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cardio.dvt.upper-extremity.v1PRODUCTION
cardio.dvt.upper-extremity.v1

Upper-extremity DVT (subclavian / axillary / brachial)

cardiologyacuteadult
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10/12 authored

Canonical 12-phase frame with authored status for this dossier.

Current phase

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Detailed

UEDVT — primary (Paget-Schroetter) vs secondary (catheter-associated) classification is the central differentiator; routes diverge significantly

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subtype classified

Patient inputs (7)

Primary UEDVT typically young; secondary UEDVT typically older with comorbidities

Primary vs secondary subtype drives management (CDT consideration vs catheter removal decision)

Compression US is first-line; CT venography or MRV if non-diagnostic (Joffe ASH 2017)

Baseline + platelet count for AC + HIT screening if heparin-exposed catheter

HAS-BLED for AC eligibility

eGFR for DOAC dosing

If indwelling catheter present: is it essential? If not, remove (Joffe ASH 2017); if essential, continue AC while in place

* = hard-required. Engine cannot meaningfully run until these are filled.

Severity triggers (5)

5 need judgement
  • informationallife_threateningsvc_syndrome_with_uedvt
    UEDVT extending to or causing SVC syndrome (facial swelling, plethora, dyspnea, dilated chest collaterals)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationallife_threateningconcurrent_pe_in_uedvt
    UEDVT with concurrent PE (~10-15% rate) — particularly common in catheter-associated UEDVT
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalseverebrachial_plexus_compression_neurologic_deficit
    Massive UEDVT with brachial plexus compression causing new motor or sensory deficit
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalmoderatepaget_schroetter_within_14d_low_bleed_risk
    Primary UEDVT (Paget-Schroetter) within 14 days of onset in patient with low bleed risk
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalmoderatecatheter_essential_must_retain
    Secondary UEDVT with catheter essential for care (chemotherapy access, no alternative) — must retain while anticoagulating
    Trigger could not be auto-evaluated — needs clinician judgement.

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ENTRYoptionalDrives risk stratification
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Recommended regimen

Upper-extremity DVT anticoagulation — DOAC-first per ACCP 2021
axis: uedvt_anticoagulation_phenotype
Selected axis "Upper-extremity DVT anticoagulation — DOAC-first per ACCP 2021" by default fallback (first axis)
  • apixaban
    first line
    doac_factor_xa_direct
    10 mg BID × 7 d → 5 mg BID • PO • BID × ≥3 months (or while catheter in place)
    triggers: uedvt_confirmed, no_active_bleed
    AMPLIFY PMID 23808982 — UEDVT extrapolated; ACCP 2021 supports DOAC for UEDVT
    rxcui 1364430
  • rivaroxaban
    first line
    doac_factor_xa_direct
    15 mg BID × 21 d → 20 mg daily • PO • BID then daily × ≥3 months
    triggers: uedvt_confirmed, egfr_above_30
    EINSTEIN-DVT subgroup; ACCP 2021
    rxcui 1114195
  • edoxaban
    first line
    doac_factor_xa_direct
    60 mg daily after 5 d LMWH lead-in • PO • daily × ≥3 months
    triggers: uedvt_confirmed, lmwh_lead_in_completed
    Hokusai-VTE PMID 23991958 — UEDVT included in trial
    rxcui 1599538
  • enoxaparin
    comorbidity specific
    lmwh
    1 mg/kg SC BID • SC • BID
    triggers: pregnancy, active_cancer_doac_unsafe, severe_renal_impairment
    ASH 2018 in pregnancy; CARAVAGGIO PMID 32223112 alt in cancer-UEDVT
    rxcui 67108
  • alteplase
    comorbidity specific
    fibrinolytic_tpa
    0.5-1 mg/h via catheter for 12-24 h • IV_catheter • continuous infusion
    triggers: paget_schroetter_within_14d, severe_symptoms, low_bleed_risk
    CDT for primary (Paget-Schroetter) within 14 d restores venous patency; Engelberger Thromb Res 2014; Joffe ASH 2017
    rxcui 8410

outpatient playbook — drug actions (2)

  1. 1. no AC post-treatment for resolved UEDVT
    n/a • n/a • n/a
    trigger: Completed 3 months AC + risk factor resolved
    ACCP 2021
  2. 2. extended-phase apixaban if unprovoked or recurrent
    rxcui 1364430
    apixaban 2.5 mg BID • PO • BID
    trigger: Unprovoked recurrent UEDVT or persistent risk
    AMPLIFY-EXT PMID 23216615

Auto-drafted A&P note

outpatient

Subjective

- Possible entry pathways: Unilateral arm swelling, pain, warmth, prominent collateral veins → suggests UEDVT; Young athlete with repetitive arm overhead activity (rowing, swimming, weightlifting) → Paget-Schroetter (primary UEDVT); CVC, PICC, port, or pacemaker lead present → secondary UEDVT (most common cause).

Objective

- No vitals, labs, or imaging entered for this encounter.

