Advertisement

The diagnostic management of upper extremity deep vein thrombosis: A review of the literature

      Highlights

      • The evidence on the diagnostic management of upper extremity deep vein thrombosis is scarce.
      • Only one study evaluated the use of a diagnostic algorithm, similar to the one used for deep vein thrombosis of the lower extremities.
      • Further studies are needed to validate the algorithm, especially in high-risk subgroups.

      Abstract

      Upper extremity deep vein thrombosis (UEDVT) accounts for 4% to 10% of all cases of deep vein thrombosis. UEDVT may present with localized pain, erythema, and swelling of the arm, but may also be detected incidentally by diagnostic imaging tests performed for other reasons. Prompt and accurate diagnosis is crucial to prevent pulmonary embolism and long-term complications as the post-thrombotic syndrome of the arm. Unlike the diagnostic management of deep vein thrombosis (DVT) of the lower extremities, which is well established, the work-up of patients with clinically suspected UEDVT remains uncertain with limited evidence from studies of small size and poor methodological quality. Currently, only one prospective study evaluated the use of an algorithm, similar to the one used for DVT of the lower extremities, for the diagnostic workup of clinically suspected UEDVT. The algorithm combined clinical probability assessment, D-dimer testing and ultrasonography and appeared to safely and effectively exclude UEDVT. However, before recommending its use in routine clinical practice, external validation of this strategy and improvements of the efficiency are needed, especially in high-risk subgroups in whom the performance of the algorithm appeared to be suboptimal, such as hospitalized or cancer patients.
      In this review, we critically assess the accuracy and efficacy of current diagnostic tools and provide clinical guidance for the diagnostic management of clinically suspected UEDVT.

      Abbreviations:

      AUROC (area under the receiver operating characteristic curve), CI (confidence interval), CVC (central venous catheter), DVT (deep vein thrombosis), PE (pulmonary embolism), UEDVT (upper extremity deep vein thrombosis)

      Keywords

      To read this article in full you will need to make a payment

      Purchase one-time access:

      Academic & Personal: 24 hour online accessCorporate R&D Professionals: 24 hour online access
      One-time access price info
      • For academic or personal research use, select 'Academic and Personal'
      • For corporate R&D use, select 'Corporate R&D Professionals'

      Subscribe:

      Subscribe to Thrombosis Research
      Already a print subscriber? Claim online access
      Already an online subscriber? Sign in
      Institutional Access: Sign in to ScienceDirect

      References

        • Di Nisio M.
        • van Es N.
        • Büller H.R.
        Deep vein thrombosis and pulmonary embolism.
        Lancet. 2016; 388: 3060-3073
        • Constans J.
        • Salmi L.-R.
        • Sevestre-Pietri M.-A.
        • Perusat S.
        • Nguon M.
        • Degeilh M.
        • Labarere J.
        • Gattolliat O.
        • Boulon C.
        • Laroche J.-P.
        • Le Roux P.
        • Pichot O.
        • Quéré I.
        • Conri C.
        • Bosson J.-L.
        A clinical prediction score for upper extremity deep venous thrombosis.
        Thromb. Haemost. 2008; 99: 202-207
        • Kleinjan A.
        • Di Nisio M.
        • Beyer-Westendorf J.
        • Camporese G.
        • Cosmi B.
        • Ghirarduzzi A.
        • Kamphuisen P.W.
        • Otten H.-M.
        • Porreca E.
        • Aggarwal A.
        • Brodmann M.
        • Guglielmi M.D.
        • Iotti M.
        • Kaasjager K.
        • Kamvissi V.
        • Lerede T.
        • Marschang P.
        • Meijer K.
        • Palareti G.
        • Rickles F.R.
        • Righini M.
        • Rutjes A.W.S.
        • Tonello C.
        • Verhamme P.
        • Werth S.
        • van Wissen S.
        • Büller H.R.
        Safety and feasibility of a diagnostic algorithm combining clinical probability, d-dimer testing, and ultrasonography for suspected upper extremity deep venous thrombosis: a prospective management study.
        Ann. Intern. Med. 2014; 160: 451-457
        • Sartori M.
        • Migliaccio L.
        • Favaretto E.
        • Cini M.
        • Legnani C.
        • Palareti G.
        • Cosmi B.
        d-dimer for the diagnosis of upper extremity deep and superficial venous thrombosis.
        Thromb. Res. 2015; 135: 673-678
        • Sartori M.
        • Migliaccio L.
        • Favaretto E.
        • Brusi C.
        • Conti E.
        • Rodorigo G.
        • Cosmi B.
        Whole-arm ultrasound to rule out suspected upper-extremity deep venous thrombosis in outpatients.
        JAMA Intern. Med. 2015; 175: 1226-1227
        • Di Nisio M.
        • Van Sluis G.L.
        • Bossuyt P.M.M.
        • Büller H.R.
        • Porreca E.
        • Rutjes A.W.S.
        Accuracy of diagnostic tests for clinically suspected upper extremity deep vein thrombosis: a systematic review.
        J. Thromb. Haemost. 2010; 8: 684-692
        • Isma N.
        • Svensson P.J.
        • Gottsäter A.
        • Lindblad B.
        Upper extremity deep venous thrombosis in the population-based Malmö thrombophilia study (MATS). Epidemiology, risk factors, recurrence risk, and mortality.
        Thromb Res. 2010; 125: e335-e338
        • Prandoni P.
        • Bernardi E.
        Upper extremity deep vein thrombosis.
        Curr. Opin. Pulm. Med. 1999; 5: 222-226
        • Hingorani A.
        • Ascher E.
        • Lorenson E.
        • DePippo P.
        • Salles-Cunha S.
        • Scheinman M.
        • Yorkovich W.
        • Hanson J.
        Upper extremity deep venous thrombosis and its impact on morbidity and mortality rates in a hospital-based population.
        J. Vasc. Surg. 1997; 26: 853-860
        • Marinella M.A.
        • Kathula S.K.
        • Markert R.J.
        Spectrum of upper-extremity deep venous thrombosis in a community teaching hospital.
        Heart Lung. 2000; 29: 113-117
        • Linnemann B.
        • Meister F.
        • Schwonberg J.
        • Schindewolf M.
        • Zgouras D.
        • Lindhoff-Last E.
        MAISTHRO registry, Hereditary and acquired thrombophilia in patients with upper extremity deep-vein thrombosis. Results from the MAISTHRO registry.
        Thromb. Haemost. 2008; 100: 440-446
        • Prandoni P.
        • Polistena P.
        • Bernardi E.
        • Cogo A.
        • Casara D.
        • Verlato F.
        • Angelini F.
        • Simioni P.
        • Signorini G.P.
        • Benedetti L.
        • Girolami A.
        Upper-extremity deep vein thrombosis. Risk factors, diagnosis, and complications.
        Arch. Intern. Med. 1997; 157: 57-62
        • Hingorani A.
        • Ascher E.
        • Hanson J.
        • Scheinman M.
        • Yorkovich W.
        • Lorenson E.
        • DePippo P.
        • Salles-Cunha S.
        Upper extremity versus lower extremity deep venous thrombosis.
        Am. J. Surg. 1997; 174: 214-217
        • Blom J.W.
        • Doggen C.J.M.
        • Osanto S.
        • Rosendaal F.R.
        Old and new risk factors for upper extremity deep venous thrombosis.
        J. Thromb. Haemost. 2005; 3: 2471-2478
        • Bleker S.M.
        • van Es N.
        • Kleinjan A.
        • Büller H.R.
        • Kamphuisen P.W.
        • Aggarwal A.
        • Beyer-Westendorf J.
        • Camporese G.
        • Cosmi B.
        • Gary T.
        • Ghirarduzzi A.
        • Kaasjager K.
        • Lerede T.
        • Marschang P.
        • Meijer K.
        • Otten H.-M.
        • Porreca E.
        • Righini M.
        • Verhamme P.
        • van Wissen S.
        • Di Nisio M.
        Current management strategies and long-term clinical outcomes of upper extremity venous thrombosis.
        J. Thromb. Haemost. 2016; 14: 973-981
        • Lindblad B.
        • Tengborn L.
        • Bergqvist D.
        Deep vein thrombosis of the axillary-subclavian veins: epidemiologic data, effects of different types of treatment and late sequelae.
        Eur. J. Vasc. Surg. 1988; 2: 161-165
        • Illig K.A.
        • Doyle A.J.
        A comprehensive review of Paget-Schroetter syndrome.
        J. Vasc. Surg. 2010; 51: 1538-1547
        • Martinelli I.
        • Cattaneo M.
        • Panzeri D.
        • Taioli E.
