Breaking the blockage by advancing treatment strategies for upper extremity deep vein thrombosis

Catheter-directed thrombolysis (CDT) and percutaneous mechanical thrombectomy (PMT) are established endovascular strategies for the treatment of deep vein thrombosis (DVT). However, comparative outcomes data specific to upper extremity DVT (UEDVT) remain limited. Given that PMT is associated with improved outcomes in lower extremity DVT, we hypothesized that PMT would be associated with improved mortality and morbidity compared with CDT in treating UEDVT. This study evaluates outcomes associated with CDT vs PMT for UEDVT and Paget-Schroetter syndrome (PSS).

A retrospective cohort study was conducted using the TriNetX US Collaborative Network. Patients diagnosed with UEDVT who underwent CDT (n = 1399) or PMT (n = 1406) between 2005 and 2025 were identified. Patients who received both modalities were excluded. Propensity score matching was performed, yielding 1198 patients in each cohort (n = 2396) balanced across demographics, comorbidities (including malignancy, type 2 diabetes mellitus, hypertension, coagulation disorders, and end-stage renal disease), and medication use. A subgroup analysis was performed for patients with PSS who underwent CDT or PMT, with similar propensity score matching (n = 280). Thirty-day and 1-year outcomes were compared using odds ratios (ORs).

After matching, pulmonary embolism rates did not differ significantly between groups at 30 days or 1 year. Compared with PMT, CDT was associated with significantly higher OR of 30-day mortality (OR, 1.82), myocardial infarction (OR, 2.43), ischemic stroke (OR, 9.11), transfusion (OR, 1.95), 30-day readmission (OR, 2.34), and intracranial hemorrhage (OR, 6.59). These differences persisted at 1 year, with CDT demonstrating a significantly higher OR for mortality (OR, 1.56), myocardial infarction (OR, 2.01), ischemic stroke (OR, 6.69), and intracranial hemorrhage (OR, 3.93). Repeat intervention occurred more frequently in the PMT cohort at 1 year (12.2% vs 7.68%; OR, 1.67). Among patients with PSS, 1-year mortality was low in both groups. There were no significant differences in pulmonary embolism or subsequent first rib resection rates between CDT and PMT treated patients. However, repeat intervention occurred more frequently in the PMT cohort (21.4% vs 10.7%; OR, 2.27).

In this national propensity-matched analysis, CDT for UEDVT was associated with higher 30-day and 1-year morbidity and mortality compared with PMT, whereas PMT was associated with a greater need for repeat intervention. In patients with PSS, CDT and PMT demonstrated similar clinical outcomes, although PMT was associated with higher reintervention rates. These findings suggest differential risk profiles between the two treatment strategies and may inform procedural selection in the management of UEDVT.