Primary Upper-extremity Deep Vein Thrombosis Research Articles

Single-center experience with catheter-directed thrombolysis and balloon angioplasty for acute upper-extremity deep vein thrombosis: a case series study

BackgroundEffective treatment of upper extremity deep vein thrombosis (UEDVT) is crucial to prevent further complications. Various treatments, including percutaneous mechanical thrombectomy (PMT), catheter-directed thrombolysis (CDT), decompression surgery, and venoplasty are suggested for UEDVT. However, no prospective study has yet favored any of these treatments. This study presents a review of our experience with CDT followed by balloon venoplasty in patients with acute primary UEDVT.MethodsWe enrolled all patients diagnosed with acute UEDVT from January 2020 to June 2021. Subjects with UEDVT due to secondary causes like malignancies, indwelling catheters, or leads were excluded. CDT was performed through brachial vein access, using a perfusion catheter, and rt-PA administration. Balloon venoplasty was performed if the treated segment had remaining stenosis after CDT. Patients were followed up at the vein clinic for any signs and symptoms in the upper extremity and lifestyle changes. Follow-up ultrasonography was done 12 months after discharge.ResultsTwelve patients with a mean age of 41.08 ± 14.0 years were included in the study. The mean duration of CDT was 25.00 ± 10.56 h. After CDT, all patients had remaining occlusions, with seven having more than 50% remaining stenosis. However, after balloon venoplasty, no patient had significant (more than 50%) stenosis. There was no serious complication after both procedures. Patients were followed up for a mean duration of twelve months after their admission, with a mean time of maintenance anticoagulation was 10.73 ± 5.77 months. Only one patient had recurrent symptoms in his target limb which required a decompression surgery, while the rest were free of symptoms in their treated extremity. No subject developed pulmonary emboli (PE) during admission or the follow-up period. There was no evidence of hospital readmission for any reason. Upper extremity color-doppler sonography of the patients at twelve months after their procedure showed normal venous flow without any significant stenosis in 8 (66.7%), and partially normal flow with patent target vein in 4 (33.3%) patients.ConclusionsCDT followed by balloon venoplasty may be an effective treatment for selected patients with acute primary UEDVT, providing desirable long-term results and potentially avoiding the need for decompression surgery in the short or long term.

An Unwonted, Pedagogic Case Report on Effort Thrombosis of Right Brachial Vein

Deep vein thrombosis (DVT) is one or more blood clots formed inside the deep vein in the body resulting in complete or partial blockage of blood flow through the affected vein. Upper Extremity DVT (UEDVT) accounts for 5% - 10% of all cases of DVTs. Previously it was thought to be a rare disorder. However in recent years with the advent of various indwelling intravenous devices, hypercoagulable state like COVID-19, secondary UEDVT did not remain infrequent presentation anymore. Though primary UEDVT, also known as Effort Thrombosis, that takes place without any underlying obvious pathology is a rare form till now. We presented a case of 46 years female who presented to the emergency with complaints of progressively increasing pain (7 days) and swelling (3 days) of her right forearm since last 7 days following strenuous and heavy work by her dominant/ right hand during the period of festival. She initially ignored her condition because of the Durga Puja festival. As her symptoms deteriorated she eventually had to attend the emergency department. Eventually an urgent ultrasonography color Doppler was done on emergency basis which diagnosed underlying DVT of her right brachial vein. She was managed with low molecular weight heparin, urgent fasciotomy owning to her impending compartment syndrome. Other tests ruled out any secondary underlying pathology. She improved and discharged without any complications on oral anticoagulant. Exigent events in her history were trauma followed by fall on her right elbow 2 months back and then presenting signs & symptoms commencing at the same region following strenuous, tedious activities over 7 days and consequential effort thrombosis of her right brachial vein. All of that compelled us to ruminate on rare differentials of her presentation and eventually come to this rare diagnosis. The author hence brought this pedagogic case to the readers, especially emergency & primary care physicians and emphasised the importance of being intuitive about rare but deadly differentials which come from proficiency & experience in the field of medicine.

