Diagnostic and Therapeutic Management of Upper Extremity Deep Vein Thrombosis

Short Course Antibiotic Therapy for Catheter-Related Septic Thrombosis: "Caveat Emptor!": Duration of Therapy Should Not Be Set a Priori

There is a growing body of evidence showing no significant difference in clinical outcomes in patients with uncomplicated Gram-negative bloodstream infections (BSIs) receiving 7 or 14 days of therapy. However, the scenario may differ when complicated forms of BSI, such as catheter-related BSIs (CRBSIs) burdened by septic thrombosis (ST), are considered. A recent study showed that a short course of antimicrobial therapy (≤3 weeks) had similar outcomes to a prolonged course on CRBSI-ST. From this perspective, starting from the desirable goal of shortening the treatment duration, we discuss how the path to the correct diagnosis and management of CRBSI-ST may be paved with several challenges. Indeed, patients with ST due to Gram-negative bacteria display prolonged bacteremia despite an indolent clinical course, requiring an extended course of antibiotic treatment guided by negative FUBCs results, which should be considered the real driver of the decision-making process establishing the length of antibiotic therapy in CRBSI-ST. Shortening treatment of complicated CRBSIs burdened by ST is ambitious and advisable; however, a dynamic and tailored approach driven by a tangible outcome such as negative FUBCs rather than a fixed-duration paradigm should be implemented for the optimal antimicrobial duration.

Efficacy and safety of rivaroxaban versus warfarin in the management of unusual site deep vein thrombosis: a retrospective cohort study

Background

Unusual site deep vein thrombosis (DVT) was defined as venous thromboembolism (VTE) occurring outside the conventional deep veins of the lower extremity or pulmonary arteries. However, the optimal anticoagulation therapy for unusual site DVT remained unclear. This study aims to evaluate the efficacy and safety of rivaroxaban in unusual site DVT.

Methods

This retrospective cohort study enrolled consecutive patients at Nanjing Drum Tower Hospital between January 2011 and December 2021 who were diagnosed with unusual site DVT. Patients were divided into two groups based on their ultimate medication choice: the warfarin group and the rivaroxaban group. The demographic characteristics were recorded for all enrolled patients. Clinical outcomes included recurrent VTE, bleeding complications and major bleeding.

Results

A total of 1,088 patients were divided into warfarin (n = 514) and rivaroxaban (n = 574) groups. After the stabilized inverse probability of treatment weighting, Hazard Ratios for warfarin vs. rivaroxaban of recurrent VTE, bleeding complications and major bleeding were 0.52(95% CI: 0.25-1.08), 0.30(95% CI: 0.14-0.60), and 0.33 (95% CI, 0.13-0.74), respectively. Risk of clinical outcomes in specified subgroups for age, gender, renal function, thrombosis sites and diagnosis were assessed. The interaction of gender and treatment on major bleeding was significant (P for interaction = 0.062). Otherwise, there was no significant interaction between the other subgroups and the treatment group in terms of clinical outcomes.

Conclusion

Compared with warfarin, rivaroxaban exhibited comparable efficacy for the anticoagulant treatment of unusual site DVT, associated with a lower risk of bleeding complications and major bleeding.

Paget-Schroetter Syndrome: A Case of a Young Weightlifter

Venous thoracic outlet syndrome is a rare type of thoracic outlet disorder that is often overlooked. When an upper extremity deep vein thrombosis (UEDVT) occurs due to thoracic outlet compression, it is commonly referred to as Paget-Schroetter syndrome (PSS). The space between the first rib and the clavicle where the subclavian vein passes through is highly vulnerable to compression and injury. This space often undergoes repetitive trauma due to extrinsic compression which ultimately results in scarring and clot formation. This case report reviews the case of a 26-year-old white male who presented with the chief complaint of right arm swelling and soreness after strenuous bench pressing. He went to urgent care and the initial diagnosis was a strained muscle. An ultrasound was ordered, revealing multiple UEDVTs. At this time, the patient was referred to vascular surgery for further management. Recommended management for PSS is to initiate anticoagulation or thrombolytic therapy depending on the timing between the onset of symptoms and diagnosis. Although there is some disagreement on the next steps after thrombolysis, most physicians agree that decompression of the thoracic outlet with first rib resection is the logical next step to prevent clot recurrence. The patient received the above-mentioned therapy and is progressing well with recovery. Recognizing the thoracic outlet as a potential location for pathology and keeping in mind those who have a presentation similar to this case study is extremely important.

