Can upper extremity Deep Vein Thrombosis (DVT) occur after removal of a peripheral Intravenous (IV) line?

Upper Extremity DVT Following Peripheral IV Removal

Yes, upper extremity deep vein thrombosis (UEDVT) can occur after peripheral IV removal, particularly in patients with risk factors such as previous thrombosis or indwelling venous devices.

Pathophysiology and Risk Factors

Upper extremity DVT accounts for approximately 10% of all diagnosed DVTs 1, and the risk factors differ from those of lower extremity DVT. Key risk factors include:

• Indwelling venous devices (highest risk factor) 1
• Previous insertion attempts or catheter placement 1
• History of previous DVT (OR=8.99) 2
• Intramedullary implant removal (OR=12.43) 2
• Advanced age 1
• Hypercoagulability 1
• Cancer 1
• Heart failure 1
• Intensive care unit admission 1
• Trauma 1

Clinical Presentation

Patients with UEDVT typically present with:

• Ipsilateral upper extremity edema
• Pain
• Paresthesia
• Functional impairment 1
• Unilateral swelling (indicating obstruction at the brachiocephalic, subclavian, or axillary veins) 1
• Pain in the supraclavicular space or neck 1

It's important to note that DVT limited to the brachial veins may not be associated with swelling, and catheter-associated thrombosis may be asymptomatic or manifest as catheter dysfunction 1.

Diagnosis

When UEDVT is suspected following peripheral IV removal:

1. Duplex ultrasound is the first-line diagnostic test:

   • Direct visualization of thrombus
   • Assessment of vein compressibility
   • Color-flow imaging to determine obstruction
   • Doppler waveform assessment 1

2. If ultrasound is inconclusive but clinical suspicion remains high:

   • CT venography with contrast
   • MR venography with contrast
   • X-ray venogram with contrast 1

Complications

UEDVT can lead to serious complications:

• Pulmonary embolism (PE) - contrary to previous beliefs, PE is not rare in UEDVT 3
• Post-thrombotic syndrome (PTS) - occurs in 7-46% of patients (weighted mean 15%) 4, 1
• Dominant arm PTS is associated with worse quality of life and disability 1

Management

For confirmed UEDVT:

1. Anticoagulation is the mainstay of therapy:

   • For most patients with UEDVT involving axillary or more proximal veins, anticoagulant therapy alone is recommended over thrombolysis 1
   • Standard duration of anticoagulation applies

2. Thrombolytic therapy may be considered in select cases:

   • Patients most likely to benefit from thrombolysis
   • Those with access to catheter-directed thrombolysis
   • Patients who place high value on prevention of PTS
   • Patients who accept the higher bleeding risk 1

3. Monitoring for recurrence:

   • If recurrent VTE occurs on anticoagulant therapy, consider switching to LMWH temporarily 1

Prevention of Post-Thrombotic Syndrome

• Unlike lower extremity DVT, there are insufficient data on compression sleeves or bandages to prevent or treat upper extremity PTS 1
• No standardized scoring system exists for diagnosis of upper extremity PTS 1
• Residual thrombosis and axillosubclavian vein thrombosis are associated with increased risk of PTS 4

Special Considerations

• For patients with cancer and UEDVT, follow cancer-associated VTE guidelines 1
• For superficial venous thrombosis of the upper extremity with increased risk factors, consider fondaparinux or LMWH for 45 days 5

Key Takeaway

While peripheral IV-related UEDVT is less common than central venous catheter-related thrombosis, it remains an important clinical entity that requires prompt diagnosis and treatment to prevent serious complications such as pulmonary embolism and post-thrombotic syndrome.