Post-Thrombotic Syndrome and Recurrent Thromboembolism in Patients with Upper Extremity Deep Vein Thrombosis: A Systematic Review and Meta-Analysis of Proportions

Background: Upper extremity deep vein thrombosis (UEDVT) is known to be less common than lower extremity DVT (LEDVT). In comparison to LEDVT, there is limited data on the occurrence of complications in patients with UEDVT. As a result, it remains uncertain as to how aggressively these patients should be treated. In this systematic review, we aimed to determine the rate of complications, including post-thrombotic syndrome and recurrent thromboembolism, in patients with UEDVT.Methods: We conducted a systematic literature search of MEDLINE and EMBASE databases for relevant studies from 1970 onwards. Our search included conference publications from major international meetings. Studies were eligible for inclusion if they were observational studies (case-control, cohort), randomized trials, or cases series including more than 20 patients. Studies must have included only patients age 18 or older and have objectively diagnosed UEDVT by means of venography or ultrasound. The primary outcome measures were the recurrence rate of UEDVT in patients with previously documented UEDVT and the rate of PTS. The secondary outcome measure was the rate of major bleeding, as defined by the International Society on Thrombosis and Haemostasis (ISTH), following the initiation of treatment for UEDVT. For each outcome, we calculated a pooled proportion using a fixed effects model and its 95% confidence interval (CI) using the Wilson score method. We also determined the mean proportions of outcomes and the interquartile ranges (IQR) of single proportions from individual studies.Results: A total of 61 studies were included in the meta-analysis (58 full text articles and 3 conference publications). The studies included a total of 5500 patients diagnosed with UEDVT. Of the 61 included studies, 39 reported data on recurrence, 21 on PTS, and 28 on major bleeding. PTS was defined either by the Villalta scale explicitly (a score of 5 or more) or by similar clinical descriptors posed by the investigators.The results are summarized in Table 1. When evaluating all studies, the pooled proportions of outcomes were: 2.4% (95% CI: 2.0-2.9%) for recurrence, 15.0% (95% CI: 12.8-17.5%) for PTS, and 2.9% (95% CI: 2.5-3.5%) for major bleeding. The mean proportions were: 8.4% (IQR: 0.0-10.1%), 18.4% (IQR: 0.0-26.7%), and 4.3% (IQR: 0.0-5.7%), respectively.When evaluating studies specific to primary UEDVT in the setting of venous thoracic outlet syndrome, the pooled proportions were: 5.5% (95% CI: 4.3-7.1%) for recurrence, 16.0% (95% CI: 13.4-19.0) for PTS, and 3.3% (95% CI: 2.0-5.3%) for major bleeding. The mean proportions were: 6.8% (IQR: 0.0-9.5%), 19.6% (IQR: 0.0-30.5%), and 3.2% (IQR: 0.0-4.8%), respectively.When evaluating studies specific to secondary UEDVT (catheter-associated and/or malignancy-associated), the pooled proportions were: 2.0% (95% CI: 1.5-2.6%) for recurrence, 8.0% (95% CI: 4.9-12.8) for PTS, and 3.9% (95% CI: 3.2-4.8%) for major bleeding. The mean proportions were: 18.1% (IQR: 1.5-18.4%), 17.1% (IQR: 9.8-26.5%), and 3.8% (IQR: 0.0-5.2%), respectively.Conclusions: This review included a large number of patients diagnosed with UEDVT and found that both primary and secondary UEDVT are associated with high rates of PTS. The pooled proportions of PTS and recurrent thromboembolism were higher in patients with primary UEDVT than in patients with secondary UEDVT. The rates of major bleeding were similar in both groups. Further analysis is needed on the association of these complications with different treatment modalities for UEDVT to better guide the management of patients. Our next step is to calculate pooled proportions using a random effects model and present this data at the 59th American Society of Hematology (ASH) Annual Meeting. [Display omitted] DisclosuresLazo-Langner:Pfizer: Honoraria; Bayer: Honoraria; Daiichi Sankyo: Research Funding; Alexion: Research Funding.

Upper Extremity Deep Vein Thrombosis: Current Knowledge and Future Directions.

Upper extremity deep vein thrombosis (UEDVT) has been increasing in incidence due to the escalating use of central venous catheters such as peripherally inserted central catheters. UEDVT can be primary idiopathic or secondary to pacemaker leads, intravascular catheters or cancer. In comparison to conventional venous thromboembolism such as lower limb deep vein thrombosis or pulmonary embolism the risk factors, investigations, and management are not well defined. We review current evidence in primary and secondary UEDVT, highlighting areas in need of further research. We also explore the entity of venous thoracic outlet syndrome, which is said to be a risk factor for recurrent primary UEDVT and is the rationale behind surgical interventions.

Management of upper extremity deep vein thrombosis: an updated review of the literature.

