Deep vein thrombosis special scenario upper extremity

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 to color Doppler) is the initial test of choice. If the initial ultrasound is negative, but clinical suspicion stays high, further testing with serial ultrasound, D-dimer, or venography should be performed.

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)

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) "