How can a Deep Vein Thrombosis (DVT) occur in the hand?

Deep Vein Thrombosis in the Hand: Causes and Mechanisms

Upper extremity deep vein thrombosis (UEDVT), including DVT in the hand, can occur but is much less common than lower extremity DVT, accounting for approximately 10% of all diagnosed DVTs. 1

Etiology of Hand/Upper Extremity DVT

Primary Causes

• Primary UEDVT accounts for approximately one-third of cases, most commonly due to venous thoracic outlet syndrome (effort-related thrombosis/Paget-Schroetter syndrome) 1
• Idiopathic cases can occur without identifiable cause 1

Secondary Causes (Most Common)

• Indwelling venous devices are the highest risk factor for hand/upper extremity DVT: 1

  • Central venous catheters
  • Peripherally inserted central catheters (PICCs)
  • Pacemakers and defibrillators
  • Venous ports for chemotherapy

• Cancer-related factors: 1

  • Active malignancy significantly increases risk
  • Cancer patients with arm DVT have increased incidence of major bleeding, recurrent VTE, and death compared to those with catheter-related DVT

• Other significant risk factors: 1, 2

  • Advanced age
  • Previous thrombophlebitis
  • Postoperative state
  • Hypercoagulability disorders
  • Heart failure
  • Right-heart procedures
  • Intensive care unit admission
  • Trauma
  • Extrinsic compression of veins

Clinical Presentation

• Patients with hand/upper extremity DVT typically present with: 1

  • Ipsilateral upper extremity edema
  • Pain in the affected hand/arm
  • Paresthesia
  • Functional impairment

• Catheter-associated thrombosis may be asymptomatic or manifest as catheter dysfunction 1

• DVT limited to smaller veins in the hand may not cause significant swelling 1

Diagnostic Approach

• Ultrasound with Doppler is the first-line diagnostic test for suspected hand/upper extremity DVT 1

  • Directly identifies thrombus through visualization of echogenic material in veins
  • Assesses for lack of compression of vein walls (indicating thrombosis)
  • Color-flow Doppler helps determine if thrombosis is obstructive or partially obstructive

• For hand veins specifically, ultrasound can evaluate the more peripheral veins but may have limitations with the smallest vessels 1

• MR venography may be considered when ultrasound results are inconclusive or for evaluating central veins that are difficult to assess with ultrasound 1

Treatment Considerations

• Anticoagulation is the mainstay of treatment for upper extremity DVT, including hand DVT 1

  • Duration should be at least 3 months for catheter-associated DVT or as long as the catheter remains in place
  • For non-catheter-associated DVT, treatment should continue while cancer is active or risk factors persist

• For symptomatic catheter-associated DVT in the hand/arm, anticoagulation should be considered for at least 3 months or as long as the catheter is in place 1

Complications and Prognosis

• Upper extremity DVT has different complication rates than lower extremity DVT: 1

  • Recurrent VTE: 5.1% in prospective studies, 9.8% in retrospective studies
  • Bleeding complications: 3.1% in prospective studies, 6.7% in retrospective studies
  • Mortality: 24% in prospective studies, 35% in retrospective studies

• Patients with arm DVT often have less clinically overt pulmonary embolism than those with lower-limb DVT (9.0% vs 29%) 1

Clinical Pearls and Pitfalls

• Hand DVT is often overlooked due to its rarity compared to lower extremity DVT 1
• Superficial thrombophlebitis in the hand can be confused with DVT but typically presents with local pain, induration, and often a palpable cord rather than diffuse swelling 1
• There may be a correlation between upper extremity DVT and lower extremity DVT, so investigation of the lower extremities should be considered if an upper extremity thrombus is found without a local cause 1
• When evaluating hand swelling, consider alternative diagnoses including lymphedema, cellulitis, and inflammatory conditions 1