Venous Thrombosis of the Upper Extremities

The goals of treating patients with upper-extremity deep vein thrombosis (UEDVT) are to relieve acute symptoms of venous occlusion, prevent pulmonary embolism, reduce the likelihood of recurrent thrombosis, and avoid the development of postphlebitic syndrome. Although the details of management differ, depending on the underlying cause and precipitating factors, anticoagulant therapy should be the first-line treatment of choice in all cases. For patients with primary or idiopathic UEDVT (Paget-von Schroetter syndrome), aggressive measures including catheter-directed thrombolysis, vascular procedures (eg, balloon angioplasty, stenting, filter), and surgical maneuvers (eg, first rib resection) have been advocated by some surgeons, but none of these high-risk interventions has been evaluated properly in prospective controlled trials. In contrast, for patients with catheter-associated central venous thrombosis (CACVT), or other secondary cases of UEDVT, many clinicians simply withdraw the catheter and avoid anticoagulant therapy. Because well-designed clinical trials are lacking, recommendations about the management of UEDVT are derived from descriptive studies and case series. Until further research identifies the natural history and optimum management of UEDVT, it seems reasonable to base treatment on anticoagulant regimens with proven effectiveness in lower-extremity deep vein thrombosis (LEDVT). The use of additional intervention(s) should be reserved for carefully selected patients.