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{{Deep vein thrombosis}} | {{Deep vein thrombosis}} | ||
==Overview== | ==Overview== | ||
Combined modality ultrasound ([[Deep vein thrombosis ultrasound|compression ultrasound]] with either Doppler | Combined modality ultrasound ([[Deep vein thrombosis ultrasound|compression ultrasound]] with either Doppler or color Doppler) is the initial test of choice for suspected upper extremity deep vein thrombosis (UEDVT). If the initial ultrasound is negative and the clinical suspicion is still high, further testing with serial [[ultrasound]], [[D-dimer]], or [[venography]] should be performed. Anticoagulation therapy with either [[low molecular weight heparin]] or [[fondaparinux]] is the preferred initial treatment for UEDVT over intravenous or subcutaneous [[unfractionated heparin]]. If the UEDVT is associated with a [[central venous catheter]], the duration of anticoagulation therapy is 3 months if the [[central venous catheter]] is removed, or as long as the [[central venous catheter]] is present in case it was not removed. | ||
==2012 VTE, Thrombophilia, Antithrombotic Therapy, and Pregnancy: Antithrombotic Therapy and Prevention of Thrombosis, 9th ed: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines (DO NOT EDIT)<ref name="pmid22315276">{{cite journal| author=Bates SM, Greer IA, Middeldorp S, Veenstra DL, Prabulos AM, Vandvik PO et al.| title=VTE, thrombophilia, antithrombotic therapy, and pregnancy: Antithrombotic Therapy and Prevention of Thrombosis, 9th ed: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines. | journal=Chest | year= 2012 | volume= 141 | issue= 2 Suppl | pages= e691S-736S | pmid=22315276 | doi=10.1378/chest.11-2300 | pmc=PMC3278054 | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=22315276 }} </ref>== | ==2012 VTE, Thrombophilia, Antithrombotic Therapy, and Pregnancy: Antithrombotic Therapy and Prevention of Thrombosis, 9th ed: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines (DO NOT EDIT)<ref name="pmid22315276">{{cite journal| author=Bates SM, Greer IA, Middeldorp S, Veenstra DL, Prabulos AM, Vandvik PO et al.| title=VTE, thrombophilia, antithrombotic therapy, and pregnancy: Antithrombotic Therapy and Prevention of Thrombosis, 9th ed: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines. | journal=Chest | year= 2012 | volume= 141 | issue= 2 Suppl | pages= e691S-736S | pmid=22315276 | doi=10.1378/chest.11-2300 | pmc=PMC3278054 | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=22315276 }} </ref>== | ||
===Ultrasonography in Patients With Upper-Extremity DVT (UEDVT) | ===Ultrasonography in Patients With Upper-Extremity DVT (UEDVT) === | ||
{|class="wikitable" | |||
|- | |||
| colspan="1" style="text-align:center; background:LemonChiffon"| [[ACC AHA guidelines classification scheme#Classification of Recommendations|Class II]] | |||
|- | |||
|bgcolor="LemonChiffon"|<nowiki>"</nowiki>'''1.''' In patients suspected of having UEDVT, we suggest initial evaluation with combined modality US (compression with either [[Doppler]] or color Doppler) over other initial tests, including highly sensitive [[D-dimer]] or [[venography]]. ''([[American College of Chest Physicians#Level of Evidence|Level of Evidence: C]])''<nowiki>"</nowiki> | |||
|- | |||
|} | |||
===Clinical Pretest Probability Assessment in Patients With UEDVT | ===Clinical Pretest Probability Assessment in Patients With UEDVT === | ||