Assessment

**Upper-extremity DVT (subclavian / axillary / brachial)** (cardio.dvt.upper-extremity.v1).
Scope: UEDVT — primary (Paget-Schroetter) vs secondary (catheter-associated) classification is the central differentiator; routes diverge significantly

No severity triggers fired against current inputs.

Plan

Regimen axis: **Upper-extremity DVT anticoagulation — DOAC-first per ACCP 2021**.
1. apixaban 10 mg BID × 7 d → 5 mg BID PO BID × ≥3 months (or while catheter in place) (doac_factor_xa_direct, first line) — AMPLIFY PMID 23808982 — UEDVT extrapolated; ACCP 2021 supports DOAC for UEDVT
2. rivaroxaban 15 mg BID × 21 d → 20 mg daily PO BID then daily × ≥3 months (doac_factor_xa_direct, first line) — EINSTEIN-DVT subgroup; ACCP 2021
3. edoxaban 60 mg daily after 5 d LMWH lead-in PO daily × ≥3 months (doac_factor_xa_direct, first line) — Hokusai-VTE PMID 23991958 — UEDVT included in trial
4. enoxaparin 1 mg/kg SC BID SC BID (lmwh, comorbidity specific) — ASH 2018 in pregnancy; CARAVAGGIO PMID 32223112 alt in cancer-UEDVT
5. alteplase 0.5-1 mg/h via catheter for 12-24 h IV_catheter continuous infusion (fibrinolytic_tpa, comorbidity specific) — CDT for primary (Paget-Schroetter) within 14 d restores venous patency; Engelberger Thromb Res 2014; Joffe ASH 2017

Setting playbook (outpatient) — Long-term surveillance: primary post-first-rib resection (most patients durable patency); secondary post-AC course; rare extended-AC scenarios
6. no AC post-treatment for resolved UEDVT n/a n/a n/a — Completed 3 months AC + risk factor resolved (ACCP 2021)
7. extended-phase apixaban if unprovoked or recurrent apixaban 2.5 mg BID PO BID — Unprovoked recurrent UEDVT or persistent risk (AMPLIFY-EXT PMID 23216615)

Non-pharmacologic actions:
- Activity modification if athlete (primary UEDVT) post-surgery
- Catheter alternatives counseling if recurrent secondary UEDVT

AVOID / contraindication checks:
- Doac_avoid_active_bleeding (FDA labels)
- Apixaban_avoid_egfr_below_15 (FDA label)
- Cdt_avoid_if_bleed_risk_high (CDT major bleed ~5% — Joffe 2017)
- Decision:remove_non_essential_catheter (Joffe ASH 2017 — most catheter UEDVTs resolve with removal + AC)
- Decision:retain_essential_catheter_with_AC (Kahale et al. Cochrane 2018)

Monitoring

Regimen monitoring:
- cbc q week x first 4 weeks (ASH 2020)
- arm circumference at baseline and 3mo for residual swelling
- venous patency us at 3mo post cdt for paget schroetter
- reassess catheter need weekly if secondary

Setting (outpatient) monitoring:
- Annual reassessment

Follow-up plan: 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)
- Close-out criterion: long-term plan documented

Monitoring phase: Bleeding screen; arm function (residual swelling, dexterity); for primary post-CDT: venous patency surveillance; for secondary: re-evaluate catheter need

Disposition

Current setting: outpatient — Long-term surveillance: primary post-first-rib resection (most patients durable patency); secondary post-AC course; rare extended-AC scenarios

Disposition criteria:
- Long-term annual follow-up

Escalation triggers (move to higher acuity):
- Recurrent UEDVT → re-evaluate anatomy and AC strategy

Earlier-Return Triggers

Return-precaution thresholds (watch for):
- [LIFE_THREATENING] UEDVT extending to or causing SVC syndrome (facial swelling, plethora, dyspnea, dilated chest collaterals)
- [LIFE_THREATENING] UEDVT with concurrent PE (~10-15% rate) — particularly common in catheter-associated UEDVT
- [SEVERE] Massive UEDVT with brachial plexus compression causing new motor or sensory deficit

Citations

- ACCP/CHEST 2021 Antithrombotic + ASH 2020 VTE Treatment + Joffe ASH 2017 UEDVT review [PMID:34352295](https://pubmed.ncbi.nlm.nih.gov/34352295/)
- Cited evidence (PMID 33007077) [PMID:33007077](https://pubmed.ncbi.nlm.nih.gov/33007077/)
- Cited evidence (PMID 23808982) [PMID:23808982](https://pubmed.ncbi.nlm.nih.gov/23808982/)
- Cited evidence (PMID 23216615) [PMID:23216615](https://pubmed.ncbi.nlm.nih.gov/23216615/)
- Cited evidence (PMID 21128814) [PMID:21128814](https://pubmed.ncbi.nlm.nih.gov/21128814/)

Last reconciled with current guidelines: 2026-05-14.
References