What is the management of upper extremity Deep Vein Thrombosis (DVT)?

From the Guidelines

The management of upper extremity deep vein thrombosis (UEDVT) primarily involves anticoagulation therapy, with a recommendation for acute treatment with parenteral anticoagulation, such as low molecular weight heparin (LMWH) or fondaparinux, over no such acute treatment 1. The initial treatment should begin with LMWH, such as enoxaparin 1 mg/kg twice daily or fondaparinux 7.5 mg daily, overlapped with warfarin (target INR 2-3) or a direct oral anticoagulant (DOAC) like rivaroxaban (15 mg twice daily for 21 days, then 20 mg daily), apixaban (10 mg twice daily for 7 days, then 5 mg twice daily), or edoxaban (60 mg daily after 5-10 days of parenteral anticoagulation) 1. Key considerations in the management of UEDVT include:

• Treatment duration, which is typically 3 months for provoked UEDVT (catheter-related or transient risk factors) and at least 3-6 months for unprovoked cases, with consideration for longer therapy in recurrent or idiopathic cases 1
• Catheter management, where the catheter can remain in place with anticoagulation if still required, but should be removed if no longer needed 1
• Thrombolysis or thrombectomy, which may be considered in severe cases with limb-threatening ischemia or extensive thrombosis, although anticoagulant therapy alone is generally suggested over thrombolysis 1
• Monitoring for complications, including post-thrombotic syndrome and pulmonary embolism, as upper extremity DVT can lead to these complications in a significant proportion of patients if left untreated 1.

From the Research

Management of Upper Extremity Deep Vein Thrombosis (DVT)

The management of upper extremity DVT involves anticoagulation therapy as the mainstay of treatment, with the goal of preventing pulmonary embolism and reducing the risk of post-thrombotic syndrome.

• Anticoagulant treatment options include:
  • Direct oral anticoagulants
  • Low molecular weight heparin followed by vitamin K antagonists
  • Low molecular weight heparin alone 2, 3
• The use of anticoagulation alone may be associated with a significant risk of post-thrombotic syndrome, and more aggressive treatments such as catheter-directed thrombolysis or surgery may be considered to reduce this risk 4
• The duration of anticoagulation therapy is typically 3-6 months, with the option for extended secondary prophylaxis depending on the individual's risk of VTE recurrence and bleeding 5
• Compression therapy may be used to prevent post-thrombotic syndrome, and acute revascularization procedures may be considered in rare special cases 5

Special Considerations

• Patients with cancer-associated thromboembolism may require special consideration, with the option for low molecular weight heparin or factor Xa inhibitors, depending on the type of cancer and potential drug-drug interactions 5
• Patients with an indwelling catheter may be at increased risk of UEDVT, and careful selection of patients for catheter placement and use of smaller catheters may help reduce this risk 6
• The risk of recurrent VTE and major bleeding should be carefully weighed when selecting an anticoagulant treatment regimen 3