0
Clinical Investigations: CLOTS |

Upper Extremity Deep Venous Thrombosis* FREE TO VIEW

Syed Mustafa; Paul D. Stein; Kalpesh C. Patel; Todd R. Otten; Robert Holmes; Allen Silbergleit
Author and Funding Information

*From the St. Joseph Mercy Oakland, Pontiac, MI.

Correspondence to: Paul D. Stein, MD, FCCP, St. Joseph Mercy Oakland, 44555 Woodward Ave, Suite 107, Pontiac MI, 48341-2985; e-mail: steinp@trinity-health.org



Chest. 2003;123(6):1953-1956. doi:10.1378/chest.123.6.1953
Text Size: A A A
Published online

Purpose: To determine the prevalence of symptomatic upper extremity deep venous thrombosis (DVT) and its association with symptomatic acute pulmonary embolism (PE) in a community teaching hospital.

Methods: The prevalence of symptomatic upper extremity DVT was evaluated retrospectively at a community teaching hospital during the 2-year period between July 1, 1998, and June 30, 2000. Patients were identified by International Classification of Disease, ninth revision, clinical modification, discharge codes and a review of the records of all compression Doppler ultrasonograms, venograms of the upper extremities, and magnetic resonance angiograms of the upper extremities.

Results: Symptomatic upper extremity DVT was diagnosed in 65 of 44,136 patients of all ages (0.15%) [or 64 of 34,567 adult patients ≥ 20 years of age; 0.19%]. In seven patients, the upper extremity DVT was shown by venography to extend proximally to the brachiocephalic vein. Among these, the DVT extended to the superior vena cava in two. All of the patients received anticoagulant therapy for upper extremity DVT. No patients developed symptomatic PE. Central lines at the site of the upper extremity DVT were inserted in 39 of 65 patients (60%). Cancer was diagnosed in 30 of 65 patients (46%), 23 cancer patients also had central lines, and 19 patients (29%) had upper extremity DVT with no apparent cause. All patients had swelling of the upper extremities. Erythema over the affected site was present in four patients (6%). Pain was present in 26 patients (40%), although some discomfort due to swelling was present in all patients.

Conclusion: Symptomatic upper extremity DVT is not uncommon in hospitalized patients. Symptomatic PE resulting from upper extremity DVT was not observed in these patients, all of whom were treated with anticoagulants.

Prior to 1967, thrombosis of the upper extremities constituted < 2% of cases of deep venous thrombosis (DVT).1 Since the 1970s there has been an increased recognition of upper extremity DVT.26 The increased incidence was attributed to the use of central venous catheters and transvenous pacemakers.2

Upper extremity DVT in the past had been considered to be benign and self-limited.7 More recent data have suggested that this is not the case.710 A systematic review of the literature in 199111 showed a 9% incidence of symptomatic pulmonary embolism (PE) in patients with upper extremity DVT, with half of the patients receiving diagnoses by objective tests. A review in 1991 by others12 showed a 7% incidence of symptomatic PE in patients with upper extremity DVT, with none of the patients receiving diagnoses that were confirmed by objective tests. More recently, symptomatic PE diagnosed by ventilation/perfusion lung scans was observed in 7% of patients with upper extremity DVT.7 Routine ventilation/perfusion lung scans in patients with upper extremity DVT had high-probability interpretations in 13% of patients.12

The prevalence of symptomatic upper extremity DVT among hospitalized patients has, to our knowledge, been evaluated only once. Kroger and associates,3 in 1998, reported that approximately 0.2% of hospitalized patients had upper extremity DVT. We reviewed the cases of upper extremity DVT in a community teaching general hospital to determine its prevalence and the prevalence of associated PE.