{|class="wikitable" | |||
|- | |||
| colspan="1" style="text-align:center; background:LightGreen"|[[ACC AHA guidelines classification scheme#Classification of Recommendations|Class I]] | |||
|- | |||
| bgcolor="LightGreen"|<nowiki>"</nowiki>'''1.''' In patients with suspected UEDVT and an initial negative combined-modality US and subsequent negative moderate or highly sensitive [[D-dimer]] or [[CT]] or [[MRI]], we recommend no further testing, rather than confirmatory [[venography]]. ''([[American College of Chest Physicians#Level of Evidence|Level of Evidence: C]])'' <nowiki>"</nowiki> | |||
|- | |||
|} | |||
=== | {|class="wikitable" | ||
|- | |||
| colspan="1" style="text-align:center; background:LemonChiffon"| [[ACC AHA guidelines classification scheme#Classification of Recommendations|Class II]] | |||
|- | |||
|bgcolor="LemonChiffon"|<nowiki>"</nowiki>'''1.''' In patients with suspected UEDVT in whom initial US is negative for thrombosis despite a high clinical suspicion of DVT, we suggest further testing with a moderate or highly sensitive [[D-dimer]], serial [[US]], or venographic-based imaging (traditional, [[CT scan]], or [[MRI]]), rather than no further testing. ''([[American College of Chest Physicians#Level of Evidence|Level of Evidence: C]])''<nowiki>"</nowiki> | |||
|- | |||
|bgcolor="LemonChiffon"|<nowiki>"</nowiki>'''2.''' We suggest that patients with an initial combined negative modality [[US]] and positive [[D-dimer]] or those with less than complete evaluation by US undergo [[venography]] rather than no further testing, unless there is an alternative explanation for their symptoms ''([[American College of Chest Physicians#Level of Evidence|Level of Evidence: B]])'', in which case testing to evaluate for the presence an alternative diagnosis should be performed. We suggest that patients with a positive [[D-dimer]] or those with less than complete evaluation by US but an alternative explanation for their symptoms undergo confirmatory testing and treatment of this alternative explanation rather than [[venography]] ''([[American College of Chest Physicians#Level of Evidence|Level of Evidence: C]])''. <nowiki>"</nowiki> | |||
|- | |||
|} | |||
=== | ===Acute Anticoagulation for Patients With UEDVT=== | ||
{|class="wikitable" | |||
|- | |||
| colspan="1" style="text-align:center; background:LightGreen"|[[ACC AHA guidelines classification scheme#Classification of Recommendations|Class I]] | |||
|- | |||
| bgcolor="LightGreen"|<nowiki>"</nowiki>'''1.''' In patients with UEDVT that involves the axillary or more proximal veins, we recommend acute treatment with parenteral anticoagulation ([[LMWH]], [[fondaparinux]], IV [[UFH]], or SC [[UFH]]) over no such acute treatment. ''([[American College of Chest Physicians#Level of Evidence|Level of Evidence: B]])''<nowiki>"</nowiki> | |||
|- | |||
|} | |||
=== | {|class="wikitable" | ||
|- | |||
| colspan="1" style="text-align:center; background:LemonChiffon"| [[ACC AHA guidelines classification scheme#Classification of Recommendations|Class II]] | |||
|- | |||
|bgcolor="LemonChiffon"|<nowiki>"</nowiki>'''1.''' In patients with acute UEDVT that involves the axillary or more proximal veins, we suggest [[LMWH]] or [[fondaparinux]] over IV [[UFH]] ''([[American College of Chest Physicians#Level of Evidence|Level of Evidence: C]])'' and over SC [[UFH]] ''([[American College of Chest Physicians#Level of Evidence|Level of Evidence: B]])''. <nowiki>"</nowiki> | |||
