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Catheter-related upper extremity venous thrombosis

Caroline Bérubé, MD
James L Zehnder, MD
Section Editors
John F Eidt, MD
Joseph L Mills, Sr, MD
Deputy Editor
Kathryn A Collins, MD, PhD, FACS


Intravenous catheters cause endothelial trauma and inflammation, which can lead to venous thrombosis. The majority (70 to 80 percent) of thrombotic events occurring in the superficial and deep veins of the upper extremity are due to the presence of intravenous catheters. The remainder is due to mechanical compression from anatomic abnormalities (ie, venous thoracic outlet syndrome) [1-3].

Superficial thrombophlebitis due to peripheral catheters is generally self-limited once the catheter is removed. Thrombosis involving the deep veins (ie, subclavian, axillary, brachial) can lead to pulmonary embolism and long-term sequelae in spite of adequate therapy [4]. Pulmonary embolism from upper extremity sources accounts for about 6 percent of cases [5-7].

Upper extremity venous thrombosis (superficial and deep) as a complication of indwelling venous catheters will be reviewed here. Thrombosis involving the lower extremity veins is discussed elsewhere. (See "Phlebitis and thrombosis of the superficial lower extremity veins" and "Diagnosis of suspected deep vein thrombosis of the lower extremity".)

General issues regarding deep venous thrombosis, primary causes of upper extremity deep venous thrombosis, and thrombosis related to hemodialysis access are also discussed elsewhere. (See "Overview of the causes of venous thrombosis" and "Primary (spontaneous) upper extremity deep vein thrombosis" and "Central catheters for acute and chronic hemodialysis access".)


The upper extremity veins are divided into the superficial and deep systems (figure 1).


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Literature review current through: Sep 2016. | This topic last updated: Apr 18, 2016.
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  1. Verso M, Agnelli G. Venous thromboembolism associated with long-term use of central venous catheters in cancer patients. J Clin Oncol 2003; 21:3665.
  2. Mustafa S, Stein PD, Patel KC, et al. Upper extremity deep venous thrombosis. Chest 2003; 123:1953.
  3. Flinterman LE, Van Der Meer FJ, Rosendaal FR, Doggen CJ. Current perspective of venous thrombosis in the upper extremity. J Thromb Haemost 2008; 6:1262.
  4. Joffe HV, Kucher N, Tapson VF, et al. Upper-extremity deep vein thrombosis: a prospective registry of 592 patients. Circulation 2004; 110:1605.
  5. Muñoz FJ, Mismetti P, Poggio R, et al. Clinical outcome of patients with upper-extremity deep vein thrombosis: results from the RIETE Registry. Chest 2008; 133:143.
  6. Kucher N. Clinical practice. Deep-vein thrombosis of the upper extremities. N Engl J Med 2011; 364:861.
  7. Owens CA, Bui JT, Knuttinen MG, et al. Pulmonary embolism from upper extremity deep vein thrombosis and the role of superior vena cava filters: a review of the literature. J Vasc Interv Radiol 2010; 21:779.
  8. Otten TR, Stein PD, Patel KC, et al. Thromboembolic disease involving the superior vena cava and brachiocephalic veins. Chest 2003; 123:809.
  9. Rooden CJ, Tesselaar ME, Osanto S, et al. Deep vein thrombosis associated with central venous catheters - a review. J Thromb Haemost 2005; 3:2409.
  10. Luciani A, Clement O, Halimi P, et al. Catheter-related upper extremity deep venous thrombosis in cancer patients: a prospective study based on Doppler US. Radiology 2001; 220:655.
  11. Paauw JD, Borders H, Ingalls N, et al. The incidence of PICC line-associated thrombosis with and without the use of prophylactic anticoagulants. JPEN J Parenter Enteral Nutr 2008; 32:443.
  12. Bonizzoli M, Batacchi S, Cianchi G, et al. Peripherally inserted central venous catheters and central venous catheters related thrombosis in post-critical patients. Intensive Care Med 2011; 37:284.
