Upper Extremity Deep Vein Thrombosis: More Questions than Answers

Behnood Bikdeli, M.D.
Shadi Kalantarian, M.D.
Provided by NATF
Posted on ClotCare January, 2008^*

Reference: Spencer FA, Emery C, Lessard D, Goldberg RJ, For the Worcester Venous Thromboembolism Study. Upper extremity deep vein thrombosis: a community-based perspective. Am J Med. 2007; 120(8): 678-84.

INTRODUCTION
The incidence of upper-extremity deep vein thrombosis (UEDVT) has increased. Indeed, 25-75% of central venous catheters may be complicated by UEDVT, of which 75% are asymptomatic. Although fatal pulmonary embolism following acute UEDVT is rare, UEDVT might cause post-thrombotic syndrome.^1-4

This retrospective study outlines a comparison of patients with UEDVT versus lower-extremity DVT.²

METHODS
Medical records of 478,000 persons were assessed. UEDVT was considered if thrombus was confirmed by ultrasonography or venography in the internal jugular, innominate, or subclavian veins. By multivariate regression analysis, factors independently associated with UEDVT were identified.

RESULTS
From the total 483 patients, 69 (14%) had UEDVT, while the rest had LEDVT. The age-adjusted incidence of UEDVT and LEDVT was 15 (95% CI 12-19) and 74 (95% CI 67-82) per 100,000 population, respectively.

Those with UEDVT were younger (59 versus 66 years, P<0.001), had a lower BMI (p=0.02), and had a greater rate of non-VTE-related hospital admission. By multivariate analysis, recent central venous catheter placement was strongly associated with UEDVT (OR 21.7, 95% CI 9.3-50.0). Additionally, recent cardiac procedures and recent ICU discharge were more common in those with UEDVT. However, prior VTE history was less evident in those with UEDVT (8.7% versus 19.8%, p= 0.03).

Bleeding, VTE recurrence, and mortality were not significantly different between the two groups at 30 days, 6 months, and one year follow-up.

Those with LEDVT received warfarin and IV heparin more frequently. Aspirin was prescribed at discharge twice as often to patients with UEDVT. Subcutaneous enoxaparin was prescribed comparably in the two groups.

CONCLUSION & COMMENTS
The authors conclude: "because the most important risk factors of UEDVT are identifiable and are hospital-related, optimal targeting of prophylaxis to patients at risk should be achievable."² However, there is a paucity of evidence about safety and efficacy of such prophylaxis protocols.

Joffe et al. reported PE in 3% of their patients (p<0.001).⁵ However, Prandoni et al., detected PE in as many as 36% of their patients.⁶

Considerable variation exists in the reported sensitivity and specificity of ultrasonography for detection of UEDVT. Particularly challenging are subclavian vein assessment and differentiation of collaterals from normal veins seen in venous obstruction. ^3,7 The available data on asymptomatic UEDVT suggest that ultrasound has even lower sensitivity in such cases.^1,8,9 Contrast venography, albeit more sensitive, cannot detect all cases of UEDVT.

Many current recommendations for UEDVT are extrapolated from experiences with LEDVT, even though some physiologic factors such as hydrostatic pressure differ significantly between the lower and upper limbs.³ Despite enormous progress in all aspects of our understanding of LEDVT, most questions about UEDVT remain to be answered. A systematic review of the available studies, and development of a global registry would be the best short-term and long-term strategies to answer such questions.

References

1. Joffe HV, Goldhaber SZ. Upper-extremity deep vein thrombosis. Circulation 2002;106:1874-80.
   
   
2. Spencer FA, Emery C, Lessard D, Goldberg RJ; Worcester Venous Thromboembolism Study. Upper extremity deep vein thrombosis: a community-based perspective. Am J Med 2007;120:678-84.
   
   
3. Weber TM, Lockhart ME, Robbin ML. Upper extremity venous Doppler ultrasound. Radiol Clin North Am 2007;45:513-24.
   
   
4. Elman EE, Kahn SR. The post-thrombotic syndrome after upper extremity deep venous thrombosis in adults: a systematic review. Thromb Res 2006; 117:609-14.
   
   
5. 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 21;110:1605-11.
   
   
6. 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.
   
   
7. Mustafa BO, Rathbun SW, Whitsett TL, Raskob GE. Sensitivity and specificity of ultrasonography in the diagnosis of upper extremity deep vein thrombosis: a systematic review. Arch Intern Med 2002;162:401-4.
   
   
8. Male C, Chait P, Ginsberg JS, et al. Comparison of venography and ultrasound for the diagnosis of asymptomatic deep vein thrombosis in the upper body in children: results of the PARKAA study. Prophylactic Antithrombin Replacement in Kids with ALL treated with Asparaginase. Thromb Haemost 2002;87:593-8.
   
   
9. Haire WD, Lynch TG, Lieberman RP, Lund GB, Edney JA. Utility of duplex ultrasound in the diagnosis of asymptomatic catheter-induced subclavian vein thrombosis. J Ultrasound Med 1991;10:493-6.

Behnood Bikdeli is student of medicine, research fellow, and student section director of Modarres Cardiovascular Research Center, Shaheed Beheshti University of Medical Sciences. He won the award of “Best Research Paper” at the seventh Annual Research Seminar of Iranian Medical Sciences Students. He has also headed development of adapted cardiovascular clinical practice guidelines on VTE, Heart failure, and CPR for generalists in collaboration with the World Health Organization in Iran. He is currently contributing to a handful of research projects, namely on atherosclerosis, thromboembolism, and atrial fibrillation.

Shadi Kalantarian is student of medicine and a research fellow at Modarres Cardiovascular Research Center, Shaheed Beheshti University of Medical Sciences. Her research subjects of interest are atherosclerosis, thromboembolic disease, and arrhythmology. Currently she is heading a systematic review on surgical AF ablation with the Cochrane Collaboration.

This posting originally appeared on the website of the North American Thrombosis Forum (NATF) and has been provided on ClotCare with NATF's permission. See www.natfonline.org for more information about NATF.