Chapter 17-11: Upper Extremity DVT (UEDVT)

TEXTBOOK PRESENTATION

Patients can be asymptomatic, but generally arm, shoulder, or neck discomfort or fullness as well as arm swelling are the presenting symptoms.

DISEASE HIGHLIGHTS

1. Classification

   1. Primary UEDVT (20% of cases)

      1. Effort-related thrombosis, also known as Paget-Schroetter syndrome (two-thirds of primary UEDVT cases)

         1. Due to microtrauma to the subclavian vein from repetitive arm movements during overhead activities or vigorous exercise; usually occurs in young males.

         2. Abnormalities of the costoclavicular junction may be present

      2. Venous thoracic outlet syndrome: compression of the subclavian vein due to abnormalities of one or more structures at the costoclavicular junction

      3. Idiopathic

   2. Secondary UEDVT (80% of cases); risk factors are shown in Table 17-10

      1. Indwelling central venous catheter-associated UEDVT (up to 70% of cases)

         1. UEDVT occurs more often with large catheters than with smaller ones.

         2. Risk increases with duration of catheter use, being negligible within 6 days and increasing significantly after 2 weeks.

         3. Risk is higher with polyvinyl chloride-coated catheters than with silicone ones.

         4. One study found that the risk is about 2.5 times higher with peripherally inserted central catheters than with other central venous catheters.

      2. Malignancy (> 40% of cases): patients with cancer and an indwelling catheter are at especially high risk.

      3. Hypercoagulable states

      4. Other miscellaneous causes (surgery, infection, immobility, concurrent lower extremity DVT)

2. Sites

   1. Subclavian (74%) and axillary (38%) most common

   2. Multiple veins are often involved, but bilateral UEDVT is rare.

3. Clinical features

   1. Pain is present in ~40% of patients.

   2. Edema is present ~80% of patients in some series, but patients with catheter-related UEDVT often do not have edema.

   3. Patients may note numbness, heaviness, paresthesias, pruritus, and coldness.

   4. Dilated cutaneous veins sometimes visible.

4. Complications

   1. Pulmonary embolism has been reported to occur in up to 36% of cases and is more often seen with secondary UEDVT, especially catheter-related

      1. More recent studies have found a much lower rate of pulmonary embolism, with symptomatic pulmonary embolism reported ~9%.

      2. Risk of pulmonary embolism due to UEDVT is lower than with lower extremity DVT

   UEDVT can cause pulmonary embolism.

   2. Recurrent thrombosis occurs in up to 2–13% of patients.

   3. Postthrombotic syndrome is seen in up to 7–46% of patients in different series.

EVIDENCE-BASED DIAGNOSIS

1. Venography is the gold standard.

2. Duplex ultrasonography is the most commonly used noninvasive test.

   1. Disadvantages include a blind spot caused by the clavicle, inability to determine compressibility in veins located in the thoracic cavity, ...