What is the current therapy for brachial vein Deep Vein Thrombosis (DVT)?

Treatment of Brachial Vein Deep Vein Thrombosis (DVT)

For patients with brachial vein DVT, anticoagulation therapy is the primary treatment, following the same principles as for proximal lower extremity DVT. 1

Initial Management

• Anticoagulation should be initiated immediately upon diagnosis of brachial vein DVT 1
• Low molecular weight heparin (LMWH) or fondaparinux is preferred over intravenous unfractionated heparin (IV UFH) for initial treatment 1, 2
• For patients transitioning to vitamin K antagonists (VKAs), parenteral anticoagulation should be continued for a minimum of 5 days and until the INR is ≥2.0 for at least 24 hours 1, 3
• Outpatient treatment is appropriate for patients with adequate home circumstances and without significant comorbidities 1, 2

Anticoagulation Options

• Direct oral anticoagulants (DOACs) such as apixaban, dabigatran, edoxaban, or rivaroxaban are recommended over VKAs for the treatment phase 1, 2
• In patients with cancer-associated brachial vein thrombosis, oral factor Xa inhibitors (apixaban, edoxaban, rivaroxaban) are recommended over LMWH 1
• If using enoxaparin (LMWH), the FDA-approved dosing is either 1.5 mg/kg once daily subcutaneously or 1 mg/kg every 12 hours subcutaneously 3

Duration of Treatment

• For brachial vein DVT not associated with a central venous catheter, a minimum duration of 3 months of anticoagulation is recommended 1, 2
• For catheter-related brachial vein DVT:
  • If the catheter is removed, 3 months of anticoagulation is recommended for patients without cancer 1
  • If the catheter remains in place, anticoagulation should continue as long as the catheter is present 1
  • For cancer patients with catheter-related DVT, anticoagulation should continue as long as the catheter remains in place 1

Special Considerations

• Catheter removal is not necessary if it is functional, free of infection, and still required for clinical care 1
• Thrombolysis is generally not recommended for routine treatment of upper extremity DVT, but may be considered in select patients who are likely to benefit, have access to catheter-directed thrombolysis, and place high value on preventing post-thrombotic syndrome 1
• Compression sleeves are not routinely recommended during acute treatment but may be considered for patients who develop post-thrombotic syndrome symptoms 1

Follow-up and Monitoring

• For patients on DOACs, routine monitoring of coagulation parameters is not required 1
• For patients on VKAs, regular INR monitoring is needed to maintain a therapeutic range of 2.0-3.0 (target INR 2.5) 1
• Patients should be monitored for signs of bleeding complications and recurrent thrombosis 2

Important Caveats

• DOACs may not be appropriate for patients with severe renal impairment, as they are primarily eliminated through the kidneys 1, 2
• For pregnant patients, DOACs are contraindicated; LMWH is the preferred anticoagulant 1
• Inferior vena cava filters are not recommended for patients who can be treated with anticoagulants 2
• If anticoagulation is contraindicated, patients should be closely followed until the contraindication resolves or if DVT progression occurs 1