Deep-Vein Thrombosis of the Upper Extremities — NEJM

Clinical Practice

Deep-Vein Thrombosis of the Upper Extremities
Nils Kucher, M.D.

N Engl J Med 2011; 364:861-869March 3, 2011

This Journal feature begins with a case vignette highlighting a common clinical problem. Evidence supporting various strategies is then presented, followed by a review of formal guidelines, when they exist. The article ends with the author's clinical recommendations.

A 58-year-old woman presents with a 3-day history of pain, heaviness, and functional impairment in her left arm. She has received chemotherapy for ovarian cancer through an implanted port and catheter (Port-a-Cath) on the left side. Physical examination reveals a swollen and erythematous left arm and visible venous collaterals at the neck, shoulder, and chest. Compression ultrasonography reveals a patent left distal subclavian vein, but there is an abnormal Doppler-flow pattern suggestive of a more proximal thrombosis. How should this case be further evaluated and managed?

The Clinical Problem

Approximately 10% of all cases of deep-vein thrombosis involve the upper extremities, resulting in an annual incidence of 0.4 to 1 case per 10,000 people.1-3 Cases have become more common because of the increased use of central venous catheters and of cardiac pacemakers and defibrillators. Axillary subclavian veins are often involved, and secondary forms are more common than primary forms (Table 1Table 1

Pathogenesis of Deep-Vein Thrombosis of an Upper Extremity.).15 As compared with patients who have thrombosis of a lower extremity, patients with deep-vein thrombosis of an upper extremity are typically younger, leaner, more likely to have a diagnosis of cancer,1,2 and less likely to have acquired or hereditary thrombophilia.4

In patients with primary deep-vein thrombosis of an upper extremity, repetitive microtrauma to the subclavian vein and its surrounding structures, the result of anatomical abnormalities within the costoclavicular junction, may cause inflammation, venous intima hyperplasia, and fibrosis, all of which characterize the venous thoracic outlet syndrome.16 Approximately two thirds of patients with primary deep-vein thrombosis of an upper extremity, most of whom are young and male, report strenuous activity involving force or abduction of the dominant arm before the development of thrombosis, known as the Paget–Schroetter syndrome.17

Complications of deep-vein thrombosis, which are less common in the upper extremities than in the lower extremities, include pulmonary embolism (6% for upper extremities2,18 vs. 15 to 32% for lower extremities19,20), recurrence at 12 months (2 to 5% for upper extremities2,21,22 vs. 10% for lower extremities23), and the post-thrombotic syndrome (5% for upper extremities24 vs. up to 56% for lower extremities25). Thrombosis of the axillary subclavian veins (as compared with thrombosis at other locations) and residual thrombosis at 6 months are associated with an increased risk of the post-thrombotic syndrome; the risk is lower for catheter-associated thrombosis.24 In a prospective study of 512 patients with deep-vein thrombosis of an upper extremity, 38% of whom had cancer, the 3-month mortality rate was 11%, and only 1 death was attributed to pulmonary embolism.2

full-text:
Deep-Vein Thrombosis of the Upper Extremities — NEJM


Source Information
From the Departments of Angiology and Cardiology, Cardiovascular Division, Inselspital, University Hospital Bern, Bern, Switzerland.

Address reprint requests to Dr. Kucher at the Departments of Angiology and Cardiology, Cardiovascular Division, Inselspital, University Hospital Bern, 3010 Bern, Switzerland, or at nils.kucher@insel.ch.