IV Line Placement in Bilateral Upper Extremity DVT
Place the IV line in a lower extremity vein (foot or leg) to avoid further thrombotic complications in the already affected upper extremity veins.
Rationale for Lower Extremity Access
Avoid thrombosed vessels: With bilateral upper extremity DVT, all arm veins carry risk of catheter-related complications including thrombus propagation, catheter malfunction, and worsening venous obstruction 1.
Preserve venous integrity: The American College of Chest Physicians guidelines emphasize that in patients with upper extremity DVT associated with central venous catheters, functional catheters may remain if needed, but this applies to existing catheters, not new IV placement 1.
Lower extremity veins are unaffected: The saphenous vein, dorsal foot veins, or other lower extremity peripheral veins provide safe alternative access sites that avoid the thrombosed upper extremity venous system 2.
Specific Placement Sites
Preferred locations in order:
- Dorsal foot veins (most peripheral, lowest risk)
- Saphenous vein at ankle or lower leg
- Popliteal fossa veins (if peripheral access fails)
Avoid these sites:
- Any upper extremity veins bilaterally (arms, forearms, hands)
- Subclavian or jugular central access unless absolutely necessary for hemodynamic monitoring or vasopressor administration 1
Critical Considerations
Anticoagulation status: These patients require immediate parenteral anticoagulation (LMWH, fondaparinux, IV UFH, or SC UFH) for their upper extremity DVT 1, 3.
If central access is unavoidable: Consider femoral vein central line placement rather than upper extremity central access, as this avoids the thrombosed venous system entirely 1.
Duration of therapy: Patients with bilateral upper extremity DVT will require minimum 3 months of anticoagulation, so plan for longer-term access needs if frequent IV medications are anticipated 1.
Common Pitfalls to Avoid
Do not attempt upper extremity IV placement thinking a small peripheral IV is safe—any catheter in thrombosed veins risks propagation and catheter dysfunction 1.
Do not place PICC lines or midlines in either arm, as these would traverse the thrombosed axillary and proximal veins 1, 2.
Assess for lower extremity DVT first: Before placing lower extremity IV access, perform clinical assessment or ultrasound to ensure no concurrent lower extremity DVT exists 1.