Upper Extremity Deep Venous Thrombosis

ABSTRACT

About 10% of all episodes of venous thrombosis are due to upper extremity deep vein thrombosis (UEDVT). Associated risk factors are indwelling central venous catheters, cancer, and coagulation defects; 20% of the episodes are unexplained. The onset of UEDVT is usually heralded by complaints such as arm swelling and pain, but may also be completely asymptomatic, especially in carriers of central venous lines. Objective confirmation is mandatory prior to instituting anticoagulation because the clinical diagnosis is unreliable; ultrasound-based methods represent the preferred diagnostic approach. Prophylaxis with low-dose heparin or low-dose warfarin may be used, especially in carriers of central venous catheters, although its efficacy is still uncertain. Unfractionated or low molecular weight heparins followed by oral anticoagulants should be regarded as the treatment of choice, whereas thrombolysis and surgery may be indicated in selected cases. Up to one third of the patients develop pulmonary embolism that may be fatal; postthrombotic syndrome and recurrent thromboembolism are also frequent complications. UEDVT should no longer be regarded as a rare and benign disease, as reported previously.

KEYWORDS

Upper extremity deep vein thrombosis - central venous catheters - cancer - pulmonary embolism - postthrombotic syndrome.

REFERENCES

• 1 Joffe H V, Kucher N, Tapson V F, Goldhaber S Z. for the Deep Vein Thrombosis (DVT) FREE Steering Committee. Upper-extremity deep vein thrombosis: a prospective registry of 592 patients.  Circulation. 2004;  110 1605-1611
• 2 Coon W W, Willis P W. Thrombosis of axillary and subclavian veins.  Arch Surg. 1966;  94 657-663
• 3 Horattas M C, Wright D J, Fenton A H et al.. Changing concepts of deep venous thrombosis of the upper extremity. Report of a series and review of the literature.  Surgery. 1988;  104 561-567
• 4 Hill S L, Berry R E. Subclavian vein thrombosis: a continuing challenge.  Surgery. 1990;  108 1-9
• 5 Lokich J J, Becker B. Subclavian vein thrombosis in patients treated with infusion chemotherapy for advanced malignancy.  Cancer. 1983;  52 1586-1589
• 6 De Cicco M, Matovic M, Balestreri L et al.. Central venous thrombosis: an early and frequent complication in cancer patients bearing long-term silastic catheters. A prospective study.  Thromb Res. 1997;  86 101-113
• 7 Martin C, Viviand X, Saux P, Gouin F. Upper-extremity deep vein thrombosis after central venous catheterization via the axillary vein.  Crit Care Med. 1999;  27 2626-2629
• 8 Van Rooden C J, Tesslar M ET, Osanto S, Rosendaal F R, Huisman M V. Deep vein thrombosis associated with central venous catheters-a review.  J Thromb Haemost. 2005;  3 2049-2419
• 9 Grove J R, Pevec W C. Venous thrombosis related to peripherally inserted central catheters.  J Vasc Interv Radiol. 2000;  11 837-840
• 10 Prandoni P, Polistena P, Bernardi E et al.. Upper extremity deep-vein thrombosis risk factors, diagnosis, and complications.  Arch Intern Med. 1997;  157 57-62
• 11 Hingorani A, Ascher E, Lorenson E et al.. Upper extremity deep venous thrombosis and its impact on morbidity and mortality rates in a hospital-based population.  J Vasc Surg. 1997;  26 853-860
• 12 Marinella M A, Kathula S K, Markert R J. Spectrum of upper-extremity deep venous thrombosis in a community teaching hospital.  Heart Lung. 2000;  29 113-117
• 13 Heron E, Lozinguez O, Alhenc-Gelas M, Emmerich J, Fiessinger J N. Hypercoagulable states in primary upper-extremity deep vein thrombosis.  Arch Intern Med. 2000;  160 382-386
• 14 Hughes E SR. Venous obstruction in the upper extremity.  Br J Surg. 1949;  36 155-163
• 15 Ellis M H, Manor Y, Witz M. Risk factors and management of patients with upper limb deep vein thrombosis.  Chest. 2000;  117 43-46
