTISEMENT
of catheter-associated thrombosis (12). The
other major risk factor for secondary upper-extremity DVT is malignancy.
Mechanisms include venous stasis due to immobilization, direct vein compression
by the tumor itself, and cancer-induced prothrombotic factors (1). The risk is
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increased in patients with distant metastases (6). Ovarian carcinoma and lung
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adenocarcinoma carry higher risks of upper-extremity DVT, especially in the
presence of indwelling catheters (13).
Diagnosis
The clinical signs and symptoms of upper-extremity DVT are nonspecific. The
diagnostic algorithms using clinical pretest probability and D-dimer have not been
validated for upper-extremity DVT as they have for lower-extremity DVT, and thus
imaging is needed (1). Compression ultrasonography is the imaging test of choice,
but the proximal subclavian and brachiocephalic veins are hard to visualize because
of overlying bony structures (5). Thrombosis is characterized by incomplete
compressibility of the venous segment involved. MRI and CT scan should be
considered as supplemental studies in cases with equivocal or negative ultrasound
despite high clinical suspicion (5).
Treatment
In patients with acute upper-extremity DVT that involves the axillary or more
proximal veins, we suggest anticoagulant therapy alone over thrombolysis (Grade
2C).
In patients with upper-extremity DVT who undergo thrombolysis, we
recommend the same intensity and duration of anticoagulant therapy as in
patients with upper-extremity DVT who do not undergo thrombolysis (Grade 1B).
The American College of Chest Physicians' previous guidelines from 2012 offered
additional specifics (17):
Randomized trials of thrombolysis for upper-extremity DVT are lacking and severe
postthrombotic syndrome is not typically seen, so thrombolysis is not usually
recommended (4). It may be considered in selected patients with acute thrombosis
of the arm veins and extensive swelling of the upper arm with severe symptoms
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who are at low risk of bleeding (1, 17). Mechanical catheter interventions
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(aspiration, fragmentation, thrombectomy, balloon angioplasty, or stenting) can be
considered in patients with persistent, severe symptoms (18).
Dr. Cohen is an internist at Lankenau Medical Center and a clinical professor of medicine at Thomas
Jefferson University in Philadelphia.
References
1. Czihal M, Hoffmann U. Upper extremity deep venous thrombosis. Vasc Med. 2011;16:191-
202. [PMID: 21343260 (http://www.ncbi.nlm.nih.gov/pubmed?term=21343260)]
doi:10.1177/1358863X10395657
2. Joffe HV, Kucher N, Tapson VF, Goldhaber SZ; Deep Vein Thrombosis (DVT) FREE Steering
Committee. Upper-extremity deep vein thrombosis: a prospective registry of 592 patients.
Circulation. 2004;110:1605-11. [PMID: 15353493 (http://www.ncbi.nlm.nih.gov/pubmed?
term=15353493)]
5. Kucher N. Clinical practice. Deep-vein thrombosis of the upper extremities. N Engl J Med.
2011;364:861-9. [PMID: 21366477 (http://www.ncbi.nlm.nih.gov/pubmed?term=21366477)]
doi:10.1056/NEJMcp1008740
6. Blom JW, Doggen CJ, Osanto S, Rosendaal FR. Old and new risk factors for upper extremity
deep venous thrombosis. J Thromb Haemost. 2005;3:2471-8. [PMID: 16241945
(http://www.ncbi.nlm.nih.gov/pubmed?term=16241945)].
7. Elman EE, Kahn SR. The post-thrombotic syndrome after upper extremity deep venous
thrombosis in adults: a systematic review. Thromb Res. 2006;117:609-14. [PMID: 16002126
(http://www.ncbi.nlm.nih.gov/pubmed?term=16002126)]
8. Kooij JD, van der Zant FM, van Beek EJ, Reekers JA. Pulmonary embolism in deep venous
thrombosis of the upper extremity: more often in catheter-related thrombosis. Neth J Med.
1997;50:238-42. [PMID: 9232088 (http://www.ncbi.nlm.nih.gov/pubmed?term=9232088)]
10. Joffe HV, Goldhaber SZ. Upper-extremity deep vein thrombosis. Circulation. 2002;106:1874-
80. [PMID: 12356644 (http://www.ncbi.nlm.nih.gov/pubmed?term=12356644)]
11. Verso M, Agnelli G, Kamphuisen PW, Ageno W, Bazzan M, Lazzaro A, et al. Risk factors for
upper limb deep vein thrombosis associated with the use of central vein catheter in cancer
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patients. Intern Emerg Med. 2008;3:117-22. [PMID: 18317868
(http://www.ncbi.nlm.nih.gov/pubmed?term=18317868)] doi:10.1007/s11739-008-0125-3
12. Van Rooden CJ, Rosendaal FR, Meinders AE, Van Oostayen JA, Van Der Meer FJ, Huisman
MV. The contribution of factor V Leiden and prothrombin G20210A mutation to the risk of
central venous catheter-related thrombosis. Haematologica. 2004;89:201-6. [PMID: 15003896
(http://www.ncbi.nlm.nih.gov/pubmed?term=15003896)]
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3/1/2019 Upper-extremity deep venous thrombosis | ACP Hospitalist
(/)13. Shivakumar SP, Anderson DR, Couban S. Catheter-associated thrombosis in patients with
malignancy. J Clin Oncol. 2009;27:4858-64. [PMID: 19738117
(http://www.ncbi.nlm.nih.gov/pubmed?term=19738117)] doi:10.1200/JCO.2009.22.6126
16. Kearon C, Akl EA, Ornelas J, Blaivas A, Jimenez D, Bounameaux H, et al. Antithrombotic
therapy for VTE disease: Chest guideline, Chest. 2016 [In press]. doi:
10.1016/j.chest.2015.11.026.
17. Kearon C, Akl EA, Comerota A J, Prandoni P, Bounameaux H, Goldhaber SZ, et al;
American College of Chest Physicians. Antithrombotic therapy for VTE disease: Antithrombotic
Therapy and Prevention of Thrombosis, 9th ed: American College of Chest Physicians Evidence-
Based Clinical Practice Guidelines. Chest. 2012;141:e419S-94S. [PMID: 22315268
(http://www.ncbi.nlm.nih.gov/pubmed?term=22315268)] doi:10.1378/chest.11-2301
18. Thomas IH, Zierler BK. An integrative review of outcomes in patients with acute primary
upper extremity deep venous thrombosis following no treatment or treatment with
anticoagulation, thrombolysis, or surgical algorithms. Vasc Endovascular Surg. 2005;39:163-74.
[PMID: 15806278 (http://www.ncbi.nlm.nih.gov/pubmed?term=15806278)]
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