[Translation into French and republication of: "Central venous catheter associated upper extremity deep vein thrombosis in cancer patients: Diagnosis and therapeutic management"]

Catheter-related thrombosis (CRT) is a relatively frequent and potentially fatal complication arising in patients with cancer who require a central catheter placement for intravenous treatment. In everyday practice, CRT remains a challenge for management; despite its frequency and its negative clinical impact, few data are available concerning diagnosis and treatment of CRT. In particular, no diagnostic studies or clinical trials have been published that included exclusively patients with cancer and a central venous catheter (CVC). For this reason, many questions regarding optimal management of CRT remain unanswered. Due to the paucity of high-grade evidence regarding CRT in cancer patients, guidelines are derived from upper extremity DVT studies for diagnosis, and from those for lower limb DVT for treatment. This article addresses the issues of diagnosis and management of CRT through a review of the available literature and makes a number of proposals based on the available evidence. In symptomatic patients, venous ultrasound is the most appropriate choice for first-line diagnostic imaging of CRT because it is noninvasive, and its diagnostic performance is high (which is not the case in asymptomatic patients). In the absence of direct comparative clinical trials, we suggest treating patients with CRT with a therapeutic dose of either a LMWH or a direct oral factor Xa inhibitor, with or without a loading dose. These anticoagulants should be given for a total of at least 3 months, including at least 1 month after catheter removal following initiation of therapy.

A Rare Cause of Deep Vein Thrombosis in a Young Orchestra Conductor

Upper extremity deep vein thrombosis (DVT) of the axillary/subclavian veins is rare (5-10% of DVT). After clinical suspicion and duplex ultrasound, anticoagulation, surgical decompression and sometimes thrombolysis are mandatory due to complications. We discuss the case of a young healthy orchestra conductor with primary DVT of the left upper extremity and concomitant left shoulder musculo-tendinous traumatic injury. Symptoms of both conditions and subtle signs of upper extremity DVT delayed the diagnosis until full-blown DVT occurred. After successful anticoagulation and surgical TOS (thoracic outlet syndrome) decompression, evolution was favorable, without recurrent thrombosis.

Central venous catheter associated upper extremity deep vein thrombosis in cancer patients: Diagnosis and therapeutic management

Catheter-related thrombosis (CRT) is a relatively frequent and potentially fatal complication arising in patients with cancer who require a central catheter placement for intravenous treatment. In everyday practice, CRT remains a challenge for management; despite its frequency and its negative clinical impact, few data are available concerning diagnosis and treatment of CRT. In particular, no diagnostic studies or clinical trials have been published that included exclusively patients with cancer and a central venous catheter (CVC). For this reason, many questions regarding optimal management of CRT remain unanswered. Due to the paucity of high-grade evidence regarding CRT in cancer patients, guidelines are derived from upper extremity DVT studies for diagnosis, and from those for lower limb DVT for treatment. This article addresses the issues of diagnosis and management of CRT through a review of the available literature and makes a number of proposals based on the available evidence. In symptomatic patients, venous ultrasound is the most appropriate choice for first-line diagnostic imaging of CRT because it is noninvasive, and its diagnostic performance is high (which is not the case in asymptomatic patients). In the absence of direct comparative clinical trials, we suggest treating patients with CRT with a therapeutic dose of either a LMWH or a direct oral factor Xa inhibitor, with or without a loading dose. These anticoagulants should be given for a total of at least three months, including at least one month after catheter removal following initiation of therapy.

Treating Deep Venous Thrombosis in a Background of Crohn's Disease: A Clinical Conundrum