• 16 Kooij J DB, van der Zant F M, van Beek E JR, Reekers J A. Pulmonary embolism in deep venous thrombosis of the upper extremity: more often in catheter-related thrombosis.  Neth J Med. 1997;  50 238-242
• 17 Hendler M F, Meschengieser S S, Blanco A N et al.. Primary upper-extremity deep vein thrombosis: high prevalence of thrombophilic defects.  Am J Hematol. 2004;  76 330-337
• 18 Hood D B, Kuehne J, Yellin A E, Weaver F A. Vascular complications of thoracic outlet syndrome.  Am Surg. 1997;  63 913-917
• 19 Martinelli I, Battaglioli T, Bucciarelli P, Passamonti S M, Mannucci P M. Risk factors and recurrence rate of primary deep vein thrombosis of the upper extremities.  Circulation. 2004;  110 566-570
• 20 Vaya A, Mira Y, Mateo J et al.. Prothrombin G20210A mutation and oral contraceptive use increase upper-extremity deep vein thrombotic risk.  Thromb Haemost. 2003;  89 452-457
• 21 Timsit J F, Farkas J C, Boyer J M et al.. Central vein catheter-related thrombosis in intensive care patients: incidence, risks factors, and relationship with catheter-related sepsis.  Chest. 1998;  114 207-213
• 22 Blom J W, Doggen C JM, Osanto S, Rosendaal F R. Old and new risk factors for upper extremity deep venous thrombosis.  J Thromb Haemost. 2005;  3 2471-2478
• 23 Monreal M, Raventos A, Lerma R et al.. Pulmonary embolism in patients with upper extremity DVT associated to venous central lines: a prospective study.  Thromb Haemost. 1994;  72 548-550
• 24 Girolami A, Prandoni P, Zanon E, Bagatella P, Girolami B. Venous thromboses of upper limbs are more frequently associated with occult cancer as compared with those of lower limbs.  Blood Coagul Fibrinolysis. 1999;  10 455-457
• 25 Hammers L W, Cohn S M, Brown J M et al.. Doppler color flow imaging surveillance of deep vein thrombosis in high-risk trauma patients.  J Ultrasound Med. 1996;  15 19-24
• 26 Linblad B, Tengblom L, Bergqvist D. Deep vein thrombosis of the axillary-subclavian veins: epidemiologic data, effects of different types of treatment and late sequelae.  Eur J Vasc Surg. 1988;  2 161-165
• 27 Loret de Mola J R, Kiwi R, Austin C, Goldfarb J M. Subclavian deep vein thrombosis associated with the use of recombinant follicle-stimulating hormone (Gonal-F) complicating mild ovarian hyperstimulation syndrome.  Fertil Steril. 2000;  73 1253-1255
• 28 Todros T, Carmazzi C M, Bontempo S, Gaglioti P, Donvito V, Massobrio M. Spontaneous ovarian hyperstimulation syndrome and deep vein thrombosis in pregnancy: case report.  Hum Reprod. 1999;  14 2245-2248
• 29 Ninet J, Demolombe-Rague S. Bureau du Colombier P, Coppere B. Les thromboses veineuses profondes des membres supérieurs.  Sang Thrombose Vaisseaux. 1994;  6 103-114
• 30 Lisse J R, Davis C P, Thurmond-Anderle M. Cocaine abuse and deep venous thrombosis.  Ann Intern Med. 1989;  110 571-572
• 31 Ruggeri M, Castaman G, Tosetto A, Rodeghiero F. Low prevalence of thrombophilic coagulation defects in patients with deep vein thrombosis of the upper limbs.  Blood Coagul Fibrinolysis. 1997;  8 191-194
• 32 Provenzale J M, Ortel T L, Allen N B. Systemic thrombosis in patients with antiphospholipid antibodies. Lesion distribution and imaging findings.  AJR Am J Roentgenol. 1998;  170 285-290
• 33 Horne M K, Mayo D J, Alexander H R et al.. Upper extremity impedance plethysmography in patients with venous access devices.  Thromb Haemost. 1994;  72 540-542
• 34 Patwardhan N A, Anderson F A, Cutler B S, Wheeler H B. Noninvasive detection of axillary and subclavian venous thrombosis by impedance plethysmography.  J Cardiovasc Surg (Torino). 1983;  24 250-255
• 35 Zufferey C, Pararas C, Monti M, Depairon M. Assessment of acute and old deep venous thrombosis in upper extremity by venous strain gauge plethysmography.  Vasa. 1992;  21 263-267
• 36 Sottiurai V S, Towner K, McDonnell A E, Zarins C K. Diagnosis of upper extremity deep vein thrombosis using noninvasive technique.  Surgery. 1982;  91 582-585
