Deep Vein Thrombosis of the Upper Extremity

Aka: Deep Vein Thrombosis of the Upper Extremity, Upper Extremity Deep Venous Thrombosis, Upper Extremity DVT, PICC Line Thrombosis, Brachial Vein Thrombosis, Axillary Vein Thrombosis, Brachiocephalic Vein Thrombosis, Subclavian Vein Thrombosis, Internal Jugular Vein Thrombosis, Radial Vein Thrombosis, Ulnar Vein Thrombosis, UEDVT, Effort Thrombosis, Paget-Schroetter Syndrome

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II. Epidemiology

  1. Upper extremity accounts for 5-10% of Deep Vein Thrombosis (DVT)
  2. Patients tend to be younger and of leaner body habitus than those with lower extremity DVT

III. Anatomy

  1. Deep Veins of Arm
    1. Proximal Deep Veins
      1. Subclavian Vein (most common DVT site)
      2. Axillary Vein (common DVT site)
      3. Internal Jugular Vein (included in Upper Extremity DVT by some authors)
      4. Brachiocephalic Vein
    2. Distal Deep Veins
      1. Brachial Vein
      2. Radial Vein
      3. Ulnar Vein
  2. Superficial Veins of Arm
    1. Cephalic Vein
    2. Basilic Vein

IV. Causes

  1. Central Venous Catheter (common)
  2. PICC Line Thrombosis (complicates 3-5% of PICC Lines)
  3. Effort Thrombosis (Paget-Schroetter Syndrome)
    1. Incidence 1 to 2 per 100,000 per year in U.S.
    2. Venous form of Thoracic Outlet Syndrome
      1. Musculoskeletal swelling of axilla and upper arm results in external
      2. Compression interferes with arm venous outflow
    3. Occurs in athletes with upper extremity Muscle hypertrophy (rowers, swimmers, pitchers, tennis players, weight lifters)
      1. Overuse with hypertrophy of scalene Muscles, especially in dominant arm
      2. Increased risk with congenital cervical ribs or subclavius ligaments
  4. Idiopathic (uncommon)
    1. Evaluate for occult cancer (up to 40% of Upper Extremity DVT causes)
      1. More likely than with lower extremity DVT
    2. Consider evaluation for Hypercoagulable state

V. Symptoms

  1. Shoulder or Neck Pain
  2. Edema of the hand or arm
  3. Decreased extremity movement

VI. Signs

  1. Arm with palpable cord
  2. Supraclavicular fullness
  3. Cyanosis or bluish discoloration of the extremity
  4. Serous drainage from PICC Line insertion site
  5. Venous distention
    1. Superficial vein distention (esp. chest wall and Shoulder)
    2. Jugular Venous Distention

VII. Differential Diagnosis

  1. Thoracic Outlet Syndrome

VIII. Imaging

  1. Images
    1. deepVeins.jpg
  2. Duplex Ultrasound of upper extremity
    1. Test Sensitivity and Test Specificity approach 100% with skilled ultrasonagrapher
    2. Proximal subclavian vein may be difficult to image (clavicle shadowing)
  3. Advanced imaging options in indeterminate Ultrasound
    1. CT or MRI (timed for venous phase evaluation)

IX. Management: Proximal Upper Extremity Deep Vein Thrombosis

  1. Indications: Proximal Deep Vein Thrombosis
    1. Subclavian Vein Thrombosis
    2. Axillary Vein Thrombosis
    3. Internal Jugular Vein Thrombosis
    4. Brachiocephalic Vein Thrombosis
  2. Anticoagulation
    1. See Anticoagulation in Thromboembolism
    2. Duration: Typically 3 months (6 months or longer may be required if persistent risk)
  3. Consider catheter directed Thrombolysis (severe acute edema, pain presentations)
    1. Large thrombus
    2. Acute within last 2 weeks
    3. Patients with low bleeding risk