|- | |||
|} | |||
=== | ===Thrombolytic Therapy for the Initial Treatment of Patients With UEDVT === | ||
{|class="wikitable" | |||
|- | |||
| colspan="1" style="text-align:center; background:LightGreen"|[[ACC AHA guidelines classification scheme#Classification of Recommendations|Class I]] | |||
|- | |||
| bgcolor="LightGreen"|<nowiki>"</nowiki>'''1.''' In patients with UEDVT who undergo [[thrombolysis]], we recommend the same intensity and duration of [[anticoagulant therapy]] as in similar patients who do not undergo [[thrombolysis]]. ''([[American College of Chest Physicians#Level of Evidence|Level of Evidence: B]])''<nowiki>"</nowiki> | |||
|- | |||
|} | |||
===Treatment of Patients With PTS of the Arm | {|class="wikitable" | ||
|- | |||
| colspan="1" style="text-align:center; background:LemonChiffon"| [[ACC AHA guidelines classification scheme#Classification of Recommendations|Class II]] | |||
|- | |||
|bgcolor="LemonChiffon"|<nowiki>"</nowiki>'''1.''' In patients with acute UEDVT that involves the axillary or more proximal veins, we suggest [[anticoagulant therapy]] alone over [[thrombolysis]]. ''([[American College of Chest Physicians#Level of Evidence|Level of Evidence: C]])'' <nowiki>"</nowiki> | |||
|- | |||
|} | |||
===Long-term Anticoagulation for Patients With UEDVT=== | |||
{|class="wikitable" | |||
|- | |||
| colspan="1" style="text-align:center; background:LightGreen"|[[ACC AHA guidelines classification scheme#Classification of Recommendations|Class I]] | |||
|- | |||
| bgcolor="LightGreen"|<nowiki>"</nowiki>'''1.''' In patients who have UEDVT that is associated with a [[central venous catheter]] that is removed, we recommend 3 months of [[anticoagulation]] over a longer duration of therapy in patients with no [[cancer]]. ''([[American College of Chest Physicians#Level of Evidence|Level of Evidence: B]])''<nowiki>"</nowiki> | |||
|- | |||
| bgcolor="LightGreen"|<nowiki>"</nowiki>'''2.''' In patients who have UEDVT that is associated with a [[central venous catheter]] that is not removed, we recommend that [[anticoagulation]] is continued as long as the [[central venous catheter]] remains over stopping after 3 months of treatment in patients with [[cancer]]. ''([[American College of Chest Physicians#Level of Evidence|Level of Evidence: C]])''<nowiki>"</nowiki> | |||
|- | |||
| bgcolor="LightGreen"|<nowiki>"</nowiki>'''3.''' In patients who have UEDVT that is not associated with a [[central venous catheter]] or with [[cancer]], we recommend 3 months of anticoagulation over a longer duration of therapy. ''([[American College of Chest Physicians#Level of Evidence|Level of Evidence: B]])''<nowiki>"</nowiki> | |||
|- | |||
|} | |||
{|class="wikitable" | |||
|- | |||
| colspan="1" style="text-align:center; background:LemonChiffon"| [[ACC AHA guidelines classification scheme#Classification of Recommendations|Class II]] | |||
|- | |||
|bgcolor="LemonChiffon"|<nowiki>"</nowiki>'''1.''' In most patients with UEDVT that is associated with a [[central venous catheter]], we suggest that the catheter not be removed if it is functional and there is an ongoing need for the catheter. ''([[American College of Chest Physicians#Level of Evidence|Level of Evidence: C]])'' <nowiki>"</nowiki> | |||
|- | |||
|bgcolor="LemonChiffon"|<nowiki>"</nowiki>'''2.''' In patients with UEDVT that involves the axillary or more proximal [[vein]]s, we suggest a minimum duration of anticoagulation of 3 months over a shorter period. ''([[American College of Chest Physicians#Level of Evidence|Level of Evidence: B]])'' <nowiki>"</nowiki> | |||
