What percentage of patients with isolated upper‑extremity deep‑vein thrombosis develop a concurrent pulmonary embolism?

Upper Extremity DVT and Concurrent Pulmonary Embolism

Upper extremity deep vein thrombosis is associated with pulmonary embolism in approximately 9–36% of cases, with the most recent high-quality data suggesting rates closer to 9–11.5%, substantially lower than the 30–50% PE rate seen with lower extremity DVT. 1, 2

Incidence Rates from Clinical Studies

The reported PE rates with upper extremity DVT vary across studies but cluster around specific ranges:

• 9% objectively confirmed PE rate in a 2012 study of 94 consecutive UEDVT patients at an academic medical center 1
• Up to 36% PE complication rate reported in earlier systematic reviews and observational studies 3, 4
• 1% PE rate in a 2011 series of 200 UEDVT patients, though this likely underestimates true incidence due to lack of systematic screening 5
• Up to 40% PE association when all upper extremity locations are included (subclavian, axillary, brachial), though this represents the upper bound 6

The European Society of Cardiology guidelines specifically note that brachial DVT carries approximately 11.5% PE risk, which is substantially lower than proximal lower extremity DVT (67–77% PE risk). 2, 6

Critical Context: Why the Wide Range?

The variation in reported PE rates reflects several methodological factors you must understand:

• Systematic imaging vs. symptomatic detection: Studies using routine chest imaging find higher PE rates (up to 36%) compared to those detecting only symptomatic PE (9%) 1, 3, 4
• Anatomic location matters: Proximal upper extremity thrombosis (subclavian/axillary) carries higher PE risk than distal (brachial) thrombosis 2
• Era of study: Older studies (1999–2001) reported higher rates (36%) before modern catheter care protocols 3, 4
• Most recent data (2010–2012) consistently show 9–11.5% rates when objectively confirmed PE is the endpoint 1, 2

Comparison to Lower Extremity DVT

Understanding the relative risk helps frame clinical decision-making:

• Lower extremity proximal DVT: 67–77% PE rate (pelvic/iliac involvement) 6
• Lower extremity thigh DVT: 67% PE rate 6
• Lower extremity calf DVT: 46% PE rate 6
• Upper extremity DVT: 9–36% PE rate, with modern data favoring 9–11.5% 1, 2

The American Society of Hematology acknowledges this lower PE risk by establishing less conservative diagnostic thresholds for upper extremity DVT (≤5% false negative rate acceptable) compared to lower extremity DVT (≤2% false negative rate). 6

Clinical Risk Factors That Increase PE Likelihood

Not all upper extremity DVTs carry equal PE risk. Higher rates occur with:

• Central venous catheters present in 93% of UEDVT cases, particularly when combined with cancer (48% of UEDVT patients) 1
• Multiple venous segment involvement (subclavian + axillary + brachial) independently predicts both anticoagulation decisions and likely PE risk 5
• Acute thrombosis on duplex imaging rather than chronic changes 5
• Younger patient age correlates with more aggressive thrombosis 5

Mortality and Morbidity Considerations

The 1-month mortality rate for UEDVT is 6.4%, with most deaths related to underlying conditions (cancer, critical illness) rather than PE itself. 1

• Two patients (1%) in one series died from intracranial bleeding on anticoagulation, highlighting that treatment risks may exceed PE risks in some patients 5
• Recurrent VTE rates at 3 years are similar between upper and lower extremity DVT (15–18%), suggesting the thrombotic tendency persists regardless of initial location. 7

Practical Management Algorithm

1. Initiate anticoagulation immediately for documented UEDVT when no contraindications exist, following the same urgency as lower extremity proximal DVT despite lower PE risk 2

2. Do NOT routinely order chest imaging to screen for PE in asymptomatic UEDVT patients, as the 9–11.5% rate does not justify universal screening and treatment is identical 1, 2

3. Obtain chest CT pulmonary angiography only when:

• Patient develops dyspnea, chest pain, or hemodynamic instability 1
• Massive proximal UEDVT (subclavian/axillary) with high clot burden 2
• Planning IVC filter placement (rare in UEDVT) 8

4. Maintain anticoagulation for minimum 3 months, identical to lower extremity DVT protocols 2, 3, 4

Common Pitfalls to Avoid

• Do not withhold anticoagulation based on "low PE risk" – the 9–11.5% rate still represents significant morbidity, and recurrent VTE risk is substantial 1, 2
• Do not assume asymptomatic UEDVT is benign – up to 36% of PE from UEDVT may be the presenting manifestation without arm symptoms 3, 4
• Recognize that 16% of UEDVT patients have concurrent lower extremity DVT, which carries much higher PE risk and should be screened for when clinical suspicion exists 1
• Weigh anticoagulation bleeding risk carefully – in the elderly or those with fall risk, the 1% PE mortality may be lower than anticoagulation-related intracranial hemorrhage risk 5