Treatment with direct oral anticoagulants in patients with upper extremity deep vein thrombosis

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Abstract

Background

Upper extremity deep vein thrombosis (UEDVT) constitutes around 10% of all DVT, and can cause both pulmonary embolism (PE) and postthrombotic syndrome (PTS) in the arm. The incidence of secondary UEDVT is increasing due to widespread use of central venous catheters in patients with cancer and other chronic diseases. The safety and efficacy of using new direct acting oral anti coagulants (DOAC) in the treatment of UEDVT has not been systematically evaluated. Our aims were to evaulate efficacy, safety, and risk of recurrence of venous thromboembolism (VTE) during DOAC treatment in UEDVT patients.

Methods

Data from the Swedish national anticoagulation registry (AuriculA) was retrospectively evaluated for all 55 patients (27 men aged 23–86 years, and 28 women aged 18–75 years) treated with DOAC because of UEDVT between 2012 and 2015 in the southernmost hospital region of Sweden with 1.3 million inhabitants in 2016. Patients were followed for 6 months.

Results

During 6 months after institution of DOAC treatment there was one recurrence (2%) of DVT during treatment and two (4%) recurrences after cessation of treatment. No patient died, whereas one (2%) suffered a clinically relevant nonmajor bleeding.

Conclusion

DOAC can be used in the treatment of UEDVT patients with acceptable efficacy and safety.

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Most cited references 9

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Clinical outcome of patients with upper-extremity deep vein thrombosis: results from the RIETE Registry.

Renzo Poggio, Mario F Muñoz, Reina Valle … (2007)

There is little information on the clinical outcome of patients with upper-extremity deep vein thrombosis (DVT). RIETE is an ongoing registry of consecutive patients with objectively confirmed, symptomatic, acute DVT or pulmonary embolism (PE). In this analysis, we analyzed the demographic characteristics, treatment, and 3-month outcome of all patients with DVT in the arm. Of the 11,564 DVT patients enrolled, 512 patients (4.4%) had arm DVT. They presented less often with clinically overt PE (9.0% vs 29%; odds ratio, 0.24; 95% confidence interval [CI], 0.18 to 0.33) than those with lower-limb DVT, but their 3-month outcome was similar. Of the 512 patients with arm DVT, 196 patients (38%) had cancer and 228 patients (45%) had catheter-related DVT. During follow-up, those with cancer DVT had an increased incidence of major bleeding (4.1% vs 0.9%; odds ratio, 4.4; 95% CI, 1.2 to 21), recurrent venous thromboembolism (6.1% vs 2.8%; odds ratio, 2.2; 95% CI, 0.91 to 5.6; p = 0.04), and death (22% vs 3.5%; odds ratio, 7.8; 95% CI, 4.0 to 16). Thirty patients had the composite event of recurrent DVT, symptomatic PE, or major bleeding. They were significantly older, more often had cancer, and presented more frequently with symptomatic PE on hospital admission. On multivariate analysis, only cancer patients with arm DVT had an increased risk for the composite event (odds ratio, 3.0; 95% CI, 1.4 to 6.4). At presentation, patients with arm DVT have less often clinically overt PE than those with lower-limb DVT, but their 3-month outcome is similar. Among patients with arm DVT, those with cancer have the worse outcome.

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Evolving use of new oral anticoagulants for treatment of venous thromboembolism.

Calvin H. Yeh, Peter Gross, Jeffrey Weitz (2014)

The new oral anticoagulants (NOACs), which include dabigatran, rivaroxaban, apixaban, and edoxaban, are poised to replace warfarin for treatment of the majority of patients with venous thromboembolism (VTE). With a rapid onset of action and the capacity to be administered in fixed doses without routine coagulation monitoring, NOACs streamline VTE treatment. In phase 3 trials in patients with acute symptomatic VTE, NOACs have been shown to be noninferior to conventional anticoagulant therapy for prevention of recurrence and are associated with less bleeding. Rivaroxaban and dabigatran are already licensed for VTE treatment in the United States, and apixaban and edoxaban are under regulatory consideration for this indication. As the number of approved drugs increases, clinicians will need to choose the right anticoagulant for the right VTE patient. To help with this decision, this review (1) compares the pharmacologic profiles of the NOACs, (2) outlines the unique design features of the phase 3 trials that evaluated the NOACs for VTE treatment, (3) reviews the results of these trials highlighting similarities and differences in the findings, (4) provides perspective about which VTE patients should receive conventional treatment or are candidates for NOACs, and (5) offers suggestions about how to choose among the NOACs.