|- | |||
|bgcolor="LemonChiffon"|<nowiki>"</nowiki>'''3.''' In patients who have UEDVT that is associated with a [[central venous catheter]] that is not removed, we recommend that anticoagulation is continued as long as the [[central venous catheter]] remains over stopping after 3 months of treatment in patients with no [[cancer]]. ''([[American College of Chest Physicians#Level of Evidence|Level of Evidence: C]])'' <nowiki>"</nowiki> | |||
|- | |||
|bgcolor="LemonChiffon"|<nowiki>"</nowiki>'''4.''' In patients who have UEDVT that is associated with a [[central venous catheter]] that is removed, we recommend 3 months of anticoagulation over a longer duration of therapy in patients with [[cancer]]. ''([[American College of Chest Physicians#Level of Evidence|Level of Evidence: C]])'' <nowiki>"</nowiki> | |||
|- | |||
|} | |||
===Prevention of PTS of the Arm=== | |||
{|class="wikitable" | |||
|- | |||
| colspan="1" style="text-align:center; background:LemonChiffon"| [[ACC AHA guidelines classification scheme#Classification of Recommendations|Class II]] | |||
|- | |||
|bgcolor="LemonChiffon"|<nowiki>"</nowiki>'''1.''' In patients with acute symptomatic UEDVT, we suggest against the use of compression sleeves or venoactive medications. ''([[American College of Chest Physicians#Level of Evidence|Level of Evidence: C]])''<nowiki>"</nowiki> | |||
|- | |||
|} | |||
===Treatment of Patients With PTS of the Arm=== | |||
{|class="wikitable" | |||
|- | |||
| colspan="1" style="text-align:center; background:LemonChiffon"| [[ACC AHA guidelines classification scheme#Classification of Recommendations|Class II]] | |||
|- | |||
|bgcolor="LemonChiffon"|<nowiki>"</nowiki>'''1.''' In patients who have [[PTS]] of the arm, we suggest a trial of compression bandages or sleeves to reduce symptoms. ''([[American College of Chest Physicians#Level of Evidence|Level of Evidence: C]])''<nowiki>"</nowiki> | |||
|- | |||
|bgcolor="LemonChiffon"|<nowiki>"</nowiki>'''2.''' In patients with [[PTS]] of the arm, we suggest against treatment with venoactive medications. ''([[American College of Chest Physicians#Level of Evidence|Level of Evidence: C]])''<nowiki>"</nowiki> | |||
|- | |||
|} | |||
==References== | ==References== | ||
Latest revision as of 12:13, 17 July 2014
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Resident Survival Guide |
Editor(s)-In-Chief: The APEX Trial Investigators, C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Rim Halaby, M.D. [2]
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Overview
Combined modality ultrasound (compression ultrasound with either Doppler or color Doppler) is the initial test of choice for suspected upper extremity deep vein thrombosis (UEDVT). If the initial ultrasound is negative and the clinical suspicion is still high, further testing with serial ultrasound, D-dimer, or venography should be performed. Anticoagulation therapy with either low molecular weight heparin or fondaparinux is the preferred initial treatment for UEDVT over intravenous or subcutaneous unfractionated heparin. If the UEDVT is associated with a central venous catheter, the duration of anticoagulation therapy is 3 months if the central venous catheter is removed, or as long as the central venous catheter is present in case it was not removed.