Deep venous thrombosis (DVT) commonly affects the lower extremities, often as a result of prolonged immobilization. However, upper limb DVT is an atypical presentation, typically associated with risk factors such as the use of a peripherally inserted central catheter (PICC) line. This case report describes an uncommon case of DVT management in a patient with Crohn's disease, a condition more frequently characterized by painful lower gastrointestinal symptoms and chronic diarrhea. A 22-year-old male with a history of Crohn's disease developed swelling and purplish discoloration at the brachial site of a PICC line site. Laboratory results indicated anemia with a hemoglobin level of 9.9 g/dL and a hematocrit of 31.9%. Doppler ultrasound confirmed the DVT in the left long axillary, left subclavian, and left long basilic veins. Given the patient's concurrent lower gastrointestinal bleeding, a cautious approach was required to balance the risks and benefits of anticoagulation. Upon recommendation by Hematology, a prophylactic dose of enoxaparin was initiated and subsequently escalated to a therapeutic dose as tolerated. The patient's condition was closely monitored, and he successfully reached the full therapeutic regimen without complications. This case underscores the importance of individualized DVT treatment strategies in the context of concurrent Crohn's disease, offering insights into managing anticoagulation in the presence of bleeding risks.

Risk for recurrence of symptomatic upper-extremity deep vein thrombosis in patients without cancer: Analysis of three RIETE cohorts

BACKGROUND

The natural history of patients with a pacemaker-related upper-extremity deep vein thrombosis (UEDVT) has not been consistently studied.

METHODS

We used the RIETE registry data to compare the outcomes during anticoagulation and after its discontinuation in noncancer patients with symptomatic UEDVT associated with a pacemaker, other catheters, or no catheter. The major outcome was the composite of symptomatic pulmonary embolism or recurrent DVT.

RESULTS

As of February 2022, 2578 patients with UEDVT were included: 156 had a pacemaker-related UEDVT, 557 had other catheters, and 1865 had no catheter. During anticoagulation, 61 patients (2.3%) developed recurrent VTE, 38 had major bleeding (1.4%), and 90 died (3.4%). After its discontinuation, 52 patients (4.4%) had recurrent acute venous thromboembolism (VTE) and six had major bleeding (0.5%). On multivariable analysis, there were no differences among subgroups in the rates of VTE recurrences or major bleeding during anticoagulation. After its discontinuation, patients with a pacemaker-related UEDVT had a higher risk for VTE recurrences than those with no catheter (adjusted OR: 4.59; 95% CI: 1.98-10.6).

CONCLUSIONS

Patients with pacemaker-related UEDVT are at increased risk for VTE recurrences after discontinuing anticoagulation. If our findings are validated in adequately designed trials, this may justify changes in the current recommendations on the duration of anticoagulation.

Left brachiocephalic venous thrombus initially presenting as acute aortic syndrome

Upper extremity deep venous thrombosis (UEDVT) is rare but carries significant morbidity. Primary UEDVT presents non-specifically and there are no clear diagnostic or management guidelines, which are essential for early treatment to prevent potentially devastating complications such as pulmonary embolus or post-thrombotic pain syndrome. A patient with left brachiocephalic vein UEDVT initially diagnosed radiographically as an acute aortic syndrome and referred to a cardiothoracic unit is presented. Computed tomography venogram confirmed the diagnosis of UEDVT and therapeutic anticoagulation was started. This case highlights the need for validated diagnostic and management algorithms for UEDVT. Furthermore, this relatively rare condition should be considered for patients with acute chest pain and abnormal imaging referred to surgical units.

Observation on the effect of intraoperative risk management combined with comfort nursing in gynecological laparoscopic surgery

To explore the effect of intraoperative risk management combined with comfort nursing in gynecological laparoscopic surgery. A retrospective analysis of 384 cases of laparoscopic surgery subjects admitted from February 2019 to June 2022 in the department of gynecology in our hospital were performed and divided into the control group (n = 192) and observation group (n = 192) according to the difference care that they received. Comfort nursing was taken in the control group, and intraoperative risk management combined with comfort nursing was given in the observation group. The coagulation indexes (activated partial thromboplastin time, prothrombin time, and thrombin time), immune inflammation indexes (monocytes and neutrophils), the incidence of lower limb deep vein thrombosis (DVT) and the satisfaction of nursing care were compared between the 2 groups. After care, activated partial thromboplastin time, prothrombin time, and thrombin time in the observation group were significantly longer than those in the control group, and the counts of monocytes and neutrophils in the observation group were significantly lower than those in the control group (P < .05). The incidence of DVT in the observation group was notablely lower than those in the control group (P = .008). The nursing satisfaction in the observation group was notablely higher than those in the control group (P < .001). Intraoperative risk management combined with comfort nursing intervention can improve the level of coagulation indicators and immune inflammation indicators after gynecological laparoscopic surgery, reduce the incidence of DVT, and improve subject nursing satisfaction.

