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What’s the best way to manage upper extremity venous thrombosis?

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References

EVIDENCE-BASED ANSWER

STANDARD MANAGEMENT IS BEST: Start with unfractionated heparin or low-molecular-weight heparin and follow with long-term therapy with a vitamin K antagonist (strength of recommendation [SOR]: C, expert consensus and case reports). Some evidence supports thrombolytic therapy, placement of a superior vena cava filter, or surgical thrombectomy in selected patients (SOR: C, expert consensus and case reports). Whether to remove venous catheters during initial treatment for catheter-induced venous thrombosis remains unclear, because limited studies address this issue specifically (SOR: C, expert consensus and case reports).

Evidence summary

Upper extremity venous thrombosis (UEVT)—which typically refers to thrombosis of the brachial, axillary, or subclavian veins—accounts for approximately 10% of all cases of venous thromboembolism.1 UEVT can occur spontaneously (Paget-Schroetter syndrome) or develop as a complication of cancer or in-dwelling medical devices (such as long-term central venous catheters).

Although significant evidence-based data exist on treatment of lower extremity venous thrombosis, no good-quality studies specifically address management of UEVT. Review of the current literature revealed several small studies that compared various treatment strategies.

Thrombolytics may work better than anticoagulants in some patients
A small retrospective study randomized 20 patients with UEVT to either treatment with anticoagulant therapy with heparin and warfarin (n=11) or thrombolytic therapy (n=9).2 After a mean follow-up period of 81.7 months for the anticoagulation group and 52.1 months for the thrombolytic group, 4 more patients in the thrombolytic group achieved complete clinical recovery and vein patency than in the anticoagulant group (P=.04). When patients who recovered completely were added to those who showed some clinical improvement, 89% of the thrombolytic therapy group had satisfactory outcomes, compared with 36% of the anticoagulant group (P=.028).

Another small retrospective study looked at 10 consecutive patients with UEVT who were treated with either anticoagulant therapy (n=6) or thrombolytics (n=4).3 Fifty percent of patients treated with anticoagulants experienced partial or complete improvement in symptoms, whereas 100% of patients treated with thrombolytics had partial or complete resolution of both symptoms and thrombi.

Overall, both studies raise the possibility that thrombolytic therapy is more effective than anticoagulation therapy in certain patients. The studies evaluated only active patients, 23 to 58 years of age, who had no contraindications to thrombolytic therapy. Neither study reported data on long-term outcomes such as recurrences, bleeding, or post-thrombotic sequelae.

Surgery may avoid long-term anticoagulation
Two case studies evaluated treatment of UEVT with thrombolytic therapy followed by various surgical interventions (angioplasty, thrombectomy, decompression via first rib resection or anterior scalenectomy, and venous bypass).4,5 The first study reported that 8 of 9 patients who underwent first-rib resection and 1 of 2 who underwent scalenectomy were free of residual symptoms at follow-up (mean 2 years, range 6 months to 5 years).4 All patients were treated with thrombolytics before surgery.

The second study demonstrated that 50% of the patients treated with a surgical intervention without thrombolysis had complete symptom relief, while the remaining 50% reported relief from pain but still had occasional swelling.5 Although more invasive, surgery may eliminate the need for long-term anticoagulation therapy and enable a more rapid return to normal activities.

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