Peripheral IV Placement in an Arm with DVT
You should avoid placing a peripheral IV line in an arm with an active DVT and instead use the contralateral unaffected arm for venous access. 1
Primary Risks of IV Placement in the Affected Limb
Placing a PIV in an arm with DVT poses several significant risks that justify avoiding this approach:
Thrombus disruption and embolization risk: Venipuncture or catheter insertion may mechanically disrupt the existing clot, potentially causing fragments to break off and embolize to the pulmonary circulation 1
Thrombus extension: The procedure can cause additional vessel wall injury in an already damaged vein, promoting further clot propagation 1
Impaired venous return: The affected limb already has compromised venous drainage; adding a catheter further obstructs flow in a system that cannot accommodate additional impedance 1
Increased post-thrombotic syndrome risk: Any additional venous trauma increases the likelihood of chronic venous insufficiency and post-thrombotic complications 1
Catheter-associated thrombosis: Indwelling venous devices are the highest risk factor for upper extremity DVT, and placing a PIV in an already thrombosed system compounds this risk 1
Recommended Alternative Approaches
Use the contralateral arm (without DVT) as the first-line site for peripheral IV access. 1 This straightforward approach avoids all the risks associated with the affected limb while providing reliable venous access.
When Peripheral Access is Not Feasible
If both arms have DVT or peripheral access is impossible, consider these alternatives in order of preference:
Central venous access via internal jugular or femoral route: Avoid the subclavian vein due to high risk of central venous stenosis 1
Femoral catheters for short-term needs: Can be used safely for up to 5 days in bed-bound patients with appropriate exit-site care 1
Tunneled cuffed catheters for longer-term needs: Associated with lower infection rates and higher blood flow rates compared to non-tunneled options 1
Technical Considerations for Any Venous Access
When placing venous access devices in patients with DVT:
Use ultrasound guidance: This minimizes insertion complications and should be employed whenever available 1
Select the smallest gauge catheter possible: Smaller catheters reduce the risk of additional thrombosis 1
Avoid subclavian vein catheterization: This site carries high risk of central venous stenosis and should be avoided 1
Concurrent DVT Management Requirements
Patients with upper extremity DVT require specific management that must continue regardless of IV access decisions:
Anticoagulation is mandatory: This remains the mainstay of treatment for upper extremity DVT 1
Duration of anticoagulation: For catheter-associated DVT, anticoagulation should continue for at least 3 months or as long as the catheter remains in place 1
Early ambulation: Patients with DVT should be encouraged to ambulate early rather than remain on bed rest 1
Avoid IVC filters with anticoagulation: In patients with acute DVT receiving anticoagulants, IVC filters should not be routinely added 2
Clinical Monitoring
Be aware that patients with upper extremity DVT typically present with: