Ryan M. Cox, Jaimo Ahn, Surena Namdari.
Response/Recommendation: Most of the signs and symptoms of an upper extremity deep venous thrombosis (DVT) are rather non-specific, such as pain and edema. However, more unusual signs such as visible venous collaterals and skin discoloration are more concerning for DVT.
Strength of Recommendation: Limited.
Rationale: Upper extremity DVT is not as common as lower extremity DVT and represents approximately 10% of all DVT overall1–5. They are often divided into primary DVT, with no underlying pathology or foreign body, and secondary or provoked DVT, which are often associated with central venous catheters, pacemaker leads, or malignancy1.
Paget-Schroetter Syndrome is a type of primary DVT commonly seen in athletes with thoracic outlet syndrome6,7. In this disorder, athletes who frequently perform repetitive external rotation and abduction of the shoulder develop thrombosis in the axillosubclavian vein. They often present after a period of physical activity with acute pain, discoloration, swelling, and heaviness of the affected extremity6.
Most of the signs and symptoms of upper extremity DVT are nonspecific and include pain, swelling, erythema, weakness, and paresthesia2–5. Less common signs that may be more indicative of an upper extremity DVT include skin discoloration and visible venous collaterals. According to the American College of Radiology (ACR), the location of the thrombosis typically correlates with the clinical presentation8. Unilateral swelling could be due to obstruction of the brachiocephalic, subclavian, or axillary veins. Superficial thrombophlebitis often presents with pain, induration, and a palpable cord. In severe cases with a more proximal thrombosis, such as superior vena cava or subclavian vein, patients may experience bilateral upper extremity or head and neck swelling.
There were four studies that specifically mentioned the signs and symptoms of patients presenting with an upper extremity DVT. Mustafa et al., identified 65 patients with an upper extremity DVT in a community teaching hospital over a 2 year period9. Extremity swelling was present in all patients with 26 (40%) experiencing pain and 4 (6%) presenting with erythema in the extremity. In a retrospective review of 90 patients with ultrasound confirmed thrombosis of the internal jugular, subclavian, axillary, or brachial veins 31 patients (34%) experienced pain in the extremity, and 76 (84%) presented with edema10. The largest series identified was a retrospective review of a prospective ultrasound DVT database with 5,451 patients of which 592 patients sustained an upper extremity DVT, 324 were associated with central venous catheters (CVC) and 268 were non-CVC associated11. They found that patients with an upper extremity DVT were more likely to have extremity edema and less likely to have extremity pain, dyspnea, or chest pain than patients with a lower extremity DVT. Most recently, Schastlivtsev et al., investigated the use of rivaroxaban for the treatment of 30 patients with an upper extremity DVT12. They found the presenting symptoms to be pain 6.6%), cramps (20.0%), heaviness (23.3%), pruritus (13.3%), and paresthesia (23.3%). The most common presenting signs were edema (16.6%), prominent subcutaneous arm veins (16.6%), prominent collateral veins (10.0%), tenderness (6.6%), redness (6.6%), and dependent cyanosis (16.6%).
Unfortunately, most of the signs and symptoms of upper extremity DVT are rather non-specific and include common postoperative findings such as pain, tenderness, swelling, and edema. However, more unusual signs such as distended or prominent collateral veins or extremity cyanosis should provoke further diagnostic testing to rule out upper extremity DVT.
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2. Kraaijpoel N, van Es N, Porreca E, Büller HR, Di Nisio M. The diagnostic management of upper extremity deep vein thrombosis: A review of the literature. Thromb Res. 2017;156:54-59. doi:10.1016/j.thromres.2017.05.035
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11. 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(12):1605-1611. doi:10.1161/01.CIR.0000142289.94369.D7
12. Schastlivtsev I, Lobastov K, Tsaplin S, et al. Rivaroxaban in the treatment of upper extremity deep vein thrombosis: A single-center experience and review of the literature. Thromb Res. 2019;181:24-28. doi:10.1016/j.thromres.2019.07.008