Walter Ageno, Nelson Socorro.
Response/Recommendation: Patients with deep venous thrombosis (DVT) of the upper extremity should receive the same anticoagulant treatment regimens used for patients with DVT of the lower extremity. These include direct oral anticoagulants (DOAC) alone (apixaban and rivaroxaban), low-molecular-weight heparin (LMWH), and DOAC (edoxaban and dabigatran), LMWH alone, or LMWH and vitamin K antagonists. Anticoagulant treatment should be continued for at least 3 months and extended beyond 3 months if the event is unprovoked or secondary to permanent risk factors (e.g., cancer) and bleeding risk is low. The use of thrombolytic treatment or surgical approaches should be restricted to highly selected cases at low-risk for bleeding.
Strength of Recommendation: Limited.
Rationale: Upper extremity DVT encompasses thrombosis of the brachial, axillary, subclavian, and jugular veins and accounts for up to one-tenth of the total of venous thromboembolic events1. There are no randomized controlled trials comparing different therapeutic strategies in patients with upper extremity DVT and therapeutic approaches are based on evidence derived from trials conducted in patients with lower limb venous thromboembolism (VTE).
The risk of pulmonary embolism (PE) was reported to be lower than in patients with lower limb DVT as well as the potential for recurrent VTE2–5. A number of studies including up to about 200 patients have reported on the safety and effectiveness of treatment with different anticoagulant regimens. No difference in outcome rates was detected between standard of treatment with LMWH and vitamin K antagonists and treatment with DOAC6–17. International guidelines on antithrombotic therapy suggest anticoagulant therapy alone over thrombolysis for patients with acute upper extremity DVT and suggest considering thrombolysis in selected patients with severe symptoms, with thrombus involving most of the subclavian vein and the axillary vein, and with low-risk of bleeding18.
1. Ageno W, Haas S, Weitz JI, et al. Upper Extremity DVT versus Lower Extremity DVT: Perspectives from the GARFIELD-VTE Registry. Thromb Haemost. 2019;119(8):1365-1372. doi:10.1055/s-0039-1688828
2. Arnhjort T, Persson LM, Rosfors S, Ludwigs U, Lärfars G. Primary deep vein thrombosis in the upper limb: A retrospective study with emphasis on pathogenesis and late sequelae. Eur J Intern Med. 2007;18(4):304-308. doi:10.1016/j.ejim.2006.12.005
3. Levy MM, Bach C, Fisher-Snowden R, Pfeifer JD. Upper extremity deep venous thrombosis: reassessing the risk for subsequent pulmonary embolism. Ann Vasc Surg. 2011;25(4):442-447. doi:10.1016/j.avsg.2011.01.005
4. Tadlock MD, Chouliaras K, Kennedy M, et al. The origin of fatal pulmonary emboli: a postmortem analysis of 500 deaths from pulmonary embolism in trauma, surgical, and medical patients. Am J Surg. 2015;209(6):959-968. doi:10.1016/j.amjsurg.2014.09.027
5. Newton DH, Monreal Bosch M, Amendola M, et al. Analysis of noncatheter-associated upper extremity deep venous thrombosis from the RIETE registry. J Vasc Surg Venous Lymphat Disord. 2017;5(1):18-24.e1. doi:10.1016/j.jvsv.2016.08.002
6. Houghton DE, Casanegra AI, Peterson LG, et al. Treatment of upper extremity deep vein thrombosis with apixaban and rivaroxaban. Am J Hematol. 2020;95(7):817-823. doi:10.1002/ajh.25820
7. Beiswenger AC, Quereshy HA, Rouabhi M, et al. Midterm outcomes in patients with upper extremity deep vein thrombosis. J Vasc Surg Venous Lymphat Disord. 2020;8(6):930-938.e2. doi:10.1016/j.jvsv.2020.02.024
8. Bleker SM, van Es N, Kleinjan A, et al. Current management strategies and long-term clinical outcomes of upper extremity venous thrombosis. J Thromb Haemost. 2016;14(5):973-981. doi:10.1111/jth.13291
9. Delluc A, Le Gal G, Scarvelis D, Carrier M. Outcome of central venous catheter associated upper extremity deep vein thrombosis in cancer patients. Thromb Res. 2015;135(2):298-302. doi:10.1016/j.thromres.2014.11.020
10. Fan F, Zou Y, Zhang S, et al. Rivaroxaban in the Treatment of PICC-associated Upper Extremity Venous Thrombosis. Clin Ther. 2017;39(9):1882-1888. doi:10.1016/j.clinthera.2017.07.041
11. Laube ES, Mantha S, Samedy P, Wills J, Harnicar S, Soff GA. Treatment of central venous catheter-associated deep venous thrombosis in cancer patients with rivaroxaban. Am J Hematol. 2017;92(1):E9-E10. doi:10.1002/ajh.24588
12. Kovacs MJ, Kahn SR, Rodger M, et al. A pilot study of central venous catheter survival in cancer patients using low-molecular-weight heparin (dalteparin) and warfarin without catheter removal for the treatment of upper extremity deep vein thrombosis (The Catheter Study). J Thromb Haemost. 2007;5(8):1650-1653. doi:10.1111/j.1538-7836.2007.02613.x
13. Davies GA, Lazo-Langner A, Gandara E, et al. A prospective study of Rivaroxaban for central venous catheter associated upper extremity deep vein thrombosis in cancer patients (Catheter 2). Thromb Res. 2018;162:88-92. doi:10.1016/j.thromres.2017.04.003
14. Rathbun SW, Stoner JA, Whitsett TL. Treatment of upper-extremity deep vein thrombosis. J Thromb Haemost. 2011;9(10):1924-1930. doi:10.1111/j.1538-7836.2011.04466.x
15. Porfidia A, Agostini F, Giarretta I, et al. Upper extremity deep vein thrombosis treated with direct oral anticoagulants: a multi-center real world experience. J Thromb Thrombolysis. 2020;50(2):355-360. doi:10.1007/s11239-020-02044-4
16. Frank DA, Meuse J, Hirsch D, Ibrahim JG, van den Abbeele AD. The treatment and outcome of cancer patients with thromboses on central venous catheters. J Thromb Thrombolysis. 2000;10(3):271-275. doi:10.1023/a:1026503526188
17. 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(7464):484-485. doi:10.1136/bmj.38167.684444.3A
18. Kearon C, Akl EA, Ornelas J, et al. Antithrombotic Therapy for VTE Disease: CHEST Guideline and Expert Panel Report. Chest. 2016;149(2):315-352. doi:10.1016/j.chest.2015.11.026