Single-center experience with catheter-directed thrombolysis and balloon angioplasty for acute upper-extremity deep vein thrombosis: a case series study

BACKGROUND

Effective treatment of upper extremity deep vein thrombosis (UEDVT) is crucial to prevent further complications. Various treatments, including percutaneous mechanical thrombectomy (PMT), catheter-directed thrombolysis (CDT), decompression surgery, and venoplasty are suggested for UEDVT. However, no prospective study has yet favored any of these treatments. This study presents a review of our experience with CDT followed by balloon venoplasty in patients with acute primary UEDVT.

METHODS

We enrolled all patients diagnosed with acute UEDVT from January 2020 to June 2021. Subjects with UEDVT due to secondary causes like malignancies, indwelling catheters, or leads were excluded. CDT was performed through brachial vein access, using a perfusion catheter, and rt-PA administration. Balloon venoplasty was performed if the treated segment had remaining stenosis after CDT. Patients were followed up at the vein clinic for any signs and symptoms in the upper extremity and lifestyle changes. Follow-up ultrasonography was done 12 months after discharge.

RESULTS

Twelve patients with a mean age of 41.08 ± 14.0 years were included in the study. The mean duration of CDT was 25.00 ± 10.56 h. After CDT, all patients had remaining occlusions, with seven having more than 50% remaining stenosis. However, after balloon venoplasty, no patient had significant (more than 50%) stenosis. There was no serious complication after both procedures. Patients were followed up for a mean duration of twelve months after their admission, with a mean time of maintenance anticoagulation was 10.73 ± 5.77 months. Only one patient had recurrent symptoms in his target limb which required a decompression surgery, while the rest were free of symptoms in their treated extremity. No subject developed pulmonary emboli (PE) during admission or the follow-up period. There was no evidence of hospital readmission for any reason. Upper extremity color-doppler sonography of the patients at twelve months after their procedure showed normal venous flow without any significant stenosis in 8 (66.7%), and partially normal flow with patent target vein in 4 (33.3%) patients.

CONCLUSIONS

CDT followed by balloon venoplasty may be an effective treatment for selected patients with acute primary UEDVT, providing desirable long-term results and potentially avoiding the need for decompression surgery in the short or long term.

Upper extremity deep vein thrombosis: An intensivist’s perspective

Upper extremity deep vein thrombosis (UEDVT) is less common than lower extremity DVT but is a cause of significant morbidity and mortality in intensive care unit patients. Increasing cancer incidence, prolonged life expectancy and increasing use of intravascular catheters and devices has led to an increased incidence of UEDVT. It is also associated with high rates of complications like pulmonary embolism, post-thrombotic syndrome and recurrent thrombosis. Clinical prediction scores and D-dimer may not be as useful in identifying UEDVT; hence, a high suspicion index is required for diagnosis. Doppler ultrasound is commonly employed for diagnosis, but other tests like computed tomography and magnetic resonance imaging venography may also be required in some patients. Contrast venography is rarely used in patients with clinical and ultrasound findings discrepancies. Anticoagulant therapy alone is sufficient in most patients, and thrombolysis and surgical decompression is seldom indicated. The outcome depends on the cause and underlying comorbidities.

Platelet/Lymphocyte Ratio Predicted Long-Term Prognosis for Acute Upper Extremity Deep Vein Thrombosis from a Retrospective Study

Background

In this study, we aimed to determine the mortality risk factors and whether placement of a vena cava filter improves the prognosis of acute upper extremity deep vein thrombosis (UEDVT).

Methods

Clinical data and follow-up results were retrospectively analyzed. Cox regression analysis was conducted to identify the risk factors associated with all-cause mortality in all patients and subgroups of patients. Results are expressed as hazard ratio (HR) with 95% confidence intervals (95% CI). Receiver operating characteristic curves (ROC) were used to determine the optimal cut-off value. Kaplan-Meier survival curves were constructed and compared by the Log rank test.

