Upper extremity deep venous thrombosis (DVT) is becoming a more common problem because of increased use of central venous catheters for chemotherapy, bone marrow transplantation, dialysis, and parenteral nutrition. One concern is that pulmonary embolism is present in an estimated one third of patients with an upper extremity DVT; however, fatal pulmonary embolisms are considered rare. Joffe and Goldhaber reviewed the etiology, diagnosis, and treatment of this condition.
Upper extremity DVT typically occurs in the axillary or subclavian veins. Upper extremity DVT has been reported in up to 25 percent of patients with central venous catheters. Other causes include types of external vein compression caused by thoracic outlet obstruction, “effort thromboses” (found in athletes with hypertrophied muscles), and anatomic anomalies. Idiopathic clots are rare and should raise concern for occult carcinoma.
Presenting Signs and Symptoms of Upper Extremity Deep Venous Thrombosis
| Type | Symptoms | Signs |
|---|---|---|
| Axillary or subclavian venous thrombosis | Vague shoulder or neck discomfort Arm or hand edema | Supraclavicular fullness Palpable cord Arm or hand edema Extremity cyanosis Dilated cutaneous veins Jugular venous distension Inability to access central venous catheter |
| Thoracic outlet syndrome | Pain radiating to arm/forearm Hand weakness | Brachial plexus tenderness Arm or hand atrophy Positive Adson* or Wright† maneuver |
*— Adson maneuver: The examiner extends the patient’s arm on the affected side while the patient extends the neck and rotates the head toward the same side. The test is positive if there is weakening of the radial pulse with deep inspiration, and suggests compression of the subclavian artery.
†— Wright maneuver: The patient’s shoulder is abducted and the humerus is externally rotated. The test is positive if symptoms are reproduced and there is weakening of the radial pulse.
Adapted with permission from Joffe HV, Goldhaber SZ. Upper-extremity deep vein thrombosis. Circulation 2002;106:1875.
The prevalence of coagulation disorders in patients with upper extremity DVT is uncertain, and routine testing has never been shown to be cost-effective. However, testing for a hypercoagulable state may be most worthwhile in patients with idiopathic upper extremity DVT, a family history of DVT, a history of recurrent miscarriage, or a personal history of DVT. Presenting signs and symptoms of upper extremity DVT are listed in the accompanying table.
Suspicion of upper extremity DVT based on history and physical examination should be confirmed or excluded with imaging studies. Duplex ultrasonography is the best initial evaluation because it is noninvasive and has a high sensitivity and specificity. Other imaging options for confirming the diagnosis include venous angiography and magnetic resonance angiography.
Anticoagulation, with agents such as warfarin, remains a key therapy for patients with upper extremity DVT. Catheter-directed thrombolysis should be considered in healthy patients, because they experience greater long-term morbidity when they receive oral anticoagulation alone. Thrombolysis also is used for patients with symptomatic superior vena cava syndrome or those who need to maintain a central venous catheter. Superior vena cava filters are an option for patients who have contraindications to anticoagulation; however, the data are limited on safety and efficacy of these filters. Surgical thrombectomy is usually only considered when other options fail. However, surgery can be used to correct causes of external vein compression such as anatomic abnormalities. Because central and peripheral catheters are risk factors for upper extremity DVT, the issue of prophylaxis is currently being evaluated.