2012 VTE, Thrombophilia, Antithrombotic Therapy, and Pregnancy: Antithrombotic Therapy and Prevention of Thrombosis, 9th ed: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines (DO NOT EDIT)[1]
Ultrasonography in Patients With Upper-Extremity DVT (UEDVT)
| Class II |
| "1. In patients suspected of having UEDVT, we suggest initial evaluation with combined modality US (compression with either Doppler or color Doppler) over other initial tests, including highly sensitive D-dimer or venography. (Level of Evidence: C)" |
Clinical Pretest Probability Assessment in Patients With UEDVT
| Class I |
| "1. In patients with suspected UEDVT and an initial negative combined-modality US and subsequent negative moderate or highly sensitive D-dimer or CT or MRI, we recommend no further testing, rather than confirmatory venography. (Level of Evidence: C) " |
| Class II |
| "1. In patients with suspected UEDVT in whom initial US is negative for thrombosis despite a high clinical suspicion of DVT, we suggest further testing with a moderate or highly sensitive D-dimer, serial US, or venographic-based imaging (traditional, CT scan, or MRI), rather than no further testing. (Level of Evidence: C)" |
| "2. We suggest that patients with an initial combined negative modality US and positive D-dimer or those with less than complete evaluation by US undergo venography rather than no further testing, unless there is an alternative explanation for their symptoms (Level of Evidence: B), in which case testing to evaluate for the presence an alternative diagnosis should be performed. We suggest that patients with a positive D-dimer or those with less than complete evaluation by US but an alternative explanation for their symptoms undergo confirmatory testing and treatment of this alternative explanation rather than venography (Level of Evidence: C). " |
Acute Anticoagulation for Patients With UEDVT
| Class I |
| "1. In patients with UEDVT that involves the axillary or more proximal veins, we recommend acute treatment with parenteral anticoagulation (LMWH, fondaparinux, IV UFH, or SC UFH) over no such acute treatment. (Level of Evidence: B)" |
| Class II |
| "1. In patients with acute UEDVT that involves the axillary or more proximal veins, we suggest LMWH or fondaparinux over IV UFH (Level of Evidence: C) and over SC UFH (Level of Evidence: B). " |
Thrombolytic Therapy for the Initial Treatment of Patients With UEDVT
| Class I |
| "1. In patients with UEDVT who undergo thrombolysis, we recommend the same intensity and duration of anticoagulant therapy as in similar patients who do not undergo thrombolysis. (Level of Evidence: B)" |
| Class II |
| "1. In patients with acute UEDVT that involves the axillary or more proximal veins, we suggest anticoagulant therapy alone over thrombolysis. (Level of Evidence: C) " |
Long-term Anticoagulation for Patients With UEDVT
| Class I |
| "1. In patients who have UEDVT that is associated with a central venous catheter that is removed, we recommend 3 months of anticoagulation over a longer duration of therapy in patients with no cancer. (Level of Evidence: B)" |
| "2. In patients who have UEDVT that is associated with a central venous catheter that is not removed, we recommend that anticoagulation is continued as long as the central venous catheter remains over stopping after 3 months of treatment in patients with cancer. (Level of Evidence: C)" |
| "3. In patients who have UEDVT that is not associated with a central venous catheter or with cancer, we recommend 3 months of anticoagulation over a longer duration of therapy. (Level of Evidence: B)" |
| Class II |
| "1. In most patients with UEDVT that is associated with a central venous catheter, we suggest that the catheter not be removed if it is functional and there is an ongoing need for the catheter. (Level of Evidence: C) " |
| "2. In patients with UEDVT that involves the axillary or more proximal veins, we suggest a minimum duration of anticoagulation of 3 months over a shorter period. (Level of Evidence: B) " |
| "3. In patients who have UEDVT that is associated with a central venous catheter that is not removed, we recommend that anticoagulation is continued as long as the central venous catheter remains over stopping after 3 months of treatment in patients with no cancer. (Level of Evidence: C) " |
| "4. In patients who have UEDVT that is associated with a central venous catheter that is removed, we recommend 3 months of anticoagulation over a longer duration of therapy in patients with cancer. (Level of Evidence: C) " |
Prevention of PTS of the Arm
| Class II |
| "1. In patients with acute symptomatic UEDVT, we suggest against the use of compression sleeves or venoactive medications. (Level of Evidence: C)" |
Treatment of Patients With PTS of the Arm
| Class II |
| "1. In patients who have PTS of the arm, we suggest a trial of compression bandages or sleeves to reduce symptoms. (Level of Evidence: C)" |
| "2. In patients with PTS of the arm, we suggest against treatment with venoactive medications. (Level of Evidence: C)" |
References
- ↑ Bates SM, Greer IA, Middeldorp S, Veenstra DL, Prabulos AM, Vandvik PO; et al. (2012). "VTE, thrombophilia, antithrombotic therapy, and pregnancy: Antithrombotic Therapy and Prevention of Thrombosis, 9th ed: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines". Chest. 141 (2 Suppl): e691S–736S. doi:10.1378/chest.11-2300. PMC 3278054. PMID 22315276.