Results

The study cohort comprised 109 patients of median age 56 years (47.5, 64.5). The median follow-up time was 25 months (8, 47): 39 patients (35.8%) had died by 12 months, 55 (50.5%) by 36 months, and 60 (55%) by the end of follow-up. Presence of malignancy (HR: 5.882, 95% CI: 2.128-16.667), D-dimer (HR: 1.56, 95% CI: 1.09-1.94), platelet/lymphocyte ratio (PLR; HR: 2.02, 95% CI: 1.15-3.54), and the systemic immune/inflammatory index (SII; HR: 1.471, 95% CI: 1.062-1.991) were identified as independent risk factors for mortality. Subgroup analysis of patients with malignancy determined gender (HR: 2.936, 95% CI: 1.599-5.393) and PLR (HR: 1.427,95% CI: 1.023-1.989) as independent risk factors. Kaplan-Meier analysis showed that the mortality rate was much higher in patients with malignancy, high D-dimer (≥ 0.92ug/mL), high PLR (≥ 291) and high SII (≥ 1487). However, there was no significant difference between patients with and without vena cava filters.

Conclusion

In this study, we identified PLR as an new independent predictor of mortality in patients with acute UEDVT. Emergency placement of a vena cava filter did not improve long-term prognosis.

Upper Extremity Deep Vein Thrombosis as the Tip of the Iceberg: Case Report and Review of Literature

Unprovoked venous thromboembolism (VTE) may be the earliest manifestation of cancer. According to recent studies, approximately 5% of patients with unprovoked VTE will be diagnosed with cancer within the first year of follow-up. Although screening extensively at the time of VTE diagnosis is attractive for clinicians, current clinical guidance documents suggest only a limited cancer screening strategy. The authors describe a rare case of Krukenberg tumor of the ovary arising from a primary gastric adenocarcinoma whose first sign was an unprovoked venous thrombosis of the upper extremity.

Subclavian Effort and Upper Limb Thrombosis – a Lesson Learned

Subclavian vein effort and upper limb thrombosis, known as the Paget-Schroetter syndrome (PSS), accounts for 30–40 % of spontaneous upper extremity deep vein thromboses (UEDVTs) and 10–20 % of all upper limb deep vein thromboses (DVTs). As complication of PSS include post-thrombotic syndrome and pulmonary embolism, early recognition and prompt initiation of anticoagulant treatment is crucial in the course of its treatment. PSS is associated with single or repeated physical activity of the upper limb, combined with obstruction of venous outflow resulting from anatomical alterations. A correct diagnosis, based on a range of imaging methods, and prompt initiation of local thrombolytic therapy, surgical decompression of the thoracic outlet (when necessary), and immediate initiation of anticoagulant treatment, aim to effectively restore the patient life quality, preventing post-thrombotic syndrome and recurrent thrombosis.

Preperitoneal Pelvic Packing is Associated With Increased Risk of Venous Thromboembolism

INTRODUCTION

Preperitoneal pelvic packing (PPP) is an important intervention for control of severe pelvic hemorrhage in blunt trauma patients. We hypothesized that PPP is associated with an increased incidence of deep vein thrombosis (DVT) and pulmonary embolism (PE).

METHODS

A retrospective cohort analysis of blunt trauma patients with severe pelvic fractures (AIS ≥4) using the 2015-2017 American College of Surgeons-Trauma Quality Improvement Program database was performed. Patients who underwent PPP within four hours of admission were matched to patients who did not using propensity score matching. Matching was performed based on demographics, comorbidities, injury- and resuscitation-related parameters, vital signs at presentation, and initiation and type of prophylactic anticoagulation. The rates of DVT and PE were compared between the matched groups.

RESULTS

Out of 5129 patients with severe pelvic fractures, 157 (3.1%) underwent PPP within four h of presentation and were matched with 157 who did not. No significant differences were detected between the two matched groups in any of the examined baseline variables. Similarly, mortality and end-organ failure rates were not different. However, PPP patients were significantly more likely to develop DVT (12.7% versus 5.1%, P = 0.028) and PE (5.7% versus 0.0%, P = 0.003).

CONCLUSIONS

PPP in severe pelvic fractures secondary to blunt trauma is associated with an increased risk of DVT and PE. A high index of suspicion and a low threshold for screening for these conditions should be maintained in patients who undergo PPP.