We used two sources for the identification of patients with DVT of the upper extremity at St. Joseph Mercy Oakland (Pontiac, MI), during a 2-year period from July 1, 1998, through June 30, 2000. One source of identification of patients was discharge diagnostic codes using the International Classification of Disease, ninth revision, clinical modification, diagnostic codes.13 The other sources were computer-generated lists of all patients who had undergone Doppler ultrasound of the upper extremity, contrast venography of the upper extremity, or magnetic resonance angiography of the upper extremity. The reports of each patient were reviewed, and cases with positive findings were included in the study. Among the patients with objective evidence of thromboembolic disease of the upper extremity, 14 were identified by contrast venography and the remainder were identified by compression ultrasound with Doppler. None were identified by magnetic resonance angiography. Those who were identified by contrast venography had compression ultrasound with Doppler in addition. Patients who had thrombosis only of a superficial vein of an upper extremity were excluded.

A computer search was made for all patients who had one of the following International Classification of Disease, ninth revision, clinical modification, hospital discharge diagnostic codes: 451.82, phlebitis and thrombophlebitis of superficial veins of upper extremities (eg, antecubital, basilic, and cephalic); 451.83, phlebitis and thrombophlebitis of deep veins of upper extremities (eg, brachial, radial, and ulnar veins); 451.84, phlebitis and thrombophlebitis of upper extremities unspecified; and 451.89, phlebitis and thrombophlebitis other (eg, axillary, jugular, subclavian, and breast). Confirmation of the diagnosis of thrombosis of the upper extremity DVT was made by reviewing the medical records of each patient for a report of a compression Doppler ultrasound, contrast venogram, or magnetic resonance angiogram. If the patient was hospitalized on more than one occasion for upper extremity DVT, we included data only from the first hospitalization. None had PE on subsequent hospitalizations.

The diagnosis of DVT of the upper extremity was made with real-time, B-mode ultrasound scanning using a commercially available scanner with a 7.4-MHz sector-imaging transducer. With the patient in the supine position, the internal jugular, subclavian, axillary, brachial, cephalic, basilic, radial, and ulnar veins were evaluated for the presence of pathologic intraluminal echoes or noncompressibility. Noncompressibility was assessed by compressing the vein with the transducer probe while observing changes in the caliber of the vein on the video monitor. According to Prandoni and associates,10 the lack of full compressibility showed a 96% sensitivity and a 94% specificity. The absence of a color signal within the lumen of the vein, or the direct visualization of an intraluminal color-filling defect showed a sensitivity of 100% and specificity of 93% for upper extremity DVT. The sensitivity and specificity of compression ultrasonography and color flow Doppler imaging were comparable. More recently, Baarslag and associates14 reported that the sensitivity of duplex ultrasonography was 82% and that the specificity was also 82%. These values were lower than those reported by Prandoni and associates.10 The isolated noncompressibility of a venous segment was relatively uncommon but, when present, correlated with the presence of DVT.14 An intraluminal thrombus was highly correlated with the presence of DVT.14

Venography of the upper extremity was obtained during the injection of contrast material into an ipsilateral peripheral vein. Contrast material was followed into the superior vena cava. The diagnosis of DVT required the visualization of an intraluminal filling defect.

The prevalence of DVT of the lower extremities and the prevalence of PE during this period at the same hospital have been reported.1516 The methods for the identification of DVT and of PE were described.1516 We used these databases to determine whether any of the patients with upper extremity DVT also had DVT of the lower extremities or PE. A diagnosis of PE was made on the basis of a high-probability interpretation of the ventilation/perfusion lung scan or positive pulmonary angiographic findings in patients with symptoms that were suggestive of PE. The ventilation/perfusion lung scans were interpreted on the basis of the revised Prospective Investigation of Pulmonary Embolism Diagnosis study criteria.17 The pulmonary angiograms required an intraluminal filling defect or the identification of an embolus obstructing a vessel for the diagnosis of PE.18 DVT of the lower extremities was diagnosed by a lack of vein compressibility during compression ultrasonography in patients with symptoms of lower extremity DVT.

St. Joseph Mercy Oakland is a general hospital with a reported census of 269 patients.19 It is designated by the American College of Surgeons as a teaching hospital category cancer center. It is also a trauma center, but it is not a burn center.

During the 2-year period of study, 44,136 patients were admitted to the hospital, including newborns. The prevalence of upper extremity DVT was 65 of 44,136 patients (0.15%). One patient was 18 years of age. She had thrombosis of the left subclavian vein associated with leukemia and a central venous access line. All others were adults (ie, ≥ 20 years of age). The prevalence of upper extremity DVT in adults was 64 of 34,567 patients (0.19%). Upper extremity DVT in adults was accompanied by DVT of the lower extremities in two patients.