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Upper extremity deep venous thrombosis in the population-based Malmö thrombophilia study (MATS). Epidemiology, risk factors, recurrence risk, and mortality.

Nazim Isma, Peter J. Svensson, Anders Gottsäter … (2010)

Deep venous thrombosis (DVT) is much less common in the upper than in the lower extremity. Furthermore, there is limited information on risk factors for and the prognosis of upper extremity (UE)DVT in the general population. To estimate incidence, risk factors, and prognosis in UEDVT. Among a total of 1203 patients with venous thromboembolism (VTE) diagnosed during 1998-2006 in the prospective population-based Malmö thrombophilia study, 63 (5%, 33 men [52%, age 54+/-17years], and 30 women [48%, age 55+/-22years]) had UEDVT and were evaluated concerning risk factors, treatment, recurrent VTE, and mortality. At diagnosis, 19(30%) patients had known malignancy and 6(10%) had VTE heredity. Among female UEDVT patients 4(13%) used hormone therapy, 1(3%) was pregnant, while none was in the postpartum period. Of all 63 UEDVT patients, 12(19%) were heterozygous, and 3(5%) homozygous for the Factor V Leiden (FVL)-mutation. Two (3%) patients were heterozygous for the prothrombin mutation, and 1 patient (1.6%) showed both heterozygous FVL-mutation and lupus anticoagulant antibodies. Phlebography had been used for diagnosis in 48(76%), ultrasonography in 16(25%), and computer tomography (CT) in 9(14%) patients. Twenty-two patients (35%) were treated in hospital, and the remaining 41(65%) as out-patients. Sixty-two (98%) was treated with low molecular weight heparin (LMH), 60(95%) with oral anticoagulants (OAC), 3(5%) with unfractionated heparin, and 3(5%) with thrombolysis. VTE recurrence rate during median 62 (range 31-117) month of follow-up was 8/63(13%). Fifteen (24%) UEDVT patients died during follow-up; 9(47%) of the 19 patients with known malignancy at diagnosis and 6(14%) of the other patients. Yearly incidence of UEDVT was 3.6/100.000 (95% confidence interval [CI], 3.3 - 4.03). Malignancies and the FVL mutation were common among patients with UEDVT. Mortality during follow-up vas high. Copyright 2010 Elsevier Ltd. All rights reserved.

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Author and article information

Contributors

Johan Elf: 00 46 40 331187 , johan.elf@skane.se

Journal

Journal ID (nlm-ta): Thromb J

Journal ID (iso-abbrev): Thromb J

Title: Thrombosis Journal

Publisher: BioMed Central (London )

ISSN (Electronic): 1477-9560

Publication date (Electronic): 3 October 2017

Publication date PMC-release: 3 October 2017

Publication date Collection: 2017

Volume: 15

Electronic Location Identifier: 26

Affiliations

ISNI 0000 0004 0623 9987, GRID grid.412650.4, Department of Vascular Diseases, , Lund University, Skåne University Hospital, ; S-205 02 Malmö, Sweden

Article

Publisher ID: 149

DOI: 10.1186/s12959-017-0149-x

PMC ID: 5625705

PubMed ID: 29026346

SO-VID: 1c1c23f1-8e85-478b-9831-b2e4597350f7

License:

Open AccessThis article is distributed under the terms of the Creative Commons Attribution 4.0 International License ( http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver ( http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated.

History

Date received : 12 May 2017

Date accepted : 15 August 2017

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ScienceOpen disciplines: Cardiovascular Medicine

Keywords: venous thromboembolism,upper extremity deep vein thrombosis,direct acting oral anti coagulants

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ScienceOpen disciplines: Cardiovascular Medicine

Keywords: venous thromboembolism, upper extremity deep vein thrombosis, direct acting oral anti coagulants

Treatment with direct oral anticoagulants in patients with upper extremity deep vein thrombosis

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Cardiovascular Innovations and Applications

Most cited references 9

Clinical outcome of patients with upper-extremity deep vein thrombosis: results from the RIETE Registry.

Evolving use of new oral anticoagulants for treatment of venous thromboembolism.

Upper extremity deep venous thrombosis in the population-based Malmö thrombophilia study (MATS). Epidemiology, risk factors, recurrence risk, and mortality.

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