X. Management: Distal Upper Extremity Deep Vein Thrombosis

  1. Indications: Distal Deep Vein Thrombosis
    1. Brachial Vein
    2. Radial Vein
    3. Ulnar Vein
  2. Approach
    1. Observation (typical) OR
    2. Prophylactic dose Anticoagulation OR
    3. Therapeutic dose Anticoagulation (high risk patients)
      1. Catheter-Associated Venous Thrombosis and catheter remaining in place (see below)
      2. Cancer patients with low risk of bleeding

XI. Management: PICC Line Venous Thrombosis

  1. PICC Line venous thrombosis risk: 2.5%
    1. May present as serous drainage from the PICC insertion site
  2. New Recommendations
    1. PICC Line does not need to be removed in most Upper Extremity DVTs (if functional and ongoing need)
    2. Anticoagulate for 3 months regardless of presence of cancer (or as long as PICC in place if longer than 3 months)
    3. Older recommendations were to remove the PICC Line and not replacing (even if placed on opposite side)
  3. References
    1. (2012) Chest 141(2): e419S-e494S [PubMed]
    2. DeLoughery and Orman in Majoewsky (2012) EM:Rap 12(12): 4-5
    3. Jones (2010) J Vasc Surg 51(1):108-13 [PubMed]

XII. Complications

  1. Pulmonary Embolism (6% of cases; contrast with lower extremity DVT related PE of 33%)
  2. Post-thrombotic Symdrome (13% of cases)
  3. Superior Vena Cava Syndrome

XIII. References

  1. McCollom (2021) EM:Rap 21(8)
  2. Mintz and Levy (2017) Upper Extremity Deep Vein Thrombosis, ACC Website, accessed 8/6/2021
    1. https://www.acc.org/latest-in-cardiology/articles/2017/11/09/13/30/upper-extremity-deep-vein-thrombosis
  3. Engelberger (2012) Circulation 126(6):768-73 +PMID: 22869858 [PubMed]
  4. Joffe (2002) Circulation 106:1874-80 [PubMed]
  5. Simon (2023) Am Fam Physician 107(5): 503-12 [PubMed]

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Related Studies

Ontology: Brachiocephalic vein thrombosis (C0559488)

Concepts Disease or Syndrome (T047)
SnomedCT 281597009
Dutch trombose in venae brachiocephalicae
French Thrombose de veine brachiocéphalique
German Thrombose der Vena brachiocephalica
Italian Trombosi della vena brachiocefalica
Portuguese Trombose da veia braquiocefálica
Spanish Trombosis de vena braquiocefálica, trombosis de la vena braquiocefálica (trastorno), trombosis de la vena braquiocefálica
Japanese 腕頭静脈血栓症, ﾜﾝﾄｳｼﾞｮｳﾐｬｸｹｯｾﾝｼｮｳ
English Brachiocephalic vein thrombos, thrombosis of brachiocephalic vein, thrombosis of brachiocephalic vein (diagnosis), venous thrombosis thoracic veins brachiocephalic, Brachiocephalic vein thrombosis, Brachiocephalic vein thrombosis (disorder)
Czech Trombóza vena brachiocephalica
Hungarian Brachycephal vena thrombosis
Derived from the NIH UMLS (Unified Medical Language System)

Ontology: Axillary vein thrombosis (C0574014)

Concepts Disease or Syndrome (T047)
SnomedCT 155492003, 297156001
Italian Trombosi della vena ascellare
Japanese 腋窩静脈血栓症, ｴｷｶｼﾞｮｳﾐｬｸｹｯｾﾝｼｮｳ
Czech Trombóza vena axillaris
English venous thrombosis axillary veins, thrombosis of axillary veins, thrombosis of axillary veins (diagnosis), Axillary vein thrombosis, Axillary vein thrombosis (disorder)
Hungarian Axillaris vena thrombosis
Spanish trombosis de vena axilar (trastorno), trombosis de vena axilar, Trombosis de la vena axilar
Portuguese Trombose da veia axilar
Dutch vena axillaris trombose
French Thrombose de la veine axillaire
German Thrombose der vena axillaris
Derived from the NIH UMLS (Unified Medical Language System)