• 37 Mukherjee D, Andersen C A, Sado A S, Bertoglio M. Use of light reflection rheography for diagnosis of axillary or subclavian venous thrombosis.  Am J Surg. 1991;  161 651-656
• 38 Knudson G J, Wiedmeyer D A, Erickson S J et al.. Color Doppler sonographic imaging in the assessment of upper-extremity deep venous thrombosis.  AJR Am J Roentgenol. 1990;  154 399-403
• 39 Baxter G M, Kincaid W, Jeffrey R F, Millar G M, Porteous C, Morley P. Comparison of color Doppler ultrasound with venography in the diagnosis of axillary and subclavian vein thrombosis.  Br J Radiol. 1991;  64 777-781
• 40 Elliott G. Upper-extremity deep vein thrombosis.  Lancet. 1997;  349 1188-1189
• 41 Fraser J D, Anderson D R. Deep venous thrombosis: recent advances and optimal investigation with US.  Radiology. 1999;  211 9-24
• 42 Mustafa B O, Rathbun S W, Whitsett T L, Raskob G E. Sensitivity and specificity of ultrasonography in the diagnosis of upper extremity deep vein thrombosis: a systematic review.  Arch Intern Med. 2002;  162 401-404
• 43 Baarslag H J, van Beek E J, Koopman M MW, Reekers J A. Prospective study of color Duplex ultrasonography compared with contrast venography in patients suspected of having deep venous thrombosis of the upper extremities.  Ann Intern Med. 2002;  136 865-872
• 44 Baarslag H J, van Beek E J, Tijssen J G, van Delden O M, Bakker A J, Reekers J A. Deep vein thrombosis of the upper extremity: intra- and interobserver study of digital subtraction venography.  Eur Radiol. 2003;  13 251-255
• 45 Fielding J R, Nagel J S, Pomeroy O. Upper extremity DVT: correlation of MR and nuclear medicine flow imaging.  Clin Imaging. 1997;  21 260-263
• 46 Baarslag H J, Van Beek E J, Reekers J A. Magnetic resonance venography in consecutive patients with suspected deep vein thrombosis of the upper extremity: initial experience.  Acta Radiol. 2004;  45 38-43
• 47 Becker D M, Philbrick J T, Walker F B. Axillary and subclavian venous thrombosis. Prognosis and treatment.  Arch Intern Med. 1991;  151 1934-1943
• 48 Urschel H C, Razzuk M A. Paget-Schroetter syndrome: what is the best management?.  Ann Thorac Surg. 2000;  69 1663-1668
• 49 Hicken G J, Ameli F M. Management of subclavian-axillary vein thrombosis: a review.  Can J Surg. 1998;  41 13-25
• 50 Thomas I H, Zierler B K. 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;  39 163-174
• 51 Savage K J, Wells P S, Schulz V et al.. Outpatient use of low molecular weight heparin (dalteparin) for the treatment of deep vein thrombosis of the upper extremity.  Thromb Haemost. 1999;  82 1008-1010
• 52 Adelman M A, Stone D H, Riles T S, Lamparello P J, Giangola G, Rosen R J. A multidisciplinary approach to the treatment of Paget-Schroetter syndrome.  Ann Vasc Surg. 1997;  11 149-154
• 53 Sheeran S R, Hallisey M J, Murphy T P, Faberman R S, Sherman S. Local thrombolytic therapy as part of a multidisciplinary approach to acute axillosubclavian vein thrombosis (Paget-Schroetter syndrome).  J Vasc Interv Radiol. 1997;  8 253-260
• 54 Haire W D, Atkinson J B, Stephens L C, Kotulak G D. Urokinase versus recombinant tissue plasminogen activator in thrombosed central venous catheters: a double-blinded, randomized trial.  Thromb Haemost. 1994;  72 543-547
• 55 Chang R, Horne M K, Mayo D J, Doppman J L. Pulse-spray treatment of subclavian and jugular venous thrombi with recombinant tissue plasminogen activator.  J Vasc Interv Radiol. 1996;  7 845-851
• 56 Spence L D, Gironta M G, Malde H M, Mickolick C T, Geisinger M A, Dolmatch B L. Acute upper extremity deep venous thrombosis: safety and effectiveness of superior vena caval filters.  Radiology. 1999;  210 53-58
• 57 Ascher E, Hingorani A, Mazzariol F, Jacob T, Yorkovich W, Gade P. Clinical experience with superior vena caval Greenfield filters.  J Endovasc Surg. 1999;  6 365-369