  13. Evans RS, Sharp JH, Linford LH, et al. Risk of symptomatic DVT associated with peripherally inserted central catheters. Chest 2010; 138:803.
  14. Trerotola SO, Stavropoulos SW, Mondschein JI, et al. Triple-lumen peripherally inserted central catheter in patients in the critical care unit: prospective evaluation. Radiology 2010; 256:312.
  15. Mino JS, Gutnick JR, Monteiro R, et al. Line-associated thrombosis as the major cause of hospital-acquired deep vein thromboses: an analysis from National Surgical Quality Improvement Program data and a call to reassess prophylaxis strategies. Am J Surg 2014; 208:45.
  16. Major KM, Bulic S, Rowe VL, et al. Internal jugular, subclavian, and axillary deep venous thrombosis and the risk of pulmonary embolism. Vascular 2008; 16:73.
  17. Saseedharan S, Bhargava S. Upper extremity deep vein thrombosis. Int J Crit Illn Inj Sci 2012; 2:21.
  18. Safdar N, Maki DG. Risk of catheter-related bloodstream infection with peripherally inserted central venous catheters used in hospitalized patients. Chest 2005; 128:489.
  19. Yukisawa S, Fujiwara Y, Yamamoto Y, et al. Upper-extremity deep vein thrombosis related to central venous port systems implanted in cancer patients. Br J Radiol 2010; 83:850.
  20. Mandal S, Pande A, Mandal D, et al. Permanent pacemaker-related upper extremity deep vein thrombosis: a series of 20 cases. Pacing Clin Electrophysiol 2012; 35:1194.
  21. Da Costa SS, Scalabrini Neto A, Costa R, et al. Incidence and risk factors of upper extremity deep vein lesions after permanent transvenous pacemaker implant: a 6-month follow-up prospective study. Pacing Clin Electrophysiol 2002; 25:1301.
  22. Saber W, Moua T, Williams EC, et al. Risk factors for catheter-related thrombosis (CRT) in cancer patients: a patient-level data (IPD) meta-analysis of clinical trials and prospective studies. J Thromb Haemost 2011; 9:312.
  23. Nifong TP, McDevitt TJ. The effect of catheter to vein ratio on blood flow rates in a simulated model of peripherally inserted central venous catheters. Chest 2011; 140:48.
  24. Wilson TJ, Brown DL, Meurer WJ, et al. Risk factors associated with peripherally inserted central venous catheter-related large vein thrombosis in neurological intensive care patients. Intensive Care Med 2012; 38:272.
  25. O'Brien J, Paquet F, Lindsay R, Valenti D. Insertion of PICCs with minimum number of lumens reduces complications and costs. J Am Coll Radiol 2013; 10:864.
  26. Fallouh N, McGuirk HM, Flanders SA, Chopra V. Peripherally Inserted Central Catheter-associated Deep Vein Thrombosis: A Narrative Review. Am J Med 2015; 128:722.
  27. Winters JP, Callas PW, Cushman M, et al. Central venous catheters and upper extremity deep vein thrombosis in medical inpatients: the Medical Inpatients and Thrombosis (MITH) Study. J Thromb Haemost 2015; 13:2155.
  28. Nitta K, Yoneyama M. Polymer concentration dependence of the helix to random coil transition of a charged polypeptide in aqueous salt solution. Biophys Chem 1975; 3:323.
  29. Chopra V, Anand S, Hickner A, et al. Risk of venous thromboembolism associated with peripherally inserted central catheters: a systematic review and meta-analysis. Lancet 2013; 382:311.
  30. Grove JR, Pevec WC. Venous thrombosis related to peripherally inserted central catheters. J Vasc Interv Radiol 2000; 11:837.
  31. Liem TK, Yanit KE, Moseley SE, et al. Peripherally inserted central catheter usage patterns and associated symptomatic upper extremity venous thrombosis. J Vasc Surg 2012; 55:761.
  32. Patel GS, Jain K, Kumar R, et al. Comparison of peripherally inserted central venous catheters (PICC) versus subcutaneously implanted port-chamber catheters by complication and cost for patients receiving chemotherapy for non-haematological malignancies. Support Care Cancer 2014; 22:121.
