The latest article in our Clinical Practice series, Deep-Vein Thrombosis of the Upper Extremities, reviews usual strategies for treating thrombosis of the upper extremities, including anticoagulation therapy and thrombolysis. The use of catheters and surgical interventions in refractory cases is also discussed. The review is authored by Dr. Nils Kucher from the University Hospital Bern in Switzerland.
Approximately 10% of all cases of deep-vein thrombosis involve the upper extremities. Complications are less common with upper extremity deep-vein thrombosis than with lower extremity thrombosis, but include pulmonary embolism in 6% (versus 15 to 32% with lower extremity thrombosis), recurrence at 12 months in 2 to 5% (versus 10% with lower extremity thrombosis), and the post-thrombotic syndrome in 5% (versus up to 56% with lower extremity thrombosis).
• What imaging technique is recommended to diagnose upper extremity deep-vein thrombosis?
Compression ultrasound, which relies on the finding that a thrombosed vein is incompressible, and is the clinical standard for diagnosing lower extremity thrombosis, is also the preferred imaging test for patients with suspected upper extremity deep-vein thrombosis. Data on the diagnostic accuracy of computed tomographic angiography or magnetic resonance angiography are limited, but either test may be useful for imaging the proximal arm veins if ultrasound is indeterminate. Ultrasound has virtually replaced conventional phlebography for diagnosing upper extremity deep-vein thrombosis; phlebography is occasionally performed in patients with indeterminate ultrasound results.
• What type of initial anticoagulation is recommended for the management of patients with upper extremity deep-vein thrombosis?
Initial anticoagulation treatment thus usually involves low-molecular-weight heparin; unfractionated heparin is preferred in patients with severe renal dysfunction.
Figure 2. Guidelines for the Management of Deep-Vein Thrombosis (DVT)
of an Upper Extremity.
Morning Report Questions
Q: How should catheter-associated thrombosis be managed?
A: In patients with catheter-associated thrombosis, routine catheter removal is not recommended. The decision whether to remove the catheter should consider the need for further intravenous medications, blood sampling, venous access difficulties, and patient preferences. Removal is generally warranted in cases of catheter malfunction or infection, contraindication to anticoagulation therapy, persistent symptoms or signs of upper extremity deep-vein thrombosis during initial anticoagulation therapy, or when the catheter is no longer needed.
Q: What duration of treatment is recommended for long-term anticoagulation in patients with upper extremity deep-vein thrombosis?
A: Based on data from cohort studies demonstrating low recurrence rates with use of vitamin K antagonists for three to six months in patients with upper extremity deep-vein thrombosis, this duration of therapy is generally recommended, including in patients whose central venous catheter is removed. Vitamin K antagonists are generally used, but low-molecular-weight heparin is preferred in patients with cancer.