Treatment of Upper Extremity Deep Vein Thrombosis (Arm DVT)
For upper extremity DVT involving the axillary or more proximal veins, initiate anticoagulation therapy alone without thrombolysis, using low-molecular-weight heparin (LMWH), fondaparinux, or unfractionated heparin as initial treatment, with LMWH or fondaparinux preferred, followed by a minimum of 3 months of anticoagulation. 1, 2
Initial Anticoagulation Approach
Parenteral anticoagulation should be started promptly with one of the following agents 1, 2:
- Low-molecular-weight heparin (preferred) 1, 2
- Fondaparinux 1, 2
- Intravenous unfractionated heparin 1
- Subcutaneous unfractionated heparin 1
LMWH or fondaparinux are preferred over unfractionated heparin options due to superior efficacy and ease of administration. 1 For patients with high clinical suspicion, treatment should begin while awaiting diagnostic test results. 1
Baseline laboratory testing should include complete blood count with platelet count, renal and hepatic function panel, activated partial thromboplastin time, and prothrombin time/international normalized ratio before initiating treatment. 2 Follow-up monitoring should include hemoglobin, hematocrit, and platelet count at least every 2-3 days for the first 14 days for inpatients and every 2 weeks thereafter. 2
Duration of Anticoagulation Based on Clinical Context
Catheter-Associated Upper Extremity DVT
If the catheter is removed:
- 3 months of anticoagulation for patients without cancer (strong recommendation) 1, 2
- 3 months of anticoagulation for patients with cancer 1, 2
If the catheter remains in place:
- Continue anticoagulation as long as the catheter remains in place for cancer patients (strong recommendation) 1
- Continue anticoagulation as long as the catheter remains in place for non-cancer patients 1
The catheter should generally not be removed if it is functional and there is an ongoing need for it. 1, 2 However, catheter removal is warranted if there is fever, signs of infected thrombophlebitis, catheter malposition, or catheter dysfunction. 2
Non-Catheter-Associated Upper Extremity DVT
For upper extremity DVT not associated with a central venous catheter or cancer, treat with 3 months of anticoagulation (strong recommendation). 1, 2
Anticoagulant Selection
For cancer patients, LMWH is the preferred anticoagulant for a minimum of 3 months. 1, 2 The American College of Chest Physicians suggests LMWH over vitamin K antagonists in cancer-associated thrombosis. 1
For non-cancer patients, direct oral anticoagulants (DOACs), LMWH, and warfarin have all been used with comparable results. 2 Rivaroxaban is FDA-approved for treatment of DVT and can be initiated at 15 mg twice daily with food for the first 21 days, followed by 20 mg once daily with food. 3
Vitamin K antagonists or LMWH are suggested over dabigatran or rivaroxaban in certain populations. 1
Role of Thrombolysis
Anticoagulation therapy alone is preferred over thrombolysis for most patients with upper extremity DVT. 1 Thrombolytic therapy may be considered only in specific circumstances when the thrombotic risk outweighs bleeding risk, such as superior vena cava thrombosis with poorly tolerated vena cava syndrome. 2
If thrombolysis is performed, the same intensity and duration of anticoagulant therapy should be used as in patients who do not undergo thrombolysis. 1, 2
Management of Post-Thrombotic Syndrome
For patients who develop post-thrombotic syndrome of the arm:
- Trial of compression bandages or sleeves to reduce symptoms 1, 2
- Venoactive medications are not recommended 1, 2
Critical Considerations
Bleeding risk must be balanced against thrombotic risk. Major bleeding events occur at similar rates with anticoagulation compared to no treatment, but clinically relevant non-major bleeding events are increased with anticoagulation. 1 The benefits of anticoagulation in preventing recurrent VTE (risk reduction of approximately 66-75%) generally outweigh bleeding risks in most patients. 1
Premature discontinuation of anticoagulation increases the risk of thrombotic events. If anticoagulation must be discontinued for reasons other than pathological bleeding or completion of therapy, consider coverage with another anticoagulant. 3