Upper extremity deep vein thrombosismanagement in a district general hospitalBabu Pusuluri, Shiva Sreenivasan

Gloucestershire Hospitals NHS Foundation Trust, Gloucester, United Kingdom shivasreenivasan@nhs.net

Recent UK guidance on venous thromboembolic disease1 is notably silent

on upper extremity deep vein thrombosis (UEDVT) management, despite its

high incidence (10% of all cases of DVT)2. Available guidance3 recommends

catheter-directed thrombolysis (CDT) (Figure 1) for patients with acute

extensive UEDVT, good functional status, and low bleeding risk, followed by

anticoagulation for 3 months. First rib resection is currently not routinely

recommended. With increasing use of CDT in UEDVT, we reviewed the

demographics and management of patients diagnosed with UEDVT at our

hospital over the past 5 years.

Cases of UEDVT were retrospectively identified over a 5–year period from

archived radiological imaging, as well as from admission records from our

Ambulatory Day Unit and Vascular Imaging Laboratory.

54 cases were identified, of which records for 4 were unavailable. 30 cases

(60%) were men. The majority of cases (70%) were provoked by central venous

catheter (CVC)/pacemaker insertion or malignancy. The rest were either

unprovoked or effort-related (Paget–Schrötter disease). 8 cases (16%) were

referred to vascular surgery for consideration of CDT, which was performed

successfully in 5 patients. 1 patient had first rib resection, and 1 patient had

cervical band excision. Anticoagulation treatment was only documented in 6

cases, and duration varied from 3 months to lifelong.

Treatment of UEDVT locally is currently haphazard and has no clear protocol

for either referral for CDT or for anticoagulation duration. We propose a

streamlined multidisciplinary pathway (Figure 2) which can be instigated

in our Ambulatory Day Unit, and which will hopefully optimise care of

patients with UEDVT. This will need subsequent audit to ascertain uptake and

compliance.

References

1. NationalClinicalGuidelineCentre(UK).VenousThromboembolicDiseases:TheManagementofVenousThromboembolicDiseasesandtheRoleofThrombophiliaTesting[Internet].London:RoyalCollegeofPhysicians(UK);2012Jun.(NICEClinicalGuidelines,No.144.)Availablefrom:http://www.ncbi.nlm.nih.gov/books/NBK132796/

2. JoffeHV,KucherN,TapsonVF,et. al.Upper-extremitydeepveinthrombosis:aprospectiveregistryof592patients.Circulation2004;110:1605–1611.

3. KearonC,AklEA,ComerotaAJ,et. al.AntithrombotictherapyforVTEdisease:antithrombotictherapyandpreventionofthrombosis,9thedition:AmericanCollegeofChestPhysiciansEvidence-BasedClinicalPracticeGuidelines.Chest2012;141:e419S–e494S.

4. EngelbergerRP,KucherN.Managementofdeepveinthrombosisoftheupperextremity.Circulation2012;126:768–773.

Introduction

Method

Results

Conclusions

Contrast venography pre (1A) and post-CDT (1B) in a case of Paget-Schrötter disease

Figure 1

1A Pre-CDT

1B Post-CDT

�rombus

Resolving thrombus

Figure 2Proposed UEDVT pathway

Acute anticoagulationProximal UEDVT:UFH/LMWH≥5daysDistal UEDVT:SurveillanceonlyorLMWHprophylaxis;Consideranticoagulationifcatheter-associatedorincancerpatientswithlowbleedingrisk

UEDVT confirmed on US, CTV or MRV

Vascular Surgery referral for consideration of catheter-directed thrombolysis if:1. Severe symptoms/signs with extensive axillary/subclavian UEDVT2. Good functional status3. Low bleeding risk

Otherwise anticoagulation alone

SVC syndromeUrgentangioplasty/stentifseveresymptoms

InmalignantSVCsyndrome:radiotherapy/chemotherapyorsurgery

Idiopathic UEDVTCancerscreening Venous thoracic outlet syndrome

Surgicaldecompression±angioplasty/stentCVC–related UEDVT

RetainCVC;ConsiderCVCremovalifcathetermalfunction/infection,anticoagulationcontraindicated,orifCVCunnecessary

Long term anticoagulation (LMWH, VKA, dabigatran, rivaroxaban)ProximalUEDVT:Anticoagulation≥3months

DistalUEDVT:Ifanticoagulated,then<3months

UEDVT–upperextremitydeepveinthrombosis;US–ultrasound;CTV–computedtomographicvenography;MRV–magneticresonancevenography;UFH–unfractionatedheparin;LMWH–lowmolecularweightheparin;SVC–superiorvenacava;CVC–centralvenouscatheter;VKA–vitaminKantagonist

Adapted from Engelberger, et al.4