Among all patients with DVT of the upper extremity, 30 (46%) were men and 35 (54%) were women. The left side was involved in 38 patients (58%), the right side was involved in 24 patients (37%), and there was bilateral involvement in 3 patients (5%).

Proximal upper extremity DVT involved the subclavian vein in 48 patients (74%), and the axillary vein in 25 patients (38%). The internal jugular vein was included among patients with upper extremity DVT, and it was involved in 29 patients (45%). Nine patients (14%) had involvement only of a deep distal vein (brachial veins, six patients; ulnar vein alone, one patient; radial vein alone, one patient; and both radial and ulnar veins, one patient). In seven patients, the upper extremity DVT was shown by venography to extend proximally to the brachiocephalic vein. Among these patients, two patients had extension to the superior vena cava. In addition to these patients with DVT of the upper extremity, 16 patients had involvement only of the superficial veins of the upper extremity. These patients were not included in the various computations.

All of the patients with upper extremity DVT received therapy with anticoagulant agents. None developed PEs. Cancer was diagnosed in 30 of 65 patients (46%). Central venous access lines on the side of the upper extremity DVT were inserted in 39 of 65 patients (60%), and 23 of 65 patients (35%) had central lines in addition to cancer. Six patients had arteriovenous shunts on the side of the upper extremity DVT. There were three additional patients who had thrombosis only of the arteriovenous shunt without the involvement of contiguous veins. These patients were not included among the patients whom we reported. The upper extremity DVTs in 19 patients (29%) had no apparent cause, although all patients had developed upper extremity DVT in the hospital and had received IV infusions of medications.

Three of 39 patients (8%) who had central venous access lines had been receiving antithrombotic prophylaxis with low-dose warfarin (1 to 2 mg per day) prior to developing upper extremity DVT. Among the 30 patients with venous access lines and upper extremity DVT for whom there were data available, the lines had been in place for 3 to 14 days in 90%.

Swelling of the arm was the most prevalent sign and was present in all patients with upper extremity DVT. Pain was present in 26 of 65 patients (40%). Some discomfort due to the swelling was present in all. Four of 65 patients (6%) had erythema over the affected site. One patient with internal jugular vein thrombosis had swelling of the neck. He also had thrombosis of the superior vena cava.

Seven to 9% of patients with upper extremity DVT have been reported to experience acute PE.1112 Most PEs (94%) in patients with upper extremity DVT occurred in untreated patients.8 We did not observe PE in any of our patients with upper extremity DVT. However, all patients with upper extremity DVT received therapy with anticoagulants after the diagnosis was made.

The prevalence of upper extremity DVT that we observed among hospitalized patients was the same as that reported by Kröger and associates.3 As the use of central venous lines and pacemaker wires has increased, their role in the etiology of upper extremity DVT has become prominent.3,2023 This association was clearly evident in our study, in which 60% of our patients had central venous access lines. Nearly the same percentage (55%) was reported by others.14 Others have reported the use of indwelling catheters in 28 to 33% of patients with upper extremity DVT.3,8,20

An association of malignancy with upper extremity DVT, which we observed in 45% of patients, is also well-established24 and was reported in 64% of patients by Baarslag and associates.14 A hypercoagulable state also may be associated with proximal upper vein thrombosis,25 but our patients generally were not evaluated for this. Campbell and associates,2 among 25 patients with upper extremity DVT, observed swelling in 96%, pain in 76%, discoloration in 52%, prominent veins in 52%, and a palpable cord in 8%.

