What is the workup and treatment for catheter-associated deep vein thrombosis (DVT) of the arm?

Workup and Treatment for Catheter-Associated Arm DVT

For catheter-associated upper extremity deep vein thrombosis (UEDVT), anticoagulation therapy should be continued for at least 3 months, and if the catheter remains in place, anticoagulation should be maintained as long as the catheter is present. 1

Diagnostic Workup

Initial Assessment

• Clinical suspicion based on:
  • Swelling of unilateral arm
  • Heaviness in extremity
  • Pain in extremity
  • Swelling in face, neck, or supraclavicular space
  • Catheter dysfunction 1

Laboratory Testing

• CBC with platelet count
• PT, aPTT ± fibrinogen
• Liver and kidney function tests 1

Imaging

1. Venous ultrasound - first-line imaging test 1
2. If negative or indeterminate:
   • Repeat venous ultrasound
   • CT venogram with contrast
   • Magnetic resonance venogram with contrast 1

Treatment Algorithm

Catheter Management

• If catheter is functional and still needed:
  • Keep catheter in place 1, 2
  • Begin anticoagulation therapy 1
• If catheter is non-functional, infected, or no longer needed:
  • Consider catheter removal 2
  • Still initiate anticoagulation therapy 1

Anticoagulation Therapy

Initial Anticoagulation

• Low-molecular-weight heparin (LMWH) - preferred option:
  • Enoxaparin: 1 mg/kg twice daily or 1.5 mg/kg once daily 2, 3
  • Dalteparin: 200 U/kg once daily 2
• Unfractionated heparin (UFH) - alternative option:
  • IV bolus followed by continuous infusion (adjusted to achieve aPTT of 55-85 seconds) 3
• Direct oral anticoagulants (DOACs) - can be considered for non-cancer patients 2

Duration of Therapy

• Minimum duration: 3 months for all patients 1
• If catheter is removed: 3 months of anticoagulation (strong recommendation for non-cancer patients, weak recommendation for cancer patients) 1
• If catheter remains in place: Continue anticoagulation as long as catheter remains in place (strong recommendation for cancer patients, weak recommendation for non-cancer patients) 1

Thrombolysis

• Anticoagulant therapy alone is preferred over thrombolysis for UEDVT involving axillary or more proximal veins (weak recommendation) 1
• If thrombolysis is performed, the same intensity and duration of anticoagulation is recommended as for patients who do not undergo thrombolysis 1
• Catheter-directed thrombolysis is rarely considered and only in specific circumstances 1

Symptom Management

• Consider compression bandages or sleeves to reduce symptoms of post-thrombotic syndrome 1
• Elevate affected arm to reduce swelling 2
• Encourage early mobilization of affected arm as tolerated 2

Special Considerations

Cancer Patients

• LMWH is preferred over vitamin K antagonists for at least the first 3-6 months 2
• Continue anticoagulation as long as cancer is active or under treatment 1

Monitoring

• For patients on warfarin:
  • Target INR of 2.0-3.0
  • Continue parenteral anticoagulation for at least 5 days and until INR ≥2.0 for at least 24 hours 2
• Regular follow-up within 1 week for outpatients 2
• Monitor renal function, especially in patients with renal impairment 2

Clinical Pitfalls and Caveats

1. Do not remove catheter immediately if it is still functional and needed - anticoagulation can be effective with the catheter in place 1

2. Avoid venoactive medications for post-thrombotic syndrome as they are not recommended 1

3. Consider bleeding risk when determining anticoagulation strategy - patients with high bleeding risk may require modified approaches 1

4. Do not discontinue anticoagulation prematurely if catheter remains in place - this increases risk of recurrent thrombosis 1

5. Do not rely on clinical symptoms alone for diagnosis - imaging confirmation is essential as clinical assessment has limited sensitivity and specificity 1

6. Do not delay anticoagulation if clinical suspicion is high - consider starting treatment while awaiting diagnostic test results 1