**11. References**


Patients with central venous catheters carry a high risk of deep arm vein thrombosis, which may exceed 60 % in certain patient groups (ICU patients, oncological and hematological patients) Van Rooden et al*.*, 2005. Therefore, approaches to prevent catheter-related thrombosis by means of pharmacological prophylaxis e.g. in cancer patients, appear attractive. However, despite an early study showing benefit of low dose warfarin in this context (Bern et al*.*, 1990), subsequent studies with warfarin and heparins could not confirm this protective effect. A recent meta-analysis did show a trend, but no significant reduction of symptomatic deep vein thrombosis with any form of thromboprophylaxis (Akl et al*.*, 2008). In accordance with these data, the current guidelines for the prevention of venous thromboembolism do not recommend routine use of thromboprophyaxis in cancer patients

The placement of superior vena cava filters has been reported in case reports and small case series. Although effective in preventing pulmonary embolism from thrombi in the upper extremities, these filters may cause severe complications, like cardiac tamponade and aortic perforation (Owens et al*.*, 2010) and do not protect from thrombi in the lower extremities. Therefore, the placement of these filters should be limited to special situations (Kucher, 2011).

About 5% of all thromboses are expected to occur in the deep veins of the upper extremities. Besides effort-related thromboses, most patients with arm vein thrombosis have typical risk factors, like central venous catheters or malignancies. Typical clinical syndromes include edema and localized pain, whereas other patients are asymptomatic or present with complex syndromes. Today, diagnosis will most often be performed by ultrasound; in some cases additional testing (e.g. computed tomography scanning, magnetic resonance imaging) will be necessary. The most important complications are recurrent thrombosis, pulmonary embolism and post-thrombotic syndrome. Treatment should be initiated without delay and consist in most cases of standard anticoagulation treatment with heparins followed by a vitamin K antagonist for at least 3 months. In selected cases, invasive therapeutic regimes including catheter-guided thrombolysis and surgical procedures may be applied. Routine prevention of catheter-related thrombosis or embolic complications by anticoagulants in prophylactic doses or implantation of superior vena cava filters is not recommended. Compared to deep vein thrombosis of the lower extremities, deep vein thrombosis of the arm veins has been studied much less intensely. For example, the optimal duration of anticoagulant therapy and the value of compression therapy are not precisely known for arm vein thromboses. Therefore, many of the current recommendation are in fact extrapolations from data on deep leg vein thrombosis. Specific studies are needed to better understand the pathogenesis of deep vein thrombosis of

Akl, E.A.; Kamath, G.; Yosuico, V.; Kim, S.Y.; Barba, M.; Sperati, F.; Cook, D.J. & Schunemann,

Baarslag, H.J.; Van Beek, E.J.R.; Tijssen, J.G.P.; van Delden, O.M.; Bakker, A.J. & Reekers, J.A.

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H.J. (2008) Thromboprophylaxis for patients with cancer and central venous

(2003) Deep vein thrombosis of the upper extremity: intra- and interobserver study of

with indwelling central venous catheters (Geerts et al*.*, 2008).

the arms and to improve diagnostic and therapeutic strategies.

catheters. *Cancer* 112, 2483-2492.

**11. References** 

**10. Conclusions / open questions** 

**9. Prevention** 


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**9** 

*1Italy 2Canada* 

**The Post Thrombotic Syndrome** 

*Sir Mortimer B. Davis Jewish General Hospital, Montreal, Quebec* 

Despite appropriate anticoagulant therapy, at least 1 of every 2-3 patients with deep-vein thrombosis (DVT) of the lower extremities will develop post-thrombotic sequelae. These vary from minor signs (i.e., stasis pigmentation, venous ectasia, slight pain and swelling) to severe manifestations such as chronic pain, intractable edema and leg ulcers (1). The established postthrombotic syndrome (PTS) remains a significant cause of chronic illness, with considerable

The precise incidence of the PTS following confirmed venous thrombosis is still controversial, as the rate of post-thrombotic sequelae reported in published studies has varied between 20% and 100%. In earlier studies, a surprisingly high rate of severe PTS complications was reported (50 to 100% of the patients within 4 to 10 years after the qualifying thrombotic episode) (4-6). This rate sharply decreased in studies performed in the last 25 years (7-39), which could be due to improved diagnostic and therapeutic approaches to patients with DVT. However, owing to large differences among studies in terms of study design, definition of PTS, sample size, length of follow-up, and use of compression elastic stockings, the reported incidence of both overall and severe PTS still shows considerable variability. In the absence of elastic stockings, PTS is expected to develop in approximately 50% of patients suffering an episode of DVT, and is severe in one fifth of patients (1). Of interest, PTS can develop, although to a lower extent, also after an asymptomatic episode of

According to the results of the most recent studies, most patients who develop postthrombotic manifestations become symptomatic within two years from the acute episode of DVT (1,18-20,29-32,35-37,39). These findings challenge the general view that the PTS

The post-thrombotic syndrome is characterized by aching pain on standing, dependent edema, and the frequent development of brawny, tender induration of the subcutaneous

socio-economic consequences for both the patient and the health care services (2,3).

**1. Introduction** 

postoperative DVT (40,41).

requires many years to become manifest.

**2.1 Clinical diagnosis and scoring systems** 

**2. Clinical diagnosis and objective diagnostic testing** 

*1Department of Cardiothoracic and Vascular Sciences, Thromboembolism Unit, University of Padua, Padua 2Centre for Clinical Epidemiology and Community Studies,* 

Paolo Prandoni1 and Susan R Kahn2

clinical course of acute deep vein thrombosis of the arm: prospective cohort study. *BMJ* 329, 484-485.

