**9. Conclusions and future directions**

Despite its proven efficacy, VTE prophylaxis in cancer patients is clearly underutilized. Strategies to improve prophylaxis rate in such high risk patients are highly needed (Abdel-Razeq, 2010). Establishment of "VTE prophylaxis multidisciplinary team" addressing this issue supported by hospital administration might help. Recently, many health advocacy groups and policy makers are paying more attention to VTE prophylaxis. The National Quality Forum (NQF) recently endorsed strict VTE risk assessment evaluation for each patient upon admission and regularly thereafter (National Quality Forum (NQF), 2011). Additionally, the Joint Commission has recently approved new measure sets that included VTE prophylaxis; this standard mandates that a VTE prophylaxis method is in place within 24 hours of hospital admission, otherwise, a risk assessment and contraindications for prophylaxis should be documented for each and every hospitalized medical or surgical patient (The Joint Commission Manual for Performance Improvement Measures, 2011). Recently, Maynard and Stein (2011) have published their experience and recommendations following their extensive efforts to better utilize VTE prophylaxis in high-risk patients. Such recommendations are worth careful attention and are summarized in table-3.


In conclusion, though published guidelines are somewhat different; hospitalized cancer patients, in the absence of bleeding or absolute contraindications, should be considered for thromboprophylaxis. Certain cancers, like Multiple Myeloma when treated with drugs like thalidomide or other immune modulators may benefit from prophylaxis. However, current guidelines do not recommend prophylaxis for ambulatory cancer patients or patients with central venous catheter.

Extended thromboprophylaxis with LMWH (21-28days) should be considered in cancer patients undergoing major pelvic/abdominal surgeries.

Venous Thromboembolism Prophylaxis in Cancer Patients 123

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### **10. Acknowledgments**

The authors would like to thank Ms. Haifa Al-Ahmad and Mrs. Alice Haddadin for their help in preparing this manuscript.

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**8** 

Peter Marschang

*Austria* 

*Innsbruck Medical University* 

**Deep Vein Thrombosis of the Arms** 

Deep vein thrombosis is often regarded as a disease limited of the veins of the lower extremities, which may sometimes – in more severe cases - extend to the pelvic veins. Although this holds true for over 90% of all thromboses, clinically relevant thromboses may be found in virtually every vein system of the body. Of these uncommon localisations of thromboses, deep vein thrombosis of the arms is one of the most frequent entities, accounting for about 5% of all thromboses (Munoz et al*.*, 2008; Isma et al*.*, 2010). Most cases of deep arm vein thrombosis develop secondary in patients with indwelling central venous catheters, pacemakers, malignant disease, or after surgery. Conversely, primary upper extremity deep venous thrombosis is observed in patients after strenuous arm exercise ("thrombosis par effort"), in thoracic outlet syndrome and inherited or acquired thrombophilia (Bernardi et al*.*, 2006). Acute and long-time complications of upper extremity thrombosis may be significant and include pulmonary embolism, post-thrombotic syndrome and recurrent thromboembolism. In this chapter, the clinical presentation, diagnostic procedures, treatment and prevention of thromboses of the upper extremity will be reviewed. It is not unusual to find thromboses of proximal arm veins and deep veins of the neck region at the same time. Therefore, thromboses of the internal jugular vein, which are also most often observed in the presence of indwelling central venous catheters, will also be discussed. In this review, special emphasis will be given to the practical aspects of the disease, like risk factors, clinical presentation, diagnosis, and treatment of arm vein thrombosis. For a detailed, comprehensive overview of pathophysiological mechanisms, the

The frequency of deep arm vein thrombosis relative to all deep thromboses has been reported to be between 1 and 14% (Hill & Berry, 1990; Joffe et al*.*, 2004; Spencer et al*.*, 2007). Recently, the prospective RIETE registry and the population based Malmö thrombophilia study reported both very similar rates of upper extremity deep vein thrombosis (4.4% and 5% of all thrombosis, respectively (Munoz et al*.*, 2008; Isma et al*.*, 2010). Therefore, it can be assumed that about 5% of all thrombosis will involve the deep arm veins, which corresponds to an annual incidence of approximately 3 per 100.000 patients per year (Bernardi et al*.*, 2006). Less than 50% of these arm vein thromboses can be expected to extend into the internal jugular vein (Gbaguidi et al*.*, 2011). About one

reader will be referred to other, excellent reviews within this field.

**1. Introduction** 

**2. Epidemiology** 

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