Clinical Commander

All dossiers
cardio.dvt.upper-extremity.v1

Upper-extremity DVT (subclavian / axillary / brachial)

cardiologyacuteadultacuteinpatienttransitionoutpatient
Start encounter →Print handoutPRODUCTION

Phase E variant of cardio.dvt.core.v1 — narrowed to upper-extremity DVT (UEDVT) including subclavian, axillary, brachial veins. Inherits AC regimen options from parent via routing; specializes for primary (Paget-Schroetter / effort thrombosis) vs secondary (catheter-associated) subtype classification, CDT consideration for primary within 14 days per Engelberger 2014, first-rib resection long-term strategy, and catheter retain-vs-remove decision tree per Joffe ASH 2017. Manifest pointer reuses cardio.dvt.core.v1 manifest. Design-brief pointer reuses parent (UEDVT-specific differences documented inline). PE risk from UEDVT 10-15% (higher in catheter-associated) — full-dose AC mandatory. SVC syndrome with airway compromise is life-threatening trigger. Status INTEGRATED. Authored 2026-05-14 by shard-06-cardio-acute as upper-extremity DVT variant.

Entry points (3)

  • symptom
    Unilateral arm swelling, pain, warmth, prominent collateral veins → suggests UEDVT
    arm_swelling_pain_warmth
  • history
    Young athlete with repetitive arm overhead activity (rowing, swimming, weightlifting) → Paget-Schroetter (primary UEDVT)
    effort_thrombosis_history
  • history
    CVC, PICC, port, or pacemaker lead present → secondary UEDVT (most common cause)
    indwelling_catheter_or_picc

Required inputs (7)

  • agerequired
    demographic • used at CONTEXT
    Primary UEDVT typically young; secondary UEDVT typically older with comorbidities
  • subtype_classificationrequired
    history • used at ENTRY
    Primary vs secondary subtype drives management (CDT consideration vs catheter removal decision)
  • compression_us_upper_extremityrequired
    imaging • used at INITIAL_WORKUP
    Compression US is first-line; CT venography or MRV if non-diagnostic (Joffe ASH 2017)
  • creatininerequired
    lab • used at TREATMENT
    eGFR for DOAC dosing
  • cbcrequired
    lab • used at INITIAL_WORKUP
    Baseline + platelet count for AC + HIT screening if heparin-exposed catheter
  • catheter_essential
    history • used at TREATMENT
    If indwelling catheter present: is it essential? If not, remove (Joffe ASH 2017); if essential, continue AC while in place
  • bleed_riskrequired
    history • used at RED_FLAGS
    HAS-BLED for AC eligibility

12-phase flow (10)

  1. 1FRAME
    UEDVT — primary (Paget-Schroetter) vs secondary (catheter-associated) classification is the central differentiator; routes diverge significantly
    inputs: subtype_classification
    advance: subtype classified
  2. 2ENTRY
    Constans clinical decision rule for UEDVT pretest probability; compression US first-line (sens 97%, spec 96% per meta-analyses)
    inputs: age
    advance: UEDVT confirmed on imaging
  3. 3CONTEXT
    Indwelling catheter status; sports/occupation history; cancer screen; thrombophilia screen if primary and young
    inputs: catheter_essential
    advance: context complete
  4. 4RED_FLAGS
    SVC syndrome features (facial swelling, dyspnea, plethora); central vein occlusion; concurrent PE; brachial plexus compression with neurologic deficit
    inputs: bleed_risk
    advance: red flags screened
  5. 5INITIAL_WORKUP
    Compression US (linear high-frequency probe); CT venography if US non-diagnostic or for SVC/central evaluation; CBC + BMP
    inputs: compression_us_upper_extremity, cbc, creatinine
    actions: panel.cardiac, panel.renal
    advance: imaging confirms UEDVT and location
  6. 6BRANCHING_WORKUP
    Primary UEDVT: thoracic outlet imaging (CT/MR), thrombophilia screen; Secondary UEDVT: catheter remove vs retain decision, cancer evaluation if not known
    advance: subtype-specific workup complete
  7. 7TREATMENT
    Primary: DOAC ≥3 months + CDT within 14 d (Paget-Schroetter) + first-rib resection long-term. Secondary: DOAC ≥3 months + remove non-essential catheter; if catheter essential, continue AC while in place
    inputs: creatinine
    advance: subtype-specific therapy initiated
  8. 8DISPOSITION
    Outpatient if hemodynamically stable; inpatient for CDT, severe symptoms, or comorbidity management
    advance: disposition documented
  9. 9MONITORING
    Bleeding screen; arm function (residual swelling, dexterity); for primary post-CDT: venous patency surveillance; for secondary: re-evaluate catheter need
    actions: panel.cardiac
    advance: monitoring plan documented
  10. 10FOLLOWUP
    Primary: surgical (thoracic surgery / vascular) consult for first-rib resection within 4-6 weeks. Secondary: AC continued while catheter in place (or 3 months if removed)
    advance: long-term plan documented