  33. Chopra V, Anand S, Krein SL, et al. Bloodstream infection, venous thrombosis, and peripherally inserted central catheters: reappraising the evidence. Am J Med 2012; 125:733.
  34. Woller SC, Stevens SM, Jones JP, et al. Derivation and validation of a simple model to identify venous thromboembolism risk in medical patients. Am J Med 2011; 124:947.
  35. Greene MT, Flanders SA, Woller SC, et al. The Association Between PICC Use and Venous Thromboembolism in Upper and Lower Extremities. Am J Med 2015; 128:986.
  36. King MM, Rasnake MS, Rodriguez RG, et al. Peripherally inserted central venous catheter-associated thrombosis: retrospective analysis of clinical risk factors in adult patients. South Med J 2006; 99:1073.
  37. Marnejon T, Angelo D, Abu Abdou A, Gemmel D. Risk factors for upper extremity venous thrombosis associated with peripherally inserted central venous catheters. J Vasc Access 2012; 13:231.
  38. Brook I, Frazier EH. Aerobic and anaerobic microbiology of superficial suppurative thrombophlebitis. Arch Surg 1996; 131:95.
  39. van Rooden CJ, Schippers EF, Barge RM, et al. Infectious complications of central venous catheters increase the risk of catheter-related thrombosis in hematology patients: a prospective study. J Clin Oncol 2005; 23:2655.
  40. O'Grady NP, Alexander M, Dellinger EP, et al. Guidelines for the prevention of intravascular catheter-related infections. Centers for Disease Control and Prevention. MMWR Recomm Rep 2002; 51:1.
  41. Dentali F, Gianni M, Agnelli G, Ageno W. Association between inherited thrombophilic abnormalities and central venous catheter thrombosis in patients with cancer: a meta-analysis. J Thromb Haemost 2008; 6:70.
  42. Warkentin TE, Cook DJ. Current perspective of venous thrombosis in the upper extremity: a rebuttal. J Thromb Haemost 2009; 7:237.
  43. Fijnheer R, Paijmans B, Verdonck LF, et al. Factor V Leiden in central venous catheter-associated thrombosis. Br J Haematol 2002; 118:267.
  44. Leebeek FW, Stadhouders NA, van Stein D, et al. Hypercoagulability states in upper-extremity deep venous thrombosis. Am J Hematol 2001; 67:15.
  45. Riordan M, Weiden PL. Factor V Leiden mutation does not account for central venous catheter-related thrombosis. Am J Hematol 1998; 58:150.
  46. Flinterman LE, van Hylckama Vlieg A, Rosendaal FR, Doggen CJ. Venous thrombosis of the upper extremity: effect of blood group and coagulation factor levels on risk. Br J Haematol 2010; 149:118.
  47. Bhakta A, Tafen M, Ahmed M, et al. Risk of catheter-associated deep venous thrombosis in inflammatory bowel disease. Dis Colon Rectum 2014; 57:1379.
  48. Martinelli I, Battaglioli T, Bucciarelli P, et al. Risk factors and recurrence rate of primary deep vein thrombosis of the upper extremities. Circulation 2004; 110:566.
  49. Van Rooden CJ, Rosendaal FR, Meinders AE, et al. The contribution of factor V Leiden and prothrombin G20210A mutation to the risk of central venous catheter-related thrombosis. Haematologica 2004; 89:201.
  50. Hong AP, Cook DJ, Sigouin CS, Warkentin TE. Central venous catheters and upper-extremity deep-vein thrombosis complicating immune heparin-induced thrombocytopenia. Blood 2003; 101:3049.
  51. Lamontagne F, McIntyre L, Dodek P, et al. Nonleg venous thrombosis in critically ill adults: a nested prospective cohort study. JAMA Intern Med 2014; 174:689.
  52. Bern MM, Lokich JJ, Wallach SR, et al. Very low doses of warfarin can prevent thrombosis in central venous catheters. A randomized prospective trial. Ann Intern Med 1990; 112:423.