Edoxaban: front-line treatment for brachiocephalic vein thrombosis in primitive mediastinal seminoma: A case report and literature review

RATIONALE

Venous thromboembolism is a feared frequent complication of cancer with a 2-way relationship. Low molecular weight heparin is the mainstay of treatment. The use of direct oral anticoagulants is supported by established evidence for the treatment of deep vein thrombosis also in active cancer and they are prioritized over low molecular weight heparin for cancer-associated thrombosis according to current guidelines. However, upper limb deep vein thrombosis is poorly studied with scant data on the use of direct oral anticoagulants in noncatheter-related deep vein thrombosis. We report the case of a patient with noncatheter-related deep vein thrombosis and a rare tumor site effectively and safely treated with a direct oral anticoagulant, edoxaban, after lack of efficacy with low molecular weight heparin.

PATIENT CONCERNS

A 35-year-old man with primitive mediastinal seminoma presented at our Cardio-Oncology Unit for prechemotherapy assessment.

DIAGNOSIS

Persistent brachiocephalic deep vein thrombosis, despite full-dose enoxaparin, was detected at ultrasonography.

INTERVENTION

We decided to switch the anticoagulant treatment from enoxaparin to edoxaban.

OUTCOME

The 3-month ultrasonography showed almost total regression of the deep vein thrombosis without any adverse effects and a good patient compliance.

LESSONS

We conducted a literature review on upper limb deep vein thrombosis, since its management is challenging due to inconsistency of evidence. This report highlights the benefits of direct oral anticoagulants compared to low molecular weight heparins in cancer-associated thrombosis therapy in terms of efficacy, safety and ease of use.

Obesity increases the risk for upper extremity deep vein thrombosis and pulmonary embolism in patients with upper extremity central venous catheters

The morbidity and mortality of deep vein thrombosis (DVT) remain a significant burden for the healthcare system. The aim of this analysis was to examine the association of upper extremity central venous catheter (UECVC) and venous thromboembolism (UEVTE) with increasing body mass index (BMI) in a large database study and to further examine disposition. Inpatient data from the National Inpatient Sample from 2017 to 2019 were used to investigate the effect of obesity on patients diagnosed with DVT of the upper extremity or pulmonary embolism (PE) who had upper extremity venous central line placement. There was a total of 1690 cases of UEVTE and 3202 cases of PE within the sample. There was an increasing odds of UEVTE in the patients with UECVCs with increasing BMI. Patients with a BMI of 30-39, 40-49 and > 50 kg/m² were significantly different than those with BMI of <19 and 20-29 kg/m² in the UECVC group for UEVTE. This study demonstrated increased odds of UEVTE for patients with increased BMI. Practitioners should assume a greater risk for UEVTE and PE in patients with increased BMI when considering CVCs.

Venous Thromboembolism During Pregnancy and the Postpartum Period: Risk Factors, Diagnostic Testing, and Treatment

Importance

The risk of venous thromboembolism (VTE) increases during pregnancy and the postpartum period. Deep vein thrombosis is the most common VTE during pregnancy, but pulmonary embolism is typically of greater concern as it contributes to far higher morbidity and mortality. Diagnosis and treatment of VTE during pregnancy differ substantially from the general nonpregnant population.

Objective

This review describes the epidemiology, risk factors, clinical presentation, diagnosis, and treatment of VTE during pregnancy and the postpartum period.

Evidence Acquisition

First, we reviewed the VTE guidelines from professional societies in obstetrics, cardiology, hematology, emergency medicine, pulmonology, and critical care. Second, we examined references from these documents and used PubMed to identify recent articles that cited the guidelines. Finally, we searched PubMed and Google Scholar for articles published since 2018 that included terms for pregnancy and the epidemiology, risk factors, diagnostic imaging, or treatment of VTE.

Results

Venous thromboembolism risk increases throughout pregnancy and peaks shortly after delivery. More than half of pregnancy-related VTE are associated with thrombophilia; other major risks include cesarean delivery, postpartum infection, and the combination of obesity with immobilization. Most VTE can be treated with low molecular weight heparin, but cases of limb- or life-threatening VTE require consideration of thrombolysis and other reperfusion therapies.

Conclusions and Relevance

Venous thromboembolism is far more frequent in antepartum and postpartum women than age-matched controls, and clinical suspicion for VTE in this population should incorporate pregnancy-specific risks. Treatment of limb- or life-threatening antepartum or postpartum VTE requires multispecialty coordination to optimize maternal and fetal outcomes.

