You have just reached Bed 3 on the ICU ward round. The 68yo male patient was admitted to the unit 6 days ago with a community acquired pneumonia. He is weaning off the last of his vasopressor infusion and will finish his antibiotics in the next 48 hours or so. The nurse makes a beeline for you.
She expresses her concern that the patient’s right arm appears to have increased in volume over the past 24 hours. She has already notified the resident, who diligently pushed for a vascular ultrasound, the outcome of which is a 3cm thombus that borders between the proximal brachial and distal axillary vein of the right upper limb.
How will you manage this diagnosis?
Upper limb DVT management has been a bit of a black spot, as far as best practice management is concerned. It is essentially a (high quality) evidence free zone.However, its incidence may be on the increase as procedures associated with its occurence become more prevalent.
Upper limb DVTs account for under 10% of all DVTs, but 5% may go on to result in a PE. About three-quarters of upper limb DVTs are attributed to venous catheters, pacemaker wires or underlying cancer.
The American College of Chest Physicians recently published their Antithrombotic Therapy and Prevention of Thrombosis, 9th ed Guidelines and it includes a consensus approach to managing upper limb DVTs. Matt Hoffman’s PulmCCM.org site summarises it beautifully here.
Here is an algorithm that I’ve put together as a result of Matt’s summary:
Antithrombotic Therapy and Prevention of Thrombosis, 9th ed: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines online
PulmCCM.org summary of the Acute Deep Venous Thrombosis (DVT) of the Arm ACCP Guidelines, 9th Ed.
Treatment of upper-extremity deep vein thrombosis. Rathbun SW, Stoner JA, Whitsett TL. J Thromb Haemost. 2011 Oct;9(10):1924-30.
Upper limb DVT on Ultrasound #1: Sonocloud – Dr. Mike Stone
Upper limb DVT on Ultrasound #2: Sonocloud – Dr. Mike Stone