  53. Lokich JJ, Becker B. Subclavian vein thrombosis in patients treated with infusion chemotherapy for advanced malignancy. Cancer 1983; 52:1586.
  54. Lokich JJ, Bothe A Jr, Benotti P, Moore C. Complications and management of implanted venous access catheters. J Clin Oncol 1985; 3:710.
  55. Oakley GJ, Downey GO, King LA, et al. Symptomatic central venous thrombosis and long-term right atrial catheters. Gynecol Oncol 1990; 36:405.
  56. Bona RD. Central line thrombosis in patients with cancer. Curr Opin Pulm Med 2003; 9:362.
  57. Vayá A, Mira Y, Mateo J, et al. Prothrombin G20210A mutation and oral contraceptive use increase upper-extremity deep vein thrombotic risk. Thromb Haemost 2003; 89:452.
  58. Héron E, Lozinguez O, Alhenc-Gelas M, et al. Hypercoagulable states in primary upper-extremity deep vein thrombosis. Arch Intern Med 2000; 160:382.
  59. Loret de Mola JR, Kiwi R, Austin C, Goldfarb JM. Subclavian deep vein thrombosis associated with the use of recombinant follicle-stimulating hormone (Gonal-F) complicating mild ovarian hyperstimulation syndrome. Fertil Steril 2000; 73:1253.
  60. Rao AK, Chitkara U, Milki AA. Subclavian vein thrombosis following IVF and ovarian hyperstimulation: a case report. Hum Reprod 2005; 20:3307.
  61. Skillman, JJ. Superficial phlebitis: Inflammatory, infectious associated with deep vein thrombosis. In: Decision Making in Vascular Surgery, Cronenwett, JL, Rutherford, RB (Eds), WB Saunders, NY, 2001.
  62. Haire WD, Lieberman RP, Lund GB, et al. Thrombotic complications of silicone rubber catheters during autologous marrow and peripheral stem cell transplantation: prospective comparison of Hickman and Groshong catheters. Bone Marrow Transplant 1991; 7:57.
  63. Baskin JL, Pui CH, Reiss U, et al. Management of occlusion and thrombosis associated with long-term indwelling central venous catheters. Lancet 2009; 374:159.
  64. Monreal M, Raventos A, Lerma R, et al. Pulmonary embolism in patients with upper extremity DVT associated to venous central lines--a prospective study. Thromb Haemost 1994; 72:548.
  65. Prandoni P, Polistena P, Bernardi E, et al. Upper-extremity deep vein thrombosis. Risk factors, diagnosis, and complications. Arch Intern Med 1997; 157:57.
  66. DeRook FA, Comess KA, Albers GW, Popp RL. Transesophageal echocardiography in the evaluation of stroke. Ann Intern Med 1992; 117:922.
  67. Di Tullio M, Sacco RL, Gopal A, et al. Patent foramen ovale as a risk factor for cryptogenic stroke. Ann Intern Med 1992; 117:461.
  68. Constans J, Salmi LR, Sevestre-Pietri MA, et al. A clinical prediction score for upper extremity deep venous thrombosis. Thromb Haemost 2008; 99:202.
  69. Kleinjan A, Di Nisio M, Beyer-Westendorf J, et al. Safety and feasibility of a diagnostic algorithm combining clinical probability, d-dimer testing, and ultrasonography for suspected upper extremity deep venous thrombosis: a prospective management study. Ann Intern Med 2014; 160:451.
  70. Sartori M, Migliaccio L, Favaretto E, et al. Whole-Arm Ultrasound to Rule Out Suspected Upper-Extremity Deep Venous Thrombosis in Outpatients. JAMA Intern Med 2015; 175:1226.
  71. Desjardins B, Rybicki FJ, Kim HS, et al. ACR Appropriateness Criteria® Suspected upper extremity deep vein thrombosis. J Am Coll Radiol 2012; 9:613.
  72. Baarslag HJ, van Beek EJ, Koopman MM, Reekers JA. Prospective study of color duplex ultrasonography compared with contrast venography in patients suspected of having deep venous thrombosis of the upper extremities. Ann Intern Med 2002; 136:865.
