Not All Clots Are Created Equal: Upper Extremity Deep-Vein Thrombosis

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How is upper extremity deep-vein thrombosis (DVT) best managed?

Have you noticed that as central venous catheters, pacemakers, and defibrillators have become more common, complications consequent to their use, such as upper extremity thrombophlebitis, are also more frequently encountered? This month’s Top Paper addresses key facts about the diagnosis and management of thrombosis in the upper extremities, especially as they contrast with lower extremity disease.¹ The data teach an important lesson: upper and lower venous thrombosis are not the same.

COMPLICATIONS OF
UPPER EXTREMITY DVT
First of all, complications from upper extremity clots do occur, but they are less common than their counterparts in the lower extremities. Pulmonary embolism rates are 6% for upper and 15% to 32% for lower venous disease; similarly, recurrence rates are 2% to 5% for upper versus 10% for lower venous disease, and post-phlebitic syndrome percentages are 5% for the upper extremities and 56% for the lower.

DIAGNOSIS
Diagnostic screening tests are also not equivalent. For example, a negative D-dimer test coupled with a low or intermediate pre-test probability for venous thrombosis is useful for ruling out lower extremity disease, but it is not recommended for the diagnosis of upper extremity thrombosis. Compression ultrasonography is the preferred imaging test for upper extremity disease.

MANAGEMENT
Routine catheter removal is not recommended for associated thrombosis. However, if the catheter is malfunctioning, the patient has a contraindication to anticoagulation or has continued signs or symptoms of thrombosis despite anticoagulation, or the catheter is no longer needed, it can be taken out. No randomized controlled trials have compared unfractionated and low molecular weight heparin in this disease. Observational studies have provided evidence that low molecular weight heparin works very well in decreasing the recurrence rate and the incidence of pulmonary emboli. After the acute event, warfarin therapy can be started, but low molecular weight heparin is recommended if the patient’s thrombophilia is a result of cancer. Therapy should be continued for 3 to 6 months. Compression devices are not recommended.

Thrombolysis may be helpful, but surgery should be reserved only for those patients with severe manifestations despite anticoagulants. Finally, the available data do not support the insertion of superior vena cava filters as a treatment for this entity. Furthermore, there are unique complications after the placement of filters for upper extremity clots: 4 of 209 patients experienced tamponade, 2 had aortic perforations, and 1 had a pneumothorax.

Kucher¹ reviewed consensus guidelines from the American College of Chest Physicians and commented that they were “largely consistent with his conclusions and data.” Much of the content was new to me and will change the way I treat this complication—a disease entity that continues to increase in incidence. ■