Ontology: Thrombosis of internal jugular vein (C0745497)

Concepts Disease or Syndrome (T047)
SnomedCT 5001000124101
English thrombosis of internal jugular veins (diagnosis), thrombosis of internal jugular veins, venous thrombosis internal jugular veins, jugular vein internal thrombosis, internal jugular vein thrombosis, internal jugular thrombosis vein, Thrombosis of internal jugular vein, Thrombosis of internal jugular vein (disorder)
Derived from the NIH UMLS (Unified Medical Language System)

Ontology: Thrombosis of subclavian vein (C0749087)

Concepts Disease or Syndrome (T047)
SnomedCT 438647008
Italian Trombosi della vena succlavia
Japanese 鎖骨下静脈血栓症, ｻｺﾂｶｼﾞｮｳﾐｬｸｹｯｾﾝｼｮｳ
Czech Trombóza vena subclavia
English Thrombosis of subclavian vein (disorder), Thrombosis of subclavian vein, thrombosis of subclavian veins (diagnosis), thrombosis of subclavian veins, subclavian vein thrombosis, Subclavian vein thrombosis
Spanish trombosis de vena subclavia (trastorno), trombosis de vena subclavia, Trombosis de la vena subclavia
Hungarian Vena subclavia thrombosis
Portuguese Trombose da veia subclávia
Dutch vena subclavia trombose
French Thrombose de la veine sous-clavière
German Thrombose der vena subclavia
Derived from the NIH UMLS (Unified Medical Language System)

Ontology: Upper Extremity Deep Vein Thrombosis (C2717899)

Definition (MSH) DEEP VEIN THROMBOSIS of an upper extremity vein (e.g., AXILLARY VEIN; SUBCLAVIAN VEIN; and JUGULAR VEINS). It is associated with mechanical factors (Upper Extremity Deep Vein Thrombosis, Primary) secondary to other anatomic factors (Upper Extremity Deep Vein Thrombosis, Secondary). Symptoms may include sudden onset of pain, warmth, redness, blueness, and swelling in the arm.
Concepts Pathologic Function (T046)
MSH D056824
SnomedCT 128054009
Dutch diepte veneuze trombose arm
French Thrombose veineuse profonde du bras, Thrombose veineuse profonde du membre supérieur
German tiefe Venenthrombose des Arms, Armvenenthrombose, Achselvenenthrombose, Tiefe Armvenenthrombose
Italian Trombosi venosa profonda del braccio, Trombosi venosa profonda delle estremità superiori
Portuguese Trombose venosa profunda do braço, Trombose Venosa Profunda de Membros Superiores
Spanish Trombosis venosa profunda en el brazo, Trombosis Venosa Profunda de la Extremidad Superior, trombosis venosa profunda de las extremidades superiores (trastorno), trombosis venosa profunda de las extremidades superiores
Japanese 腕深部静脈血栓症, ﾜﾝｼﾝﾌﾞｼﾞｮｳﾐｬｸｹｯｾﾝｼｮｳ, ｳﾃﾞｼﾝﾌﾞｼﾞｮｳﾐｬｸｹｯｾﾝｼｮｳ, 上肢深部静脈血栓症, 深部静脈血栓症-上肢
Czech Hluboká žilní trombóza paže, horní končetina - flebotrombóza, horní končetina - hluboká žilní trombóza
English Upper Extremity Deep Vein Thrombosis, thrombosis of deep veins of upper extremity, thrombosis of deep veins of upper extremity (diagnosis), venous thrombosis upper extremity deep veins, DVT of upper extremity, Upper Extremity Deep Vein Thrombosis [Disease/Finding], Deep venous thrombosis arm, Deep venous thrombosis of upper extremity (disorder), Deep venous thrombosis of upper extremity
Russian ВЕРХНИХ КОНЕЧНОСТЕЙ ГЛУБОКИХ ВЕН ТРОМБОЗ, KONECHNOSTEI VERKHNIKH GLUBOKIKH VEN TROMBOZ, VERKHNIKH KONECHNOSTEI GLUBOKIKH VEN TROMBOZ PERVICHNYI, КОНЕЧНОСТЕЙ ВЕРХНИХ ГЛУБОКИХ ВЕН ТРОМБОЗ, PEDZHETA-SHRETTERA SINDROM, TROMBOZ GLUBOKIKH VEN VERKHNIKH KONECHNOSTEI, VERKHNIKH KONECHNOSTEI GLUBOKIKH VEN TROMBOZ, ВЕРХНИХ КОНЕЧНОСТЕЙ ГЛУБОКИХ ВЕН ТРОМБОЗ ПЕРВИЧНЫЙ, ПЕДЖЕТА-ШРЕТТЕРА СИНДРОМ, ТРОМБОЗ ГЛУБОКИХ ВЕН ВЕРХНИХ КОНЕЧНОСТЕЙ
Swedish Upper Extremity Deep Vein Thrombosis
Polish Zakrzepica żył głębokich kończyny górnej, Zakrzepica żył głębokich kończyny górnej pierwotna, Powysiłkowa zakrzepica żył głębokich kończyny górnej, Idiopatyczna zakrzepica żył głębokich kończyny górnej, Zakrzepica żył głębokich kończyny górnej wtórna, Zespół Pageta-Schroettera, Zakrzepica żył głębokich kończyny górnej po ćwiczeniach
Hungarian Kar mélyvenás thrombosisa
Norwegian Dyp venetrombose i overekstremitetene
Derived from the NIH UMLS (Unified Medical Language System)

