Scanning for Upper Extremity DVT

The correct answer is “All of the Above”

In the Emergency Department, 1/1000 people are diagnosed with a DVT. Of note, upper extremity DVT (UEDVT) is much rarer than lower extremity DVT (LEDVT). Most commonly, in the clinical setting, indwelling intravenous catheters and cardiac devices increase the risk of UEDVTs encountered. A delay inappropriate treatment can increase the risk of serious complications including chronic limb pain, superior vena cava syndrome, and pulmonary emboli therefore, care should be noted to perform a thorough exam and consider suspected thromboembolic to expedite care when evaluating a patient with upper extremity pain.

LEDVTs occur at almost a 5 fold higher rate than UEDVTS. Current data supports that the rate of pulmonary emboli may be higher than previously suspected for UEDVTs.1 The most common sites of UEDVT are the axillary and subclavian veins. In some patients, empiric anticoagulation may be indicated in the event that comprehensive radiology vascular ultrasound is unavailable at the time of presentation. POCUS can be extremely valuable in a situation where a patient presents with pain, swelling, or erythema. Physicians can quickly at the bedside make a diagnosis, initiate treatment, decrease unnecessary testing and decrease the length of stay.

There are two subtypes of UEDVTS. More commonly we encounter the secondary subtype over the primary subtype. The primary subtype is considered effort-induced, Paget-Schroetter Syndrome, a venous form of thoracic outlet syndrome occurring in the dominant arm of young male athletes. In these cases, the subclavian vein is the most commonly involved. Indwelling devices like central venous lines, pacemaker leads, tunneled central access lines can lead to the second subtype of UEDVTs. The secondary subtype is the most common type of UEDVT occurring in over 90% of patients with UEDVT. In the setting of intravascular devices, acquired thrombophilia and malignancy may increase the risk of developing UEDVT.

How to Perform a UEDVT Scan

Gold Standard for Diagnosis:

Triplex Ultrasonography (2D, Compression and Doppler). Compression alone is very close to triplex scanning in sensitivity/specificity

Setting: B- Mode with Color Doppler or Pulse Wave Doppler

Patient Positioning: Trendelenburg

Sequence: In the transverse axis, scan the neck vessels (internal jugular, brachiocephalic and subclavian veins) and upper extremity vessels (axillary, deep brachial, antecubital, ulnar, and radial veins +- the basilic vein). Apply compression and/or flow. 

Why? POCUS performed by trained EM Physicians is highly sensitive and specific for the identification of DVT

DVT confirmation?

1-    Direct visualization of thrombus

2-    Lack of compressibility

3-    Lack of augmentation

4-    Lack of Doppler signal within the vein

5-    Lack of respiratory variation

Limitations? Obesity, Anatomic variability