What is Upper Extremity Deep Venous Thrombosis?
Deep vein thrombosis (DVT) is a condition that has been researched a lot. It typically affects the lower parts of the body, like the legs. But nowadays, due to an increased use of devices – such as central venous catheters (tubes put into a large vein in your neck, chest or groin to give medication), heart pacemakers and defibrillators (devices that can correct an irregular heart beat), and PICCs (tubes inserted in the arm to reach large veins near the heart to give treatments) – there are more cases of DVT affecting the upper parts of the body like the arms. This makes it necessary for healthcare professionals to be more aware or suspicious about spotting it.
Patients may not show any signs of having DVT, but a common symptom is a swelling in the affected limb. The most dangerous risk with any DVT, whether it’s in the upper or lower body, is a pulmonary embolus (PE). This is a blockage in one of the lung’s blood vessels that can be life threatening. Spotting a DVT and taking the right steps to treat it quickly can stop serious harm to the patient and even save their life.
What Causes Upper Extremity Deep Venous Thrombosis?
Upper extremity DVT (Deep Vein Thrombosis) affects veins in the upper body, like the ones in the arms, near the shoulder, and around the collarbone. Less frequently, it can also involve the veins that drain blood from the brain, called the internal jugular veins, and the veins in the wrist and hand (the radial and ulnar veins).
There are 2 types of upper extremity DVT: primary and secondary. The primary type is also known as Paget-Schroetter syndrome (PSS). This typically happens in the arm that younger, sports-oriented people use most. It’s commonly seen in activities where the upper body is excessively and repeatedly moved, such as wrestling, swimming, gymnastics, and sports where you’re frequently throwing a ball, like football, baseball, and basketball.
The secondary type of upper extremity DVT usually happens in people who have had a central venous catheter (a tube inserted into a large vein for medical treatment or procedures) or people with cancer.
Risk Factors and Frequency for Upper Extremity Deep Venous Thrombosis
Upper extremity DVTs, or blood clots in the upper limbs, make up 5% to 10% of all DVTs and this number is increasing every year. Most of these patients have a central line, a tube used to administer medication or fluids. However, only 10% to 20% of cases are due to Paget-Schroetter Syndrome (PSS), a rare condition causing blood clots in the upper arms. Among patients with a central catheter, 14% to 23% can develop an upper extremity DVT. Such DVTs can lead to a pulmonary embolism (PE), or a blood clot in the lungs, in up to 6% of cases, compared to 15% to 30% for DVTs in the lower limbs. Moreover, less than 5% of upper extremity DVTs result in post-thrombotic syndrome, a condition with long-term complications, compared to over 50% in the case of lower extremity DVTs.
- Between 5% to 10% of all DVTs are upper extremity DVTs and this is increasing every year.
- Most of these patients have a central line, but only 10% to 20% have Paget-Schroetter Syndrome (PSS).
- Patients with a central catheter have a 14% to 23% chance of developing an upper extremity DVT.
- Up to 6% of upper extremity DVTs can lead to a pulmonary embolism, compared to 15% to 30% of lower extremity DVTs.
- Less than 5% of upper extremity DVTs result in post-thrombotic syndrome, compared to over 50% of lower extremity DVTs.
Signs and Symptoms of Upper Extremity Deep Venous Thrombosis
Upper extremity DVT, or Deep Vein Thrombosis in the arm, is a condition that can usually be identified with a detailed personal history and physical examination, followed by imaging studies for confirmation. Most people with this condition experience swelling and discomfort in their arm. It’s important to take note of how long the swelling has been there, as well as any previous episodes of DVT.
Patients might also report a feeling of heaviness in the arm. The physical exam could reveal redness in the limb and visible veins across the chest and arm – a symptom known as Urschel’s sign. It’s also important to consider a patient’s personal and family history of blood clotting disorders, as well as any previous attempts to insert a central venous catheter.
In some cases, patients might have what’s known as “Primary Subclavian Vein Thrombosis”, where severe pain and swelling in the arm come on suddenly. This often happens in the dominant arm of young patients who do activities that involve a lot of repetitive arm movements, like pitching a baseball.
In all patients with suspected upper extremity DVT, it’s also essential to check the pulses in the affected limb. A limb that’s pale, cool to the touch, and has a mottled appearance may not be getting enough blood, a condition called “ischemia”. Additionally, any loss of movement or sensation in the limb is an emergency and requires immediate medical attention.
Testing for Upper Extremity Deep Venous Thrombosis
If your doctor suspects that you have a Deep Vein Thrombosis (DVT) in your arm, they’ll start by asking about your medical history and doing a physical exam. If they need to confirm this suspicion, they’re likely to use a test called compression duplex ultrasonography. This test is pretty good at catching DVT in the arm—it catches it about 97% of the time and only gives a wrong result about 4% of the time—so it’s often the go-to.
