The post-thrombotic syndrome after upper extremity deep venous thrombosis in adults

PTS is a frequent complication of UEDVT, yet little is known regarding risk factors and optimal management. A standardized means of diagnosis would help to establish better management protocols. The impact of upper extremity PTS on quality of life should be further quantified.
Seven studies were reviewed. The frequency of PTS after UEDVT ranges from 7- 46% (weighted mean 15%). Residual thrombosis and Axillo-Subclavian vein thrombosis appear to be associated with an increased risk of PTS, whereas catheter-associated UEDVT may be associated with a decreased risk. There is currently no validated, standardized scale to assess upper extremity PTS, and little consensus regarding the optimal management of this condition. Quality of life is impaired in patients with upper extremity PTS, especially after DVT of the dominant arm.

In our clinical practice, we generally recommend heparin therapy for the  upper limb DVT,  which is less expensive and easy to administer. We do not have  cost benefit evaluation studies comparing the thrombolytic and heparin therapies for upper limb DVT. It is possible to expect the results of thrombolysis in the Upper limb DVT, similar to lower limb DVT. It is also common to see the upper limb DVT in the patients who are on IJV or subclavian catheter for the hemodialysis. In our hospital this aspect of the DVT in the upper limb can be studied further to understand the significance of the PTS in the upper limb DVT associated with central venous catheters.


References:

Elman E E, Kahn SR.The post-thrombotic syndrome after upper extremity deep venous thrombosis in adults: a systematic review. Thromb Res.2006;117(6):609-14. Epub 2005 Jul 6.

Impact of the Initial High Dose of Rivaroxaban on Thrombus Resolution in VTE patients

Initial heparin therapy followed by oral anticoagulation for 3 to 6 month has been standard therapy for DVT in many clinics. The recently introduced Rivaroxaban, Apixaban are given without initial heparin therapy. So, few doctors are still comfortable giving initial heparin therapy and later oral anticoagulation. The question is about the effectiveness of the high dose of Rivaroxaban or Apixaban given initially? Can resolution of the thrombus in those who received Rivaroxaban and Apixaban  can be comparable to that in patients who received the Inj. Heparin? 

Bauersachs R et al (Feb 2017) presented Data accumulating on the use of non-VKA oral anticoagulants, such as Rivaroxaban. He is of the opinion that these may provide greater thrombus resolution compared with VKAs. Data from the phase III Rivaroxaban studies discussed showed that a 21-day intensive dosing regimen of Rivaroxaban 15 mg twice daily is effective during the acute treatment phase for VTE, with similar recurrence rates and thrombus resolution to standard anticoagulation.

Probably one may need some more time, studies and availability of the antidote to reverse these drug effects, before he or she can consider recommending the high dose initial therapies of NOACs with more confidence.

References:

1). Bauersachs R¹, Koitabashi N. Overview of Current Evidence on the Impact of the Initial High Dose of the Direct Factor Xa Inhibitor Rivaroxaban on Thrombus Resolution in the Treatment of Venous Thromboembolism. Int Heart J. 2017 Feb 7;58(1):6-15.

https://www.ncbi.nlm.nih.gov/pubmed/28123163