Upper extremity deep vein thrombosis (UEDVT) represents about 5-10% of all cases of deep vein thrombosis (DVT) with a steadily increasing incidence mostly due to the high prevalence of cancer and frequent use of intravascular devices such as central venous catheters and pacemaker. In primary UEDVT, the venous outflow obstruction and subsequent thrombosis are related to congenital or acquired anatomical abnormalities, whereas secondary UEDVT is often associated with malignancy or indwelling lines. A considerable proportion of patients with UEDVT develops serious complications such as recurrent thrombosis, post-thrombotic syndrome, and pulmonary embolism, therefore timely diagnosis and adequate treatment are of crucial importance. Despite sharing many similarities with lower extremity DVT, UEDVT has distinctive features requiring specific diagnostic and therapeutic approaches. The present review discusses the latest evidence on the epidemiology, diagnosis, and treatment of UEDVT, and provides management indications which may help guide clinical decision making.

Diagnostic and Therapeutic Management of Upper Extremity Deep Vein Thrombosis.

Upper extremity deep vein thrombosis (UEDVT) accounts for 5% of all deep vein thromboses (DVTs). UEDVT may be complicated by post thrombotic syndrome and pulmonary embolism, and early recognition and prompt start of anticoagulant treatment are key. Primary UEDVT, also known as Paget-von Schrötter syndrome, is associated with repeated or sudden physical activity of the upper arm and venous outflow obstruction due to anatomical variations. Secondary UEDVT is often associated with malignancy or use of intravenous devices, such as central venous catheters or pacemaker leads. Although the diagnosis and treatment of UEDVT have many similarities with DVT of the lower extremities, knowledge of specific aspects regarding UEDVT is important to guide optimal management. In this review, we will discuss the epidemiology, diagnosis, and treatment of UEDVT based on the current literature.

Post-thrombotic syndrome and recurrent thromboembolism in patients with upper extremity deep vein thrombosis: A systematic review and meta-analysis

IntroductionThere is limited data on the occurrence of complications in patients with upper extremity deep vein thrombosis (UEDVT). AimsWe aimed to determine the frequency of post-thrombotic syndrome (PTS), thrombosis recurrence and major bleeding (MB) in patients with UEDVT. Material and methodsWe conducted a systematic review of the literature including studies from 1970 onwards. We included observational studies, randomized trials, or cases series including >20 patients. We calculated pooled proportions using a random effects model. Subgroup analyses according to etiology and treatment modality were conducted. ResultsA total of 62 studies comprising 3550 patients were included. The pooled proportions for PTS and recurrence were 19.4% (95% CI 11.3–27.6) and 7.5% (95% CI 4.1–10.9), respectively. With a mean follow up of 6 months, the proportion of PTS was higher in patients with primary (unprovoked) UEDVT compared to secondary, whereas recurrence was higher in secondary UEDVT. PTS was more frequent in patients treated with anticoagulation alone compared to thrombolysis or surgical decompression. The pooled proportion for MB was 5.0% (95% CI 0.3–9.7) after anticoagulation alone and 3.8% (95% CI: 2.4–5.8%) after thrombolysis and/or surgery. ConclusionsThis study suggests that UEDVT is associated with significant rates of PTS and recurrence and its treatment has a relatively low risk of major bleeding. Differences exist depending on etiology and treatment modality.

Primary Upper Extremity Deep Venous Thrombosis and Comorbidity: A Population-Based Nationwide Study in Sweden

Abstract BackgroundThere have been few studies on primary upper extremity deep vein thrombosis (UEDVT) and the comorbidity is not very well known, in contrast to secondary UEDVT.MethodsWe conducted a nationwide, population-based case control study in Sweden using data from the Swedish National Patient Register (NPR).We examined comorbidity in 25 cases with a confirmed UEDVT with a control group (appendicitis) during the years 2001–2011 in patients over 18 years old. We defined comorbidity as the number of unique ICD codes (International Statistical Classification of Diseases and Related Health Problems) and the total number of healthcare contacts.ResultsThe number of unique ICD codes was similar between cases and controls, although they differed regarding specific diagnoses. Patients with a UEDVT were more likely to later have a diagnosis related to blood-forming organs, the endocrine system, the nervous system, the circulatory system, and to the skin and musculoskeletal systems, compared with the controls.Diagnoses for symptoms from the brachial plexus and diagnoses referring to pain and discomfort of the upper extremity were more frequent in the cases. The major difference occurred in diagnoses involving the circulatory system, which were more frequent in the cases. The most important cases and controls were similar regarding diagnoses of malignancy. The cases had a significantly higher number of healthcare contacts.ConclusionThe type of comorbidity and the number of healthcare contacts differed between patients with a diagnosis of UEDVT, compared with those with appendicitis. There was no difference regarding malignancies, which implies that primary UEDVT is a benign disorder.