There are some other tests that can do an even better job than the ultrasound, like magnetic resonance and computed tomographic venography, but these might not be used as often because they cost more, expose you to radiation, and/or might not be available everywhere. That’s why most doctors continue to prefer the ultrasound to diagnose DVT in the arm: it’s very good, non-invasive, cheaper, and more widely available.
While lab tests aren’t necessary to diagnose DVT, your doctor might ask for a coagulation assay. This is a kind of blood test that helps the doctor figure out if your blood has a tendency to clot more than usual. If your doctor suspects you have upper extremity DVT but the suspicion is not very strong, they might order a d-dimer test. If this test is negative, it means that you likely don’t have a DVT.
Lastly, if the DVT in your arm complicates and leads to a pulmonary embolism (PE), a sudden blockage in a lung artery, you might have chest pain and difficulty breathing. In cases like this, your doctor might do an Electrocardiogram (ECG) because this test often shows an increased heart rate.
Treatment Options for Upper Extremity Deep Venous Thrombosis
The process of treating Deep Vein Thrombosis (DVT) in the upper extremities (arms) can depend on the patient’s symptoms. Most people experience swelling in their arm, often linked to a central venous catheter (a tube inserted into a large vein to deliver medications or nutrients). The American College of Chest Physicians suggests doctors should first decide if the catheter is still necessary. If it is needed, it should stay in place, and the patient should start their anticoagulation therapy (treatment to prevent blood clots). If not, it should be removed after the patient has been on the anticoagulation therapy for 3 to 5 days.
In the hospital, patients can be given warfarin in combination with heparin to treat DVT. Heparin is a medication that prevents blood clots from getting bigger and stops new clots from forming. Patients should usually continue taking warfarin for 3 to 6 months after being diagnosed. Recently, other newer blood thinners (e.g., dabigatran) have been studied for treating upper extremity DVT, and early results suggest they could be effective and safe.
If the patient has Paget-Schroetter syndrome (PSS), the approach is slightly different because it typically involves sudden blood clot formation. These patients often have significant pain and swelling and may need intravenous catheter-directed thrombolysis (a procedure that dissolves blood clots). This can help with the pain and swelling but does not address the root cause. Therefore, patients with PSS usually need urgent surgery to remove the first rib. This operation offers more room in the thoracic outlet (space between the collarbone and the first rib) and helps avoid future compression of the nerves, blood vessels and muscles in that area.
What else can Upper Extremity Deep Venous Thrombosis be?
Swelling of the arm or leg, a common symptom of Deep Vein Thrombosis (DVT), can also be a sign of other medical conditions.
The following conditions can show signs similar to DVT:
- Cellulitis: This is a skin infection that can cause vein congestion, mimicking DVT. Symptoms include a starting point for the infection such as a cut or insect bite, redness and discomfort around this area.
- Necrotizing Fasciitis: Also known as flesh-eating disease, this serious bacterial skin infection can show signs like DVT but may also have blisters, fever, increased white blood cell count, raised inflammation markers, and low sodium in blood. Early diagnosis and prompt surgical intervention can aid to prevent death and loss of limb.
- Superficial Thrombophlebitis: This condition involves inflammation of a superficial vein, usually in the arm. It usually get better with rest, heat application, and anti-inflammatory drugs. However, if infection is present, it can lead to serious health issues and demands immediate treatment, including surgical removal of the infected vein. This is more common among those who have significant burns or use intravenous drugs.
- Lymphedema: Swelling due to the blockage of lymphatic system, often as a result of a surgical procedure targeting the lymph nodes in the underarm region, can mimic signs of DVT.
Remember, if you experience swelling in your arm or leg, it is important to get medical attention – it could be DVT or another of these conditions, all of which need medical care.
What to expect with Upper Extremity Deep Venous Thrombosis
How well a patient recovers varies depending on whether their upper extremity Deep Vein Thrombosis (DVT), or blood clot in the arm, is a primary or secondary form. Those with the primary form, known as PSS, are usually young and overall healthy people, whereas those with secondary forms might have other serious illnesses like cancer and are often already in the hospital for other reasons.
In a large study, researchers found that about 11% of patients with DVT in the arm passed away within three months. Among patients also diagnosed with cancer, this rate went up to 28%. Other complications can arise too. For instance, a Pulmonary Embolism (PE), which is when a blood clot travels to the lungs, can happen in up to 6% of cases, usually in those with the secondary form of DVT in the arm.
Another complication, known as post-thrombotic syndrome, happens in less than 5% of arm DVT cases. This condition can cause long-term swelling, pain, and a heavy feeling in the limb. However, up to 45% of PSS patients can develop this syndrome, leading to changes in skin color and the growth of new blood vessels around the blocked ones, a process known as collagenization. To prevent and treat post-thrombotic syndrome, doctors are exploring the effectiveness of compression therapy, which involves applying pressure to the affected area to reduce swelling and improve blood flow.
