07. Upper Extremity Deep Vein Thrombosis

Definition: deep veins of the upper extremity include the subclavian, axillary, and brachial veins. 

Diagnosis

  • Doppler ultrasound of the upper extremity (UE) should be the first test, but realize that it is hard to image the proximal UE veins as they are deep to other structures.
  • The “sniff test” can be used to increase sensitivity of UE Doppler ultrasound. While looking with the ultrasound probe, the patient inhales quickly and deeply, causing increased negative intrathoracic pressure. Distal venous blood flow should flow proximally (seen by Doppler). If blood is not flowing adequately, there is probably an obstruction in a proximal deep vein.
  • The gold standard for diagnosis, though rarely used, is upper extremity venography.

Etiology

Primary upper extremity DVT:

  • Paget-Schrotter syndrome (effort thrombosis): young patients who develop spontaneous UE DVT due to repetitive arm motion (e.g., baseball pitcher) which causes micro-trauma and a local pro-coagulable state. Most common in patients with compression of the vessel (usually due to aberrant anatomy of the thoracic outlet).
  • Idiopathic UE DVT: no known trigger (though in one study, 25% of patients found later to have occult malignancy – usually lung cancer or lymphoma).

Secondary upper extremity DVT:

  • Much more common than primary UE DVT.
  • Occurs in patients with catheters (70-80% of cases), pacemakers, or malignancy. Have been reported in as many as 25% of patients with longstanding central catheters.
  • Some studies suggest that method of catheter placement is important in preventing UE DVT.
  • Upper extremity catheters should be positioned with the tip at the junction of the superior vena cava and right atrium (where blood flow is most rapid).

Treatment

  • Upper extremity DVT should be treated just like lower extremity DVT in terms of drug, intensity, duration. Superficial thrombophelibitis is generally self-limited and does not require treatment.
  • Consider thrombolysis in young, healthy patients with primary UE DVT, patients with symptomatic SVC syndrome, and those who require preservation of a mandatory central venous catheter as this reduces the risk of long-term complications such as post-thrombotic syndrome.
  • It remains controversial whether catheters associated with UE DVT should be removed. The decision to remove a catheter associated with DVT may be driven by the expected duration of need for the catheter, as well as any concern for infection of the thrombus or line-associated infection. It also remains unclear whether prophylactic anticoagulation should be continued for the duration of the line for patients with catheter-associated DVT. Furthermore, there is increased risk of clot embolization when such a catheter is removed.
  • All patients with acute UE DVT should be treated with graduated compression sleeves.

Key Points

  • Thromboses in these veins should be taken seriously and treated similarly to a lower extremity DVT, as pulmonary embolism occurs in up to 1/3 of patients with upper extremity DVT.
  • The incidence of upper extremity DVT is rising because of increased catheter use for purposes such as chemotherapy, bone marrow transplantation, dialysis, and parenteral nutrition. They account for approximately 10 percent of all DVTs.
  • There are a number of potential complications of upper extremity DVT, including persistent UE pain/swelling, superior vena cava (SVC) syndrome, thoracic outlet obstruction, and loss of vascular access.

Baarslag HJ, van Beek EJ, Koopman MM, et al.  Prospective study of color duplex ultrasonography compared with contrast venography in patients suspected of having deep venous thrombosis of the upper extremity.  Ann Intern Med 2002;136:865-872.

Joffe HV, Goldhaber SZ. Upper-extremity deep vein thrombosis.  Circulation 2002;106:1874-1880.

Shivakumar SP, Anderson DR, Couban S. Catheter-associated thrombosis in patients with malignancy.

J Clin Oncol. 2009 Oct 10;27(29):4858-64.