Treatment of upper-extremity outflow thrombosis.

Approximately 10% of all cases of deep vein thrombosis (DVT) occur in the upper extremities. The most common secondary cause of upper-extremity DVT (UEDVT) is the presence of a venous catheter. Primary UEDVT is far less common and usually occurs in patients with anatomic abnormalities of the costoclavicular space causing compression of the subclavian vein, called venous thoracic outlet syndrome (VTOS). Subsequently, movement of the arm results in repetitive microtrauma to the vein and its surrounding structures causing apparent 'spontaneous' thrombosis, or Paget-Schrötter syndrome. Treatment of UEDVT aims at elimination of the thrombus, thereby relieving acute symptoms, and preventing recurrence. Initial management for all UEDVT patients consists of anticoagulant therapy. In patients with Paget-Schrötter syndrome the underlying VTOS necessitates a more aggressive management strategy. Several therapeutic options exist, including catheter-directed thrombolysis, surgical decompression through first rib resection, and percutaneous transluminal angioplasty of the vein. However, several controversies exist regarding their indication and timing.

Nonleg venous thrombosis in critically ill adults.

Venous thromboembolism (VTE) comprises deep vein thrombosis (DVT) of the lower extremity and pulmonary embolism (PE) and is the third most common cardiovascular disease after acute myocardial infarction and stroke, affecting up to 5% of the population during their lifetime.1 The epidemiology of thrombosis at other sites, including upper extremity veins, intra-abdominal veins, and cerebral veins, is less well defined, and the reported frequency depends on the data source.2 The optimal treatment for nonleg deep vein thrombosis (NLDVT) is unclear because there are no prospective management studies and current recommendations are based on expert opinion and extrapolation from proximal leg DVT studies. Of NLDVTs, upper extremity DVT (UEDVT) is the most common, accounting for approximately 10% of all DVT.3 The incidence of UEDVT is increasing, paralleling an increase in central line and cardiac device usage.3 Upper extremity DVT involves the brachial, axillary, subclavian, and more proximal veins, with proximal events defined as occurring in or proximal to the axillary vein. Unprovoked or primary events are effort related or may be caused by costoclavicular junction anatomic abnormalities. Secondary UEDVT is more common than primary UEDVT and may be caused by central venous catheters, cardiac pacemakers and defibrillators, and malignancies.4 Complications of UEDVT include PE, postthrombotic syndrome, and, in those related to central venous catheters, JAMA INTERNALMEDICINE

The importance of the costoclavicular space in upper limb primary deep vein thrombosis, a study with magnetic resonance imaging (MRI) technique enhanced by a blood pool agent

BackgroundPrimary upper extremity deep vein thrombosis (UEDVT) can be divided into idiopathic and effort thrombosis. Anatomical factors probably play an important role in effort thrombosis, whereas the cause remains mostly unknown in idiopathic thrombosis. ObjectivesThe primary objective of this study was to examine the anatomy of the subclavian region and evaluate how these factors contribute to primary UEDVT. The secondary objective was to investigate if venous compression correlates with post thrombotic syndrome (PTS). Patients and methodsFifteen patients and 15 controls were enrolled in the study. The subclavian region (the costoclavicular distance and vessel area) was examined by MRI enhanced by a blood-pool contrast agent (Vasovist). The MRI was performed in two arm positions: alongside and elevated. PTS and disability were quantified with the modified Villalta score and the Disability of the Arm, Shoulder and Hand (DASH) test. ResultsThe costoclavicular distance was significantly narrower in the UEDVT patients with the arms alongside the body but there was a significant difference only in the left arm with the arms elevated. Area of the subclavian vein: When comparing the patients non-thrombotic arm with the controls, there was a significant difference only when the arms in the supine position. Disability: There was a high correlation between DASH, Villalta and VAS but no correlation between the MRI measurement and patient's symptoms or the Villalta Score. ConclusionOur results suggest that primary UEDVT is dependent on the subclavian anatomy and area of vena subclavia.

Paget-schroetter Syndrome- A Case Report

A rare case of primary upper-extremity deep vein thrombosis or Paget-Schroetter syndrome is reported. It is effort thrombosis usually affecting young healthy individuals and is a rare condition. Our patient was a middle aged male daily laborer with history of exertion using the right upper limb. He responded to limb elevation and anticoagulation. No other cause for thrombosis was found.

