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Treatment of Acute Upper Extremity Venous Occlusion
The incidence of deep vein thrombosis (DVT) and pulmonary embolism (PE) has been estimated to exceed 900,000 cases annually in the United States. Upper extremity DVT can result in PE in 4% to 12% of the cases, and there are known case reports of fatal PE. The number of cases of upper extremity DVT is increasing as a result of widespread use of central venous catheters, pacemakers, and implantable defibrillators.
The etiology of upper extremity DVT can be divided into two classifications: primary (venous thoracic outlet syndrome) and secondary (related to central venous catheters in 50% of the cases). Current literature suggests aggressive management of upper extremity DVT, because it is associated with significant complications, including PE, post-thrombotic venous insufficiency, and superior vena cava (SVC) syndrome. PEs are observed most commonly with secondary upper extremity DVT.
Catheter-Associated Deep Vein Thrombosis of the Upper Extremity
Multiple catheter characteristics contribute to thrombus formation. Large-bore and multilumen catheters are associated with higher incidence of DVT. The incidence of PE is also affected by the type of catheter used, being observed more commonly with polyvinyl chloride and/or polyethylene catheters, as compared to either polyurethane or silicone catheters. The position of the catheter placement can also influence upper extremity DVT formation. Catheters that are positioned in the innominate vein have a higher incidence of upper extremity DVT. Therefore, it is important to properly position and confirm placement of the catheter. Infection is also associated with increased risk of catheter-induced venous thrombosis. Sterile handling of the catheter and removal of the indwelling catheter upon completion of therapy are important steps in preventing this complication.
The incidence of upper extremity DVT in peripherally inserted central catheters (PICC) is similar to that in centrally inserted ones. Diameter of PICC line, history of recent surgery, malignancy, and prior history of DVT are all risk factors associated with thrombus formation. Implanted ports, on the other hand, have a lower incidence of DVT as compared to PICC lines, and therefore they may be preferable for use in cancer patients.
The treatment of patients with upper extremity DVT is anticoagulation. The goal of anticoagulation is to halt propagation of thrombus, maintain collaterals, and prevent PE. In the 8th edition of the American College of Chest Physicians guidelines, it is recommended to initiate therapy with low-molecular-weight heparin (LMWH), unfractionated heparin (UFH), or fondaparinux, in therapeutic doses. Based on lower extremity treatment protocols, anticoagulation with heparin is adjusted to obtain an activated partial thromboplastin time of 2 to 2.5 times the upper limit of normal. This should be followed by at least 3 months of anticoagulation with vitamin K antagonist (warfarin) to obtain a international normalization ratio of 2.0 to 3.0.
In general, it is not necessary to remove catheters in patients with upper extremity DVT, provided that the catheter is functional, is needed for therapy, and there is no evidence of infection at or around the catheter site. In cases where the catheter has been removed, the risk of DVT complications remains, and therefore patients should be managed with anticoagulation therapy for at least 3 months.
Cancer Patients with Central Venous Catheters
Cancer patients with central venous catheters have a higher risk of upper extremity DVT, and this presents a dilemma for the managing physician. In addition to anticoagulation, the treatment of this group of patients may include thrombolytic therapy. To date, there have been no randomized trials comparing anticoagulation therapy to thrombolytic therapy for the treatment of upper extremity DVT. Available studies are mostly retrospective. Based on guidelines, thrombolytic therapy is only indicated in selected cases when risk of bleeding is low and symptoms are severe and of recent onset. The author's practice does not routinely employ thrombolytic therapy for managing upper extremity DVT other than that associated with thoracic outlet syndrome.
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