Antithrombotic Therapy After Venous Interventions: AJR Expert Panel Narrative Review

Interventions for thrombotic and nonthrombotic venous disorders have increased with technical advances and more trained venous specialists. Antithrombotic therapy is essential to clinical and procedural success; however, post-procedural therapeutic regimens exhibit significant heterogeneity due to limited prospective randomized data as well as incomplete mechanistic understanding of the critical factors driving long-term patency. Post-interventional antithrombotic therapy for thrombotic venous disorders should adhere to existing venous thromboembolism management guidelines, which include 3-6 months of therapeutic anticoagulation at minimum and consideration of extended therapy in patients with higher risk of thrombosis due to procedural or patient factors. The additive benefit of antiplatelet agents in the acute and intermediate period is unknown, having shown improved long-term stent patency in some retrospective studies. Dual and/or triple agent therapy should be limited based on individual risks of thrombosis and bleeding. The treatment of non-thrombotic disorders is more heterogeneous, though patients with limited flow, extensive stent material, or underlying prothrombotic states such as malignancy or chronic inflammation may benefit from single- or multi-agent antithrombotic therapy. However, the agent, dose, and duration of therapy remain indeterminate. Future prospective studies are warranted to improve patient risk stratification and standardize post-procedural antithrombotic therapy in patients receiving venous interventions.

Anticoagulant treatment for upper extremity deep vein thrombosis: A systematic review and meta-analysis

BACKGROUND

Data on anticoagulant treatment for upper extremity deep vein thrombosis (UEDVT) are largely derived from studies on usual site venous thromboembolism (VTE).

OBJECTIVES

The objective of this meta-analysis was to evaluate the efficacy and safety of anticoagulant therapy for UEDVT.

PATIENTS/METHODS

A systematic search of MEDLINE and EMBASE was conducted for studies including patients with UEDVT. Primary outcomes were recurrent VTE and major bleeding. Secondary outcomes included clinically-relevant non-major bleeding and all-cause mortality. Summary estimates with 95% confidence intervals (CIs) were calculated by random-effect meta-analysis.

RESULTS

A total of 1473 patients from 11 prospective and nine retrospective studies were included. Sixty percent of patients had an indwelling catheter and 56.1% had cancer. Anticoagulant treatment consisted of direct oral anticoagulants, low molecular weight heparin followed by vitamin K antagonists, and low molecular weight heparin alone in 45.1%, 35.0%, and 19.9% of patients, respectively. During a median follow-up of 13 months, recurrent VTE occurred in 3% of patients (95% CI: 2-4; 21/1334 patients), major bleeding in 3% (95% CI: 2%-5%; 29/1235 patients), clinically-relevant non-major bleeding in 4% (95% CI: 3-6; 40/1075 patients), and all-cause mortality in 9% (95% CI: 5-15; 108/1084 patients). Rates of these outcomes were not significantly different between patients with or without cancer, patients with or without an indwelling catheter, and among those receiving different anticoagulant treatments.

CONCLUSIONS

In patients with UEDVT, anticoagulant treatment is associated with a low risk of recurrent VTE and a nonnegligible risk of major bleeding.

Detection of upper extremity deep vein thrombosis by magnetic resonance non-contrast thrombus imaging

BACKGROUND

Compression ultrasonography (CUS) is the first-line imaging test for diagnosing upper extremity deep vein thrombosis (UEDVT), but often yields inconclusive test results. Contrast venography is still considered the diagnostic standard but is an invasive technique.

OBJECTIVES

We aimed to determine the diagnostic accuracy of magnetic resonance noncontrast thrombus imaging (MR-NCTI) for the diagnosis of UEDVT.

METHODS

In this international multicenter diagnostic study, we prospectively included patients with clinically suspected UEDVT who were managed according to a diagnostic algorithm that included a clinical decision rule (CDR), D-dimer test, and diagnostic imaging. UEDVT was confirmed by CUS or (computed tomography [CT]) venography. UEDVT was excluded by (1) an unlikely CDR and normal D-dimer, (2) a normal serial CUS or (3) a normal (CT) venography. Within 48 h after the final diagnosis was established, patients underwent MR-NCTI. MR-NCTI images were assessed post hoc by two independent radiologists unaware of the presence or absence of UEDVT. The sensitivity, specificity, and interobserver agreement of MR-NCTI for UEDVT were determined.