Management of Deep Vein Thrombosis of the Upper Extremity

Case 1: A 34-year-old previously healthy male office manager was admitted with acute onset of heaviness, pain, and functional impairment of his right arm. The arm was cyanotic and massively swollen (Figure 1). For the past weeks, he reported transient paresthesia of his right arm during overhead activities and was unable to perform repetitive or strenuous arm exercise. He had a fracture of the right clavicle after a ski accident 5 years previously. The fracture was managed conservatively. There was no personal or family history of thrombosis. Conventional phlebography confirmed axillary and subclavian vein thrombosis (Figure 2, top), and treatment with intravenous unfractionated heparin was started. Figure 1. Clinical presentation of case 1 with massive swelling and cyanosis of the right arm (left). One day after pharmacomechanical thrombolysis, signs of thrombosis have markedly improved (right). Figure 2. Baseline digital subtraction venogram from case 1 with extensive filling defects in the axillary subclavian veins (top). Control venogram after 15 hours of pharmacomechanical thrombectomy confirmed resolution of filling defects and restored venous flow (middle). Positional venography obtained during abduction of the right arm confirmed the venous thoracic outlet syndrome with residual stenosis of the subclavian vein at the costoclavicular junction (white arrow, bottom). Case 2: A 55-year-old man with lung cancer presented with swelling, heaviness, and pain in his left arm 1 week after completion of chemotherapy administered via a left-sided indwelling central venous catheter. Axillary and subclavian vein thrombosis was confirmed by ultrasonography. Low-molecular-weight heparin (LMWH) was initiated, and the catheter was removed 3 days later because it was no longer functional. At 1 week, pain and functional impairment had not improved, and the circumference of the left upper arm had increased by 2 cm. Case 3: A 65-year-old woman with metastatic ovarian cancer presented with swelling of the face and both arms, headache, …

Abstract No. 356: Power Pulse Spray Pharmacomechanical Thrombectomy for the Treatment of Upper Extremity Deep Vein Thrombosis

While upper-extremity deep vein thrombosis (UEDVT) represents 1-4% of the all DVT, it is associated with 29-40% morbidity and mortality from the pulmonary embolism (2-35%) and post-thrombotic syndrome (7-46%). Primary UEDVT (30%) is due to thrombophilia, venous compression (Paget-Schroetter syndrome) or activity-related venous trauma. Secondary UEDVT (70%) is due to central venous catheters and malignancy. Treatment options for UEDVT include anticoagulation and less frequently pharmacomechanical thrombectomy. Recently, rapid thrombectomy methods including power pulse spray pharmacomechanical thrombectomy (PPS) have been described for the extraction of the venous thrombus. The purpose of this presentation is to report a single center experience in treatment of UEDVT with PPS. Eight patients with subclavian/axillary vein thromboses (3 women and 5 men) at a tertiary academic medical center underwent PPS. Mean age was 44 years (range, 21-57 years). All patients' records were reviewed for technical success of the procedure, duration time, dosage of lytics administered, need for adjunctive treatment, and venous patency at follow up. Rheolytic pharmacomechanical thrombectomy device was performed with the AngioJet catheter (Possis Medical, Minneapolis, MN) in PPS mode. The treatment was performed in a single setting in all patients. Time range was 60 - 300 min. Mean thrombolytic dose of alteplase was 25 mg. Adjunctive procedures were required in 7/8 patients (PTA and stenting 1 and PTA alone in 6). All patients demonstrated angiographic evidence of complete thrombus extraction and venous patency. Complications included 2 hematomas at the brachial venous puncture site. None of the patients required ICU admission or overnight lytic infusion. No patients developed clinical symptoms of pulmonary embolism. At 6 month follow up all 8 patients demonstrated patent central veins. PPS pharmacomechanical thrombectomy is a minimally invasive, low-risk therapeutic option in patients with UEDVT. Clinical benefits include rapid thrombus extraction and improved venous patency. In our experience PPS for UEDVT can be performed in a single setting with an excellent safety profile.

Primary upper-extremity deep vein thrombosis: high prevalence of thrombophilic defects.