During the 2-year period of this investigation, 10 of 34,567 patients (0.03%) had thrombosis of the superior vena cava or brachiocephalic vein, unaccompanied by DVT of the subclavian or axillary veins or more distal veins of the upper extremity and unaccompanied by DVT of the lower extremity.26 During the same period, DVT of the lower extremity was diagnosed in 271 of 34,567 patients (0.78%).16 Among the patients on whom we are now reporting, DVT of the upper extremity, sometimes accompanied by thrombosis of the superior vena cava or brachiocephalic vein but unaccompanied by proximal DVT of the lower extremity, was observed in 62 of 34,567 adult patients (0.18%). Among all patients with symptomatic DVT, thrombosis of the superior vena cava or brachiocephalic vein alone was seen in 10 of 343 patients (3%), upper extremity DVT unaccompanied by proximal lower extremity DVT but sometimes accompanied by thrombosis of the superior vena cava or brachiocephalic vein was seen in 62 of 343 patients (18%), and proximal lower extremity DVT was seen in 271 of 343 patients (79%).

In summary, upper extremity DVT is not uncommon in hospitalized patients (ie, 0.18% of adult admissions), constituting 18% of all cases of DVT. Pain and swelling of the upper extremity are generally present in those in whom a diagnosis is made. The etiology is usually malignancy, a central venous access line, or a combination of the two. Our findings suggest that upper extremity DVT is important in the spectrum of thromboembolic disease.

Abbreviations: DVT = deep venous thrombosis; PE = pulmonary embolism

We thank Rebecca G. Estrellado for her assistance.

Coon, WW, Willis, PW, III (1967) Thrombosis of axillary and subclavian veins.Arch Surg94,657-663. [PubMed] [CrossRef]
 
Campbell, CB, Chandler, JG, Tegtmeyer, CJ, et al Axillary, subclavian, and brachiocephalic vein obstruction.Surgery1977;82,816-826. [PubMed]
 
Kröger, K, Schelo, C, Rudofsky, G Colour Doppler sonographic diagnosis of upper limb venous thromboses.Clin Sci (Lond)1998;94,657-661. [PubMed]
 
Huber, P, Häuptli, W, Schmitt, HE, et al Die Axillar-Subclaviavenenthrombose und ihre Folgen.Internist (Berl)1987;28,336-343. [PubMed]
 
Theis, SW, Zaus, M, Kiefhaber, M, et al Primäre und sekundäre Schultergürtelvenenthrombose: eine Analyse von 227 patienten [abstract]. VASA. 1994;;43(suppl) ,.:102
 
Layher, T, Heinrich, F Retrospektive Betrachtung von Arm-bzw-Schultervenenthrombosen am Krankenhaus Bruchsal im Zeitraum von 1973 und 1993 [abstract]. VASA. 1994;;43(suppl) ,.:103
 
Hingorani, A, Ascher, E, Lorenson, E, et al Upper extremity deep venous thrombosis and its impact on morbidity and mortality rates in a hospital-based population.J Vasc Surg1997;26,853-860. [PubMed]
 
Horattas, MC, Wright, DJ, Fenton, AH, et al Changing concepts of deep venous thrombosis of the upper extremity-report of a series and review of the literature.Surgery1988;104,561-567. [PubMed]
 
Monreal, M, Raventos, A, Lerma, R, et al Pulmonary embolism in patients with upper extremity DVT associated to venous central lines-a prospective study.Thromb Haemost1994;72,548-550. [PubMed]
 
Prandoni, P, Polistena, P, Bernardi, E, et al Upper-extremity deep vein thrombosis: risk factors, diagnosis, and complications.Arch Intern Med1997;157,57-62. [PubMed]
 
Becker, DM, Philbrick, T, Walker, FB, IV Axillary and subclavian venous thrombosis: prognosis and treatment.Arch Intern Med1991;151,1934-1943. [PubMed]
 
Monreal, M, Lafoz, E, Ruiz, J, et al Upper-extremity deep venous thrombosis and pulmonary embolism: a prospective study.Chest1991;99,280-283. [PubMed]
 
Jones, ML Brouch, KL Allen, MMet al eds. St. Anthony’s ICD-9-CM Code Book. 1991; St. Anthony Publishers. Alexandria, VA:.
 