RESULTS

Magnetic resonance noncontrast thrombus imaging demonstrated UEDVT in 28 of 30 patients with UEDVT and was normal in all 30 patients where UEDVT was ruled out, yielding a sensitivity of 93% (95% CI 78-99) and specificity of 100% (95% CI 88-100). The interobserver agreement of MR-NCTI had a kappa value of 0.83 (95% CI 0.69-0.97).

CONCLUSIONS

Magnetic resonance noncontrast thrombus imaging is an accurate and reproducible method for diagnosing UEDVT. Clinical outcome studies should determine whether MR-NCTI can replace venography as the second-line imaging test in case of inconclusive CUS.

Upper extremities deep vein thrombosis treated with oral direct anticoagulants: A prospective cohort study

BACKGROUND

Limited data are available on the role of direct oral anticoagulants (DOACs) for the treatment of upper extremities deep vein thrombosis (UEDVT).

OBJECTIVES

The aim of this study was to assess the effectiveness and safety of DOACs in the treatment of UEDVT.

METHODS

Patients with an objectively confirmed acute UEDVT treated with DOACs were merged from prospective cohorts to a collaborative database. Primary study outcomes were recurrent venous thromboembolism (VTE) and major bleeding occurring during DOAC treatment.

RESULTS

Overall, 188 patients were included in the study: mean age 52.4 ± 20.4 years, males 43.6%, patients with active cancer 29.2%. Twenty-nine percent of patients had 2 or more risk factors for VTE, 33.0% had catheter-related or pacemaker-related UEDVT. In 13.8% of patients, DOACs were started one month after UEDVT diagnosis or later. Active cancer was an independent predictor for delayed initiation of DOACs (OR 8.1, 95% CI 3.0-22.2). Mean duration of treatment with DOACs was 5.1 ± 2.8 months. During treatment with DOACs, recurrent VTE occurred in 0.9 per 100 patient-year, major bleeding in 1.7 and all-cause deaths in 6.0 per 100 patient-year. No fatal bleeding or fatal VTE recurrence were observed. During 232.1 patient-years of follow-up after DOAC withdrawal, recurrent VTE occurred in 3.0 per 100 patient-year. The 2019 ESC categories for risk of VTE recurrences were able to discriminate patient groups at different risk of events in the on and off-treatment periods.

CONCLUSIONS

Our data support the feasibility as well as the effectiveness and safety of DOACs for the treatment of acute UEDVT.

Management of upper extremity deep vein thrombosis: an updated review of the literature

Upper extremity deep vein thrombosis (UEDVT) represents about 5-10% of all cases of deep vein thrombosis (DVT) with a steadily increasing incidence mostly due to the high prevalence of cancer and frequent use of intravascular devices such as central venous catheters and pacemaker. In primary UEDVT, the venous outflow obstruction and subsequent thrombosis are related to congenital or acquired anatomical abnormalities, whereas secondary UEDVT is often associated with malignancy or indwelling lines. A considerable proportion of patients with UEDVT develops serious complications such as recurrent thrombosis, post-thrombotic syndrome, and pulmonary embolism, therefore timely diagnosis and adequate treatment are of crucial importance. Despite sharing many similarities with lower extremity DVT, UEDVT has distinctive features requiring specific diagnostic and therapeutic approaches. The present review discusses the latest evidence on the epidemiology, diagnosis, and treatment of UEDVT, and provides management indications which may help guide clinical decision making.

Direct oral anticoagulants for unusual-site venous thromboembolism

Direct oral anticoagulants (DOACs) are currently the preferred oral anticoagulant treatment for most of the patients with deep vein thrombosis of the lower extremities and/or pulmonary embolism. DOACs have several advantages over vitamin K antagonists, such as availability of fixed dosages, fewer drug interactions, faster onset of action, shorter half-life, and lower risk of major and intracranial bleeding. Although the evidence on the use of DOACs in patients with unusual-site venous thromboembolism (VTE) is limited to a few, small randomized controlled trials, these drugs are increasingly used in clinical practice, and several observational cohort studies have been published recently. This narrative review will describe the latest evidence for the use of the DOACs in patients with thrombosis in atypical locations (splanchnic, cerebral, upper extremity, ovarian, and renal vein thrombosis) and will provide some practical advice for their use in patients with unusual-site VTE.