• 58 Monreal M, Lafoz E, Ruitz J, Valls R, Alastrue A. Upper-extremity deep venous thrombosis and pulmonary embolism. A prospective study.  Chest. 1991;  99 280-283
• 59 Kerr T M, Lutter K S, Moeller D M et al.. Upper extremity venous thrombosis diagnosed by Duplex scanning.  Am J Surg. 1990;  160 202-206
• 60 Randolph A G, Cook D J, Gonzales C A, Andrew M. Benefit of heparin in central venous and pulmonary artery catheters: a meta-analysis.  Chest. 1998;  113 165-171
• 61 Prandoni P, Bernardi E, Marchiori A et al.. The long-term clinical course of acute deep vein thrombosis of the arm: prospective cohort study.  BMJ. 2004;  329 484-485
• 62 Baarslag H J, Koopman M M, Hutten B A et al.. Long-term follow-up of patients with suspected deep vein thrombosis of the upper extremity: survival, risk factors and post-thrombotic syndrome.  Eur J Intern Med. 2004;  15 503-507
• 63 Hingorani A, Ascher E, Markevich N et al.. Risk factors for mortality in patients with upper extremity and internal jugular deep venous thrombosis.  J Vasc Surg. 2005;  41 476-478
• 64 Monagle P, Adams M, Mahoney M et al.. Outcome of pediatric thromboembolic disease: a report from the Canadian Childhood Thrombophilia Registry.  Pediatr Res. 2000;  47 763-766
• 65 Donayre C E, White G H, Mehringer S M, Wilson S E. Pathogenesis determines late morbidity of axillosubclavian vein thrombosis.  Am J Surg. 1986;  152 179-184
• 66 Kahn S R, Elman E A, Bornais C, Blostein M, Wells P S. Post-thrombotic syndrome, functional disability and quality of life after upper extremity deep venous thrombosis in adults.  Thromb Haemost. 2005;  93 499-502
• 67 Van Rooden C J, Schippers E F, Barge R MY et al.. Infectious complications of central venous catheters increase the risk of catheter related thrombosis in hematology patients: a prospective study.  J Clin Oncol. 2005;  23 2655-2660
• 68 Bern M M, Lokich J J, Wallach S R et al.. Very low doses of warfarin can prevent thrombosis in central venous catheters.  Ann Intern Med. 1990;  112 423-428
• 69 Monreal M, Alastrue A, Rull M et al.. Upper extremity deep venous thrombosis in cancer patients with venous access devices. Prophylaxis with a low molecular weight heparin (Fragmin).  Thromb Haemost. 1996;  75 251-253
• 70 Mismetti P, Mille D, Laporte S et al.. Low-molecular-weight heparin (nadroparin) and very low doses of warfarin in the prevention of upper extremity thrombosis in cancer patients with indwelling long-term central venous catheters: a pilot randomised study.  Haematologica. 2003;  88 67-73
• 71 Couban S, Goodyear M, Burnell M et al.. A randomized double-blind placebo-controlled study of low dose warfarin for the prevention of symptomatic central venous catheter associated thrombosis in patients with cancer.  Blood. 2002;  100(suppl) 703a (abst)
• 72 Heaton D C, Han D Y, Inder A. Minidose (1 mg) warfarin as prophylaxis for central vein catheter thrombosis.  Intern Med. 2002;  32 84-88
• 73 Reichardt P, Kretzschmar A, Biakhov M et al.. A phase III double-blind, placebo-controlled study evaluating the efficacy and safety of daily low-molecular-weight heparin (dalteparin sodium, Fragmin) in preventing catheter-related complications in cancer patients with central venous catheters.  Clin Oncol. 2002;  21 1474 (abst)
• 74 Walshe L J, Malak S F, Eagan J et al.. Complication rates among cancer patients with peripherally inserted central catheters.  J Clin Oncol. 2002;  20 3276-3281
• 75 Verso M, Agnelli G, Bertoglio S et al.. Enoxaparin for the prevention of venous thromboembolism associated with central vein catheter: a double-blind, placebo-controlled, randomized study in cancer patients.  J Clin Oncol. 2005;  23 4057-4062
• 76 Karthaus M, Kretzschmar A, Kröning H et al.. Dalteparin for prevention of catheter-related complications in cancer patients with central venous catheters: final results of a double-blind, placebo-controlled phase III trial.  Ann Oncol. 2006;  17 289-296