Baarslag, HJ, van Beek, EJR, Koopman, MMW, et al Prospective study of color duplex ultrasonography compared with contrast venography in patients suspected of having deep venous thrombosis of the upper extremities.Ann Intern Med2002;136,865-872. [PubMed]
 
Stein, PD, Patel, KC, Kalra, NJ, et al Estimated incidence of acute pulmonary embolism in a community/teaching general hospital.Chest2002;121,802-805. [PubMed]
 
Stein, PD, Patel, KC, Kalra, NK, et al Deep venous thrombosis in a general hospital.Chest2002;122,960-962. [PubMed]
 
Gottschalk, A, Sostman, HD, Coleman, RE, et al Ventilation-perfusion scintigraphy in the PIOPED study: Part II. Evaluation of the scintigraphic criteria and interpretationsJ Nucl Med1993;34,1119-1126. [PubMed]
 
PIOPED Investigators.. Value of the ventilation/perfusion scan in acute pulmonary embolism: results of the Prospective Investigation of Pulmonary Embolism Diagnosis (PIOPED).JAMA1990;263,2753-2759. [PubMed]
 
American Hospital Association.. American Hospital Association guide to the health field, 2000–2001 edition: health forum.2000,A221 American Hospital Association. Chicago, IL:
 
Timsit, J-F, Farkas, J-C, Boyer, J-M, et al Central vein catheter-related thrombosis in intensive care patients: incidence, risks factors, and relationship with catheter-related sepsis.Chest1998;114,207-213. [PubMed]
 
Haire, WD, Lieberman, RP, Edney, J, et al Hickman catheter-induced thoracic vein thrombosis.Cancer1990;66,900-908. [PubMed]
 
Ryan, JA, Abel, RM, Abbott, WM, et al Catheter complications in total parenteral nutrition: a prospective study of 200 patients.N Engl J Med1974;290,757-761. [PubMed]
 
Dollery, CM, Sullivan, ID, Bauraind, O, et al Thrombosis and embolism in long-term central venous access for parenteral nutrition.Lancet1994;344,1043-1045. [PubMed]
 
Prandoni, P, Bernardi, E Upper extremity deep vein thrombosis.Curr Opin Pulm Med1999;5,222-226. [PubMed]
 
Martinelli, I, Cattaneo, M, Panzeri, D, et al Risk factors for deep venous thrombosis of the upper extremities.Ann Intern Med1997;126,707-711. [PubMed]
 
Otten, TR, Stein, PD, Patel, KC, et al Thromboembolic disease involving the superior vena cava and brachiocephalic veins.Chest2003;123,809-812. [PubMed]
 

Figures

Tables

References

Coon, WW, Willis, PW, III (1967) Thrombosis of axillary and subclavian veins.Arch Surg94,657-663. [PubMed] [CrossRef]
 
Campbell, CB, Chandler, JG, Tegtmeyer, CJ, et al Axillary, subclavian, and brachiocephalic vein obstruction.Surgery1977;82,816-826. [PubMed]
 
Kröger, K, Schelo, C, Rudofsky, G Colour Doppler sonographic diagnosis of upper limb venous thromboses.Clin Sci (Lond)1998;94,657-661. [PubMed]
 
Huber, P, Häuptli, W, Schmitt, HE, et al Die Axillar-Subclaviavenenthrombose und ihre Folgen.Internist (Berl)1987;28,336-343. [PubMed]
 
Theis, SW, Zaus, M, Kiefhaber, M, et al Primäre und sekundäre Schultergürtelvenenthrombose: eine Analyse von 227 patienten [abstract]. VASA. 1994;;43(suppl) ,.:102
 
Layher, T, Heinrich, F Retrospektive Betrachtung von Arm-bzw-Schultervenenthrombosen am Krankenhaus Bruchsal im Zeitraum von 1973 und 1993 [abstract]. VASA. 1994;;43(suppl) ,.:103
 
Hingorani, A, Ascher, E, Lorenson, E, et al Upper extremity deep venous thrombosis and its impact on morbidity and mortality rates in a hospital-based population.J Vasc Surg1997;26,853-860. [PubMed]
 
Horattas, MC, Wright, DJ, Fenton, AH, et al Changing concepts of deep venous thrombosis of the upper extremity-report of a series and review of the literature.Surgery1988;104,561-567. [PubMed]
 