  73. Elman EE, Kahn SR. The post-thrombotic syndrome after upper extremity deep venous thrombosis in adults: a systematic review. Thromb Res 2006; 117:609.
  74. Debourdeau P, Kassab Chahmi D, Le Gal G, et al. 2008 SOR guidelines for the prevention and treatment of thrombosis associated with central venous catheters in patients with cancer: report from the working group. Ann Oncol 2009; 20:1459.
  75. Martinelli I, Franchini M, Mannucci PM. How I treat rare venous thromboses. Blood 2008; 112:4818.
  76. Kearon C, Akl EA, Ornelas J, et al. Antithrombotic Therapy for VTE Disease: CHEST Guideline and Expert Panel Report. Chest 2016; 149:315.
  77. Kearon C, Akl EA, Comerota AJ, et al. Antithrombotic therapy for VTE disease: Antithrombotic Therapy and Prevention of Thrombosis, 9th ed: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines. Chest 2012; 141:e419S.
  78. Debourdeau P, Farge D, Beckers M, et al. International clinical practice guidelines for the treatment and prophylaxis of thrombosis associated with central venous catheters in patients with cancer. J Thromb Haemost 2013; 11:71.
  79. Jones MA, Lee DY, Segall JA, et al. Characterizing resolution of catheter-associated upper extremity deep venous thrombosis. J Vasc Surg 2010; 51:108.
  80. Kovacs MJ, Kahn SR, Rodger M, et al. A pilot study of central venous catheter survival in cancer patients using low-molecular-weight heparin (dalteparin) and warfarin without catheter removal for the treatment of upper extremity deep vein thrombosis (The Catheter Study). J Thromb Haemost 2007; 5:1650.
  81. Baskin JL, Reiss U, Wilimas JA, et al. Thrombolytic therapy for central venous catheter occlusion. Haematologica 2012; 97:641.
  82. Monagle P, Chan AK, Goldenberg NA, et al. Antithrombotic therapy in neonates and children: Antithrombotic Therapy and Prevention of Thrombosis, 9th ed: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines. Chest 2012; 141:e737S.
  83. Semba CP, Deitcher SR, Li X, et al. Treatment of occluded central venous catheters with alteplase: results in 1,064 patients. J Vasc Interv Radiol 2002; 13:1199.
  84. Ponec D, Irwin D, Haire WD, et al. Recombinant tissue plasminogen activator (alteplase) for restoration of flow in occluded central venous access devices: a double-blind placebo-controlled trial--the Cardiovascular Thrombolytic to Open Occluded Lines (COOL) efficacy trial. J Vasc Interv Radiol 2001; 12:951.
  85. Haire WD, Atkinson JB, Stephens LC, Kotulak GD. Urokinase versus recombinant tissue plasminogen activator in thrombosed central venous catheters: a double-blinded, randomized trial. Thromb Haemost 1994; 72:543.
  86. Schiffer CA, Mangu PB, Wade JC, et al. Central venous catheter care for the patient with cancer: American Society of Clinical Oncology clinical practice guideline. J Clin Oncol 2013; 31:1357.
  87. Zwicker JI, Connolly G, Carrier M, et al. Catheter-associated deep vein thrombosis of the upper extremity in cancer patients: guidance from the SSC of the ISTH. J Thromb Haemost 2014; 12:796.
  88. Kahn SR, Lim W, Dunn AS, et al. Prevention of VTE in nonsurgical patients: Antithrombotic Therapy and Prevention of Thrombosis, 9th ed: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines. Chest 2012; 141:e195S.
  89. Prandoni P. Prophylaxis of catheter-related thrombosis in cancer patients. Lancet 2009; 373:523.
  90. De Cicco M, Matovic M, Balestreri L, et al. Early and short-term acenocumarine or dalteparin for the prevention of central vein catheter-related thrombosis in cancer patients: a randomized controlled study based on serial venographies. Ann Oncol 2009; 20:1936.
  91. Couban S, Goodyear M, Burnell M, et al. Randomized placebo-controlled study of low-dose warfarin for the prevention of central venous catheter-associated thrombosis in patients with cancer. J Clin Oncol 2005; 23:4063.