        • Mannucci P.M.
        Risk factors for deep venous thrombosis of the upper extremities.
        Ann. Intern. Med. 1997; 126: 707-711
        • Martinelli I.
        • Battaglioli T.
        • Bucciarelli P.
        • Passamonti S.M.
        • Mannucci P.M.
        Risk factors and recurrence rate of primary deep vein thrombosis of the upper extremities.
        Circulation. 2004; 110: 566-570
        • Evans R.S.
        • Sharp J.H.
        • Linford L.H.
        • Lloyd J.F.
        • Tripp J.S.
        • Jones J.P.
        • Woller S.C.
        • Stevens S.M.
        • Elliott C.G.
        • Weaver L.K.
        Risk of symptomatic DVT associated with peripherally inserted central catheters.
        Chest. 2010; 138: 803-810
        • van Rooden C.J.
        • Molhoek S.G.
        • Rosendaal F.R.
        • Schalij M.J.
        • Meinders A.E.
        • Huisman M.V.
        Incidence and risk factors of early venous thrombosis associated with permanent pacemaker leads.
        J. Cardiovasc. Electrophysiol. 2004; 15: 1258-1262
        • Parienti J.-J.
        • Mongardon N.
        • Mégarbane B.
        • Mira J.-P.
        • Kalfon P.
        • Gros A.
        • Marqué S.
        • Thuong M.
        • Pottier V.
        • Ramakers M.
        • Savary B.
        • Seguin A.
        • Valette X.
        • Terzi N.
        • Sauneuf B.
        • Cattoir V.
        • Mermel L.A.
        • du Cheyron D.
        • 3SITES Study Group
        Intravascular complications of central venous catheterization by insertion site.
        N. Engl. J. Med. 2015; 373: 1220-1229
        • Chopra V.
        • Ratz D.
        • Kuhn L.
        • Lopus T.
        • Lee A.
        • Krein S.
        Peripherally inserted central catheter-related deep vein thrombosis: contemporary patterns and predictors.
        J. Thromb. Haemost. 2014; 12: 847-854
        • Patel G.S.
        • Jain K.
        • Kumar R.
        • Strickland A.H.
        • Pellegrini L.
        • Slavotinek J.
        • Eaton M.
        • McLeay W.
        • Price T.
        • Ly M.
        • Ullah S.
        • Koczwara B.
        • Kichenadasse G.
        • Karapetis C.S.
        Comparison of peripherally inserted central venous catheters (PICC) versus subcutaneously implanted port-chamber catheters by complication and cost for patients receiving chemotherapy for non-haematological malignancies.
        Support Care Cancer. 2014; 22: 121-128
        • Merminod T.
        • Pellicciotta S.
        • Bounameaux H.
        Limited usefulness of d-dimer in suspected deep vein thrombosis of the upper extremities.
        Blood Coagul. Fibrinolysis. 2006; 17: 225-226
        • Di Nisio M.
        • Squizzato A.
        • Rutjes A.W.S.
        • Büller H.R.
        • Zwinderman A.H.
        • Bossuyt P.M.M.
        Diagnostic accuracy of d-dimer test for exclusion of venous thromboembolism: a systematic review.
        J. Thromb. Haemost. 2007; 5: 296-304
        • Mazzolai L.
        • Aboyans V.
        • Ageno W.
        • Agnelli G.
        • Alatri A.
        • Bauersachs R.
        • Brekelmans M.P.A.
        • Büller H.R.
        • Elias A.
        • Farge D.
        • Konstantinides S.
        • Palareti G.
        • Prandoni P.
        • Righini M.
        • Torbicki A.
        • Vlachopoulos C.
        • Brodmann M.
        Diagnosis and management of acute deep vein thrombosis: a joint consensus document from the European society of cardiology working groups of aorta and peripheral circulation and pulmonary circulation and right ventricular function.
        Eur. Heart J. 2017;
        • Kim H.-C.
        • Chung J.W.
        • Park J.H.
        • Yin Y.H.
        • Park S.H.
        • Yoon C.J.
        • Choi Y.H.
        Role of CT venography in the diagnosis and treatment of benign thoracic central venous obstruction.
        Korean J. Radiol. 2003; 4: 146-152
        • Baarslag H.J.
        • Van Beek E.J.R.
        • Reekers J.A.
        Magnetic resonance venography in consecutive patients with suspected deep vein thrombosis of the upper extremity: initial experience.
        Acta Radiol. 2004; 45: 38-43
        • Righini M.
        • Van Es J.
        • Den Exter P.L.
        • Roy P.-M.
        • Verschuren F.
        • Ghuysen A.
        • Rutschmann O.T.
        • Sanchez O.
        • Jaffrelot M.
        • Trinh-Duc A.
        • Le Gall C.
        • Moustafa F.
        • Principe A.
        • Van Houten A.A.
        • Ten Wolde M.
        • Douma R.A.
        • Hazelaar G.
        • Erkens P.M.G.
        • Van Kralingen K.W.
        • Grootenboers M.J.J.H.
        • Durian M.F.
        • Cheung Y.W.
        • Meyer G.
        • Bounameaux H.
        • Huisman M.V.
        • Kamphuisen P.W.
        • Le Gal G.
        Age-adjusted d-dimer cutoff levels to rule out pulmonary embolism: the ADJUST-PE study.
        JAMA. 2014; 311: 1117-1124
        • van Es N.
        • Bleker S.M.
        • Di Nisio M.
        • Kleinjan A.
        • Beyer-Westendorf J.
        • Camporese G.
        • Aggarwal A.
        • Verhamme P.
        • Righini M.
        • Büller H.R.
        • Bossuyt P.M.
        Improving the diagnostic management of upper extremity deep vein thrombosis.
        J. Thromb. Haemost. 2017; 15: 66-73
        • van Es N.
        • Bleker S.M.
        • Di Nisio M.
        • Kleinjan A.
        • Beyer-Westendorf J.
        • Camporese G.
        • Kamphuisen P.W.
        • Büller H.R.
        • Bossuyt P.M.
        ARMOUR study investigators, a clinical decision rule and d-dimer testing to rule out upper extremity deep vein thrombosis in high-risk patients.
        Thromb. Res. 2016; 148: 59-62