Monreal, M, Raventos, A, Lerma, R, et al Pulmonary embolism in patients with upper extremity DVT associated to venous central lines-a prospective study.Thromb Haemost1994;72,548-550. [PubMed]
 
Prandoni, P, Polistena, P, Bernardi, E, et al Upper-extremity deep vein thrombosis: risk factors, diagnosis, and complications.Arch Intern Med1997;157,57-62. [PubMed]
 
Becker, DM, Philbrick, T, Walker, FB, IV Axillary and subclavian venous thrombosis: prognosis and treatment.Arch Intern Med1991;151,1934-1943. [PubMed]
 
Monreal, M, Lafoz, E, Ruiz, J, et al Upper-extremity deep venous thrombosis and pulmonary embolism: a prospective study.Chest1991;99,280-283. [PubMed]
 
Jones, ML Brouch, KL Allen, MMet al eds. St. Anthony’s ICD-9-CM Code Book. 1991; St. Anthony Publishers. Alexandria, VA:.
 
Baarslag, HJ, van Beek, EJR, Koopman, MMW, et al Prospective study of color duplex ultrasonography compared with contrast venography in patients suspected of having deep venous thrombosis of the upper extremities.Ann Intern Med2002;136,865-872. [PubMed]
 
Stein, PD, Patel, KC, Kalra, NJ, et al Estimated incidence of acute pulmonary embolism in a community/teaching general hospital.Chest2002;121,802-805. [PubMed]
 
Stein, PD, Patel, KC, Kalra, NK, et al Deep venous thrombosis in a general hospital.Chest2002;122,960-962. [PubMed]
 
Gottschalk, A, Sostman, HD, Coleman, RE, et al Ventilation-perfusion scintigraphy in the PIOPED study: Part II. Evaluation of the scintigraphic criteria and interpretationsJ Nucl Med1993;34,1119-1126. [PubMed]
 
PIOPED Investigators.. Value of the ventilation/perfusion scan in acute pulmonary embolism: results of the Prospective Investigation of Pulmonary Embolism Diagnosis (PIOPED).JAMA1990;263,2753-2759. [PubMed]
 
American Hospital Association.. American Hospital Association guide to the health field, 2000–2001 edition: health forum.2000,A221 American Hospital Association. Chicago, IL:
 
Timsit, J-F, Farkas, J-C, Boyer, J-M, et al Central vein catheter-related thrombosis in intensive care patients: incidence, risks factors, and relationship with catheter-related sepsis.Chest1998;114,207-213. [PubMed]
 
Haire, WD, Lieberman, RP, Edney, J, et al Hickman catheter-induced thoracic vein thrombosis.Cancer1990;66,900-908. [PubMed]
 
Ryan, JA, Abel, RM, Abbott, WM, et al Catheter complications in total parenteral nutrition: a prospective study of 200 patients.N Engl J Med1974;290,757-761. [PubMed]
 
Dollery, CM, Sullivan, ID, Bauraind, O, et al Thrombosis and embolism in long-term central venous access for parenteral nutrition.Lancet1994;344,1043-1045. [PubMed]
 
Prandoni, P, Bernardi, E Upper extremity deep vein thrombosis.Curr Opin Pulm Med1999;5,222-226. [PubMed]
 
Martinelli, I, Cattaneo, M, Panzeri, D, et al Risk factors for deep venous thrombosis of the upper extremities.Ann Intern Med1997;126,707-711. [PubMed]
 
Otten, TR, Stein, PD, Patel, KC, et al Thromboembolic disease involving the superior vena cava and brachiocephalic veins.Chest2003;123,809-812. [PubMed]
 
NOTE:
Citing articles are presented as examples only. In non-demo SCM6 implementation, integration with CrossRef’s "Cited By" API will populate this tab (http://www.crossref.org/citedby.html).

Some tools below are only available to our subscribers or users with an online account.

Related Content

Customize your page view by dragging & repositioning the boxes below.

CHEST Journal Articles
CHEST Collections
PubMed Articles
McCleery syndrome: etiology and outcome. Vasc Endovascular Surg 2014;48(2):106-10.
  • CHEST Journal
    Print ISSN: 0012-3692
    Online ISSN: 1931-3543