Primary deep venous thrombosis of the upper extremity (UEDVT) is an unusual disorder. Limited data are available on the contribution of hypercoagulable status in the pathogenesis of this disease. This study aims to report the prevalence of inherited and acquired thrombophilic risk factors (TF) in patients with primary (effort-related and spontaneous) UEDVT. From 1993 to 2002, 31 patients (17 females, median age 38.8 years, range 16-60 years; and 14 males, median age 31.4 years, range 20-56 years) with primary UEDVT (n = 15 effort-related and n = 16 spontaneous) were referred for screening of hypercoagulable status. Nineteen (61.3%) patients had at least one coagulation abnormality. The most common acquired TF were antiphospholipid antibodies (31% lupus anticoagulant and 12.9% anticardiolipin antibodies). Factor V Leiden (12.9%) and prothrombin G20210A mutation (20%) were the most prevalent genetic risk factors. Five patients (16.1%) had high plasma homocysteine levels, and one patient (4.7%) had protein S deficiency. Effort-related UEDVT was associated with male gender (P = 0.04) and younger age (P = 0.02). There was no significant difference in the prevalence of acquired or inherited TF between patients with effort-related or spontaneous UEDVT. A local anatomic abnormality was detected in seven patients (22.5%), and the prevalence of TF was significantly lower within this group (P = 0.006). The incidence of TF in patients without an anatomic abnormality was 75% (RR 5.25). This study found a high prevalence of an underlying thrombophilic status in spontaneous and effort-related UEDVT. Hypercoagulable status may play a significant role in both groups. Screening for local anatomical abnormalities and thrombophilia should be included in the evaluation of primary UEDVT.

Prothrombin G20210A mutation and oral contraceptive use increase upper-extremity deep vein thrombotic risk

The role played by a hypercoagulable state, either inherited or acquired, in the pathogenesis of upper-extremity deep vein thrombosis (UEDVT) remains a question of debate. We performed a case-control study including 79 patients with a first objectively confirmed episode of UEDVT, 31 secondary and 48 primary, and 165 healthy controls. Nine patients (11.4%) with UEDVT were carriers of the prothrombin G20210A mutation vs. six (3.7%) in controls; P = 0.025, OR: 3.39 (95% CI 1.16 to 9.88). No statistical difference was observed between cases and controls for the factor V Leiden mutation, AT, protein C or protein S deficiency and anticardiolipin antibodies (ACAs). Thirteen (35.1%) UEDVT patients were oral contraceptive (OC) users vs. 12 (16%) controls; P = 0.020, OR: 2.89 (95% CI 1.16-7.21). When secondary UEDVT patients were compared with controls, no differences were observed in any of the risk factors analysed. On the other hand, when primary UEDVT was considered, six (12.5%) patients were carriers of the prothrombin G20210A mutation vs. six (3.7%) controls; P = 0.031, OR: 3.76 (95% CI 1.15-12.26). Regarding ACAs, a borderline statistical significance was observed when primary UEDVT was compared with controls, P = 0.048; OR: 4.88 (95% CI 1.05-22.61). In primary UEDVT, 52% of the fertile women were OC users vs. 16% of controls; P = 0.001, OR: 5.78 (95% CI 2.13-15.67). When the interaction of both factors, i.e. prothrombin G20210A mutation and OC intake, were considered, the risk increased markedly, indicating a synergistic effect as observed with other thrombotic locations. In patients with primary UEDVT screening for antithrombin, protein C and protein S deficiency and APC resistance would not be justified, although it might be reasonable to determine the carrier status of the prothrombin G20210A mutation only in OC users.

Venous Thrombosis of the Upper Extremities.

The goals of treating patients with upper-extremity deep vein thrombosis (UEDVT) are to relieve acute symptoms of venous occlusion, prevent pulmonary embolism, reduce the likelihood of recurrent thrombosis, and avoid the development of postphlebitic syndrome. Although the details of management differ, depending on the underlying cause and precipitating factors, anticoagulant therapy should be the first-line treatment of choice in all cases. For patients with primary or idiopathic UEDVT (Paget-von Schroetter syndrome), aggressive measures including catheter-directed thrombolysis, vascular procedures (eg, balloon angioplasty, stenting, filter), and surgical maneuvers (eg, first rib resection) have been advocated by some surgeons, but none of these high-risk interventions has been evaluated properly in prospective controlled trials. In contrast, for patients with catheter-associated central venous thrombosis (CACVT), or other secondary cases of UEDVT, many clinicians simply withdraw the catheter and avoid anticoagulant therapy. Because well-designed clinical trials are lacking, recommendations about the management of UEDVT are derived from descriptive studies and case series. Until further research identifies the natural history and optimum management of UEDVT, it seems reasonable to base treatment on anticoagulant regimens with proven effectiveness in lower-extremity deep vein thrombosis (LEDVT). The use of additional intervention(s) should be reserved for carefully selected patients.