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upper extremity deep vein thrombosis (UEDVT)

Etiology: 1) primary (30%) a) idiopathic b) associated with thoracic outlet syndrome [3] (60% of primary UEDVT) 2) secondary a) indwelling catheter-related (45%) [1,3] larger catheter confers higher risk b) 10% of patients with pacemakers [3] c) malignancy confers 8-fold increased risk [3] d) hypercoagulable state [3] e) obesity NOT risk factor f) hormone replacement therapy NOT risk factor Epidemiology: - not rare [1] - 4-10% of all DVT [3] Pathology: - not benign [1] - more likely to have cancer than patients with lower extremity DVT (38% vs 20%) - less likely to present with acute pulmonary embolism than patients with lower extremity DVT (9% vs 29%) Laboratory: see deep vein thrombosis Radiology: 1) non-invasive tests a) ultrasound 1] criteria is failure of venous lumen to fully collapse under gentle pressure from ultrasound transducer/probe 2] 82% sensitivity & specificity vs venography [2] for upper extremity DVT Diagnostic criteria: - an algorithm is proprosed [4], consisting of - clinical decision score - presence of a central venous catheter or lead - localized pain - unilateral edema - lack of an alternative diagnosis - d-dimer testing - ultrasonography Complications: - pulmonary emboli (~30%) - postphlebitic syndrome less common than in patients with lower extremity DVT Management: 1) treatment not standardized [3] 2) anticoagulation: generally 3 months with target INR of 2.0-3.0 - see deep vein thrombosis - if catheter associated thrombosis, anticoagulation as long as the catheter remains in place [5] 2) prognosis: a) recurrence lower than that for lower extremity DVT b) patients without catheters & without cancer with have lowest incidence of recurrence (0.5%) [1]

General

deep vein thrombosis (DVT)

References

  1. Munoz FJ et al, Clinical outcome of patients with upper-extremity deep vein thrombosis: results from the RIETE Registry. Chest 2008, 133:143 PMID: 17925416
  2. Journal Watch 22(5):36, 2002 Fraser DG et al, Diagnosis of lower-limb deep vein thrombosis: a prospective blinded study of magnetic resonance direct thrombus imaging. Ann Intern Med 136:89, 2002 PMID: 11790060
  3. Flinterman LE et al. Current perspective of venous thrombosis in the upper extremity. J Thromb Haemost 2008 Aug; 6:1262. PMID: 18485082
  4. Kleinjan A et al. Safety and feasibility of a diagnostic algorithm combining clinical probability, d-dimer testing, and ultrasonography for suspected upper extremity deep venous thrombosis: A prospective management study. Ann Intern Med 2014 Apr 1; 160:451 PMID: 24687068 http://annals.org/article.aspx?articleid=1852866
  5. Medical Knowledge Self Assessment Program (MKSAP) 17, 18, 19. American College of Physicians, Philadelphia 2015, 2018, 2022.