  92. Young AM, Billingham LJ, Begum G, et al. Warfarin thromboprophylaxis in cancer patients with central venous catheters (WARP): an open-label randomised trial. Lancet 2009; 373:567.
  93. Mismetti P, Mille D, Laporte S, et al. Low-molecular-weight heparin (nadroparin) and very low doses of warfarin in the prevention of upper extremity thrombosis in cancer patients with indwelling long-term central venous catheters: a pilot randomized trial. Haematologica 2003; 88:67.
  94. Heaton DC, Han DY, Inder A. Minidose (1 mg) warfarin as prophylaxis for central vein catheter thrombosis. Intern Med J 2002; 32:84.
  95. Ruud E, Holmstrøm H, De Lange C, et al. Low-dose warfarin for the prevention of central line-associated thromboses in children with malignancies--a randomized, controlled study. Acta Paediatr 2006; 95:1053.
  96. Vidal E, Sharathkumar A, Glover J, Faustino EV. Central venous catheter-related thrombosis and thromboprophylaxis in children: a systematic review and meta-analysis. J Thromb Haemost 2014; 12:1096.
  97. Akl EA, Kamath G, Yosuico V, et al. Thromboprophylaxis for patients with cancer and central venous catheters: a systematic review and a meta-analysis. Cancer 2008; 112:2483.
  98. Cunningham MS, White B, Hollywood D, O'Donnell J. Primary thromboprophylaxis for cancer patients with central venous catheters--a reappraisal of the evidence. Br J Cancer 2006; 94:189.
  99. Kirkpatrick A, Rathbun S, Whitsett T, Raskob G. Prevention of central venous catheter-associated thrombosis: a meta-analysis. Am J Med 2007; 120:901.e1.
  100. Chaukiyal P, Nautiyal A, Radhakrishnan S, et al. Thromboprophylaxis in cancer patients with central venous catheters. A systematic review and meta-analysis. Thromb Haemost 2008; 99:38.
  101. Rawson KM, Newburn-Cook CV. The use of low-dose warfarin as prophylaxis for central venous catheter thrombosis in patients with cancer: a meta-analysis. Oncol Nurs Forum 2007; 34:1037.
  102. Carrier M, Tay J, Fergusson D, Wells PS. Thromboprophylaxis for catheter-related thrombosis in patients with cancer: a systematic review of the randomized, controlled trials. J Thromb Haemost 2007; 5:2552.
  103. Akl EA, Ramly EP, Kahale LA, et al. Anticoagulation for people with cancer and central venous catheters. Cochrane Database Syst Rev 2014; :CD006468.
  104. D'Ambrosio L, Aglietta M, Grignani G. Anticoagulation for central venous catheters in patients with cancer. N Engl J Med 2014; 371:1362.
  105. Akl EA, Vasireddi SR, Gunukula S, et al. Anticoagulation for patients with cancer and central venous catheters. Cochrane Database Syst Rev 2011; :CD006468.
  106. Lavau-Denes S, Lacroix P, Maubon A, et al. Prophylaxis of catheter-related deep vein thrombosis in cancer patients with low-dose warfarin, low molecular weight heparin, or control: a randomized, controlled, phase III study. Cancer Chemother Pharmacol 2013; 72:65.
  107. Pierce CM, Wade A, Mok Q. Heparin-bonded central venous lines reduce thrombotic and infective complications in critically ill children. Intensive Care Med 2000; 26:967.
  108. Krafte-Jacobs B, Sivit CJ, Mejia R, Pollack MM. Catheter-related thrombosis in critically ill children: comparison of catheters with and without heparin bonding. J Pediatr 1995; 126:50.
  109. Anton N, Cox PN, Massicotte MP, et al. Heparin-bonded central venous catheters do not reduce thrombosis in infants with congenital heart disease: a blinded randomized, controlled trial. Pediatrics 2009; 123:e453.
  110. Shah PS, Shah N. Heparin-bonded catheters for prolonging the patency of central venous catheters in children. Cochrane Database Syst Rev 2014; :CD005983.