Acute Deep Venous Thrombosis (DVT) of the Arm:
from the ACCP Guidelines, 9th Ed.
The ACCP published its 9th edition of their clinical practice guidelines for prevention and treatment of venous thromboembolism (VTE) in February 2012, and we’re summarizing the 801-page long document by topic. (See also the other sections of the 9th edition ACCP recommendations.)
Here we review the section on the initial treatment of acute deep venous thrombosis (DVT) of the arm (upper extremity) with antithrombotic / anticoagulant therapy. In all cases, the ACCP’s recommendations for anticoagulation assume an acceptable bleeding risk; in all cases, the patient’s bleeding risk must be weighed against the need for anticoagulation.
Acute DVT of the Upper Extremity: Overview
Acute deep venous thrombosis of the upper extremity involve the brachial, axillary, or subclavian veins, and can extend more proximally to the brachiocephalic vein, internal jugular, or superior vena cava. Acute arm DVTs comprise a small minority of DVTs (<10%); about 3/4 are considered provoked by central venous catheters, pacemakers, or malignancy. Their incidence is probably rising, as these provoking factors become more common.
Not long ago, physicians disregarded many arm DVTs as clinically insignificant. However, up to 5% of patients with arm DVT will experience pulmonary embolism (PE), up to 20% post-thrombotic syndrome in the arm, and about 8% will have recurrence of their arm DVT later if untreated. If the axillary or more proximal veins are not affected (i.e., isolated brachial DVT), these complication rates are much lower.
There have been no randomized trials evaluating treatment of arm DVTs, and all evidence derives from observational trials or is extrapolated from the large body of data on leg DVTs, so “quality of evidence is, at best, moderate,” say Clive Kearon et al.
Removing Central Lines Causing DVT Is Optional, and Waiting Is OK
ACCP advises that when a central venous catheter is responsible for an acute DVT, and the central line is not needed or is not working, it should be removed. If there is a good reason to keep a working central line in, though, providing systemic anticoagulation and continuing to use the central line is appropriate (Grade 2C).
For Axillary or More-Proximal DVTs, Anticoagulate with LMWH or Fondaparinux
- The ACCP recommends treating acute DVTs of the arm with full anticoagulation when the DVT involves the axillary or more proximal veins, rather than watchful waiting (Grade 1B).
- For anticoagulation, ACCP suggests using low-molecular weight heparin (enoxaparin, dalteparin or tinzaparin) or fondaparinux rather than intravenous or subcutaneous heparin (Grade 2B/2C). They suggest not using thrombolysis (Grade 2C); thrombolysis should only be considered in selected patients with severe symptoms, large thrombus burden involving the subclavian and axillary veins, life expectancy > 1 year, good functional status and low bleeding risk. If thrombolysis is elected, anticoagulate afterward as long as you would have without thrombolysis (Grade 1B).
Although they don’t say so explicitly in their recommendations, it’s safe to assume you should transition patients to warfarin as you would when treating leg DVTs or pulmonary embolism.
Arm DVT Isolated to the Brachial Vein: Ideal Management Uncertain
There is little evidence to guide the management of isolated brachial vein DVT. Authors advise full anticoagulation for DVT isolated to the brachial vein if it is causing symptoms, or associated with cancer or a central line that will remain.
- For asymptomatic brachial DVT not meeting these criteria, they endorse serial examination, ultrasound surveillance for extension to the axillary vein (while withholding anticoagulation), therapeutic doses of anticoagulation for less than 3 months, or prophylactic-only doses of anticoagulation (not graded).
Treat Most Upper Extremity DVTs for 3 Months
- One important distinction between arm and leg DVT is that for unprovoked upper extremity DVT involving proximal veins (axillary or more proximal), ACCP recommends 3 months of anticoagulation, and no more. (Grade 1B)
- For patients with a central venous catheter that was just removed, ACCP also recommends 3 months of anticoagulation (Grade 1B) (even if they also have cancer — Grade 2C).
- For patients with cancer and an arm DVT (but no central line), ACCP doesn’t make an explicit recommendation.
Kearon C et al. Antithrombotic Therapy for VTE Disease: Antithrombotic Therapy and Prevention of Thrombosis, 9th ed: American College of Chest Physicians Evidence-Based Clinical Practice Guideline. Chest 2012; 141 (2_suppl): e419-e494S.