Ontology: Upper Extremity Deep Vein Thrombosis, Secondary (C2717900)

Definition (MSH) DEEP VEIN THROMBOSIS of an upper extremity vein (e.g., AXILLARY VEIN; SUBCLAVIAN VEIN; and JUGULAR VEINS) that develops as a complication of upper extremity central venous catheters and pacemaker uses, or cancer.
Concepts Pathologic Function (T046)
MSH D056824
English Upper Extremity Deep Vein Thrombosis, Secondary, Central Venous Catheter Thrombosis
French Thrombose sur cathéter veineux central, Thrombose veineuse profonde secondaire du membre supérieur
German Achselvenenthrombose, sekundaere, Armvenenthrombose, sekundaere, Armvenenthrombose, sekundäre, Achselvenenthrombose, sekundäre
Czech horní končetina - hluboká žilní trombóza sekundární
Norwegian Sekundær dyp venetrombose i overekstremitetene
Italian Trombosi venosa profonda secondaria delle estremità superiori
Derived from the NIH UMLS (Unified Medical Language System)

Ontology: thrombosis of brachial vein (C2729008)

Concepts Pathologic Function (T046)
English thrombosis of brachial vein (diagnosis), thrombosis of brachial vein, venous thrombosis upper extremity deep veins brachial
Derived from the NIH UMLS (Unified Medical Language System)

Ontology: thrombosis of radial vein (C2729010)

Concepts Pathologic Function (T046)
English thrombosis of radial vein, DVT of radial vein, thrombosis of radial vein (diagnosis), venous thrombosis upper extremity deep veins radial
Derived from the NIH UMLS (Unified Medical Language System)

Ontology: thrombosis of ulnar vein (C2729012)

Concepts Pathologic Function (T046)
English thrombosis of ulnar vein (diagnosis), venous thrombosis upper extremity deep veins ulnar, thrombosis of ulnar vein, DVT of ulnar vein
Derived from the NIH UMLS (Unified Medical Language System)

Related Topics in Cardiovascular Medicine

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