Workup for Suspected Upper Extremity DVT with Prior DVT History
Start with combined modality ultrasound (compression with Doppler or color Doppler) as your initial test for suspected arm DVT, regardless of prior clot history. 1
Initial Diagnostic Approach
Perform combined modality ultrasound immediately as the first-line imaging test for suspected upper extremity DVT, which combines compression ultrasound with either Doppler or color Doppler techniques. 1
Do not rely on D-dimer testing alone for initial evaluation of upper extremity DVT, as ultrasound is preferred over highly sensitive D-dimer or venography for the initial assessment. 1
Obtain baseline laboratory tests including complete blood count with platelet count, PT, aPTT, liver function tests, and kidney function tests to guide anticoagulation decisions if DVT is confirmed. 2
If Initial Ultrasound is Negative but Clinical Suspicion Remains High
When the initial combined modality ultrasound is negative but you still strongly suspect DVT based on clinical presentation (arm swelling, heaviness, pain, catheter dysfunction if present), you have several options: 1
Order a moderate or highly sensitive D-dimer test as the next step. 1
Consider serial ultrasound imaging to detect propagating thrombus. 1
Proceed to venographic-based imaging (traditional venography, CT venography, or MR venography) for definitive evaluation, particularly for central veins like the subclavian or brachiocephalic that are difficult to visualize with standard ultrasound. 1, 3
Decision Algorithm After Negative Initial Ultrasound
If initial ultrasound is negative AND D-dimer is negative (or CT/MRI is negative): Stop further testing—DVT is excluded. 1
If initial ultrasound is negative BUT D-dimer is positive: Proceed to venography (traditional, CT, or MRI) unless there is a clear alternative explanation for symptoms. 1
If ultrasound evaluation is incomplete: Proceed to venography rather than stopping workup, unless an alternative diagnosis clearly explains the symptoms. 1
Special Considerations for Recurrent DVT
The history of prior blood clot does not fundamentally change the initial diagnostic approach for upper extremity DVT, as the American College of Chest Physicians guidelines specifically address recurrent DVT primarily in the context of lower extremity thrombosis. 1 However, this history should heighten your clinical suspicion and lower your threshold for additional imaging if initial tests are equivocal.
Important Caveats
Avoid D-dimer testing in patients with comorbid conditions typically associated with elevated D-dimer levels (cancer, infection, inflammation), as further radiologic testing is more reliable in these populations. 1
Consider early anticoagulation while awaiting imaging results if clinical suspicion is high and there are no contraindications to anticoagulation. 1
Evaluate for alternative diagnoses such as lymphedema, superficial thrombophlebitis, or musculoskeletal causes if imaging is negative and symptoms persist. 1, 2
CT venography or MR venography may be superior to standard ultrasound for visualizing central veins (subclavian, brachiocephalic) that are technically difficult to assess with compression ultrasound. 3