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Upper Limb DVT

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April 19, 2023

Upper Extremity DVT (UEDVT) is far less common than Lower Extremity DVT, and posses a diagnostic challenge. We can use the Constant score in combination with D-Dimer.

Constants Score

FeatureScore
Venous Material Present(Central venous catheter or Pacemaker thread)1
Localised Pain1
Unilateral Oedema1
Other Diagnosis at least as plausible-1

Investigations

  • FBC
  • Renal function
  • Liver function
  • CRP
  • Clotting
  • D-Dimer 

Actions

  1. Does the patient need an Ultrasound ? (Constant’ Actions)
    • Low Risk Constant‘ (≤1) & Low Age Adjusted D-Dimer [500ng/ml (age≤50) OR 10ng/ml x Age (age>50)]
      • No further investigation required (Remember: it is known there are DVT’s in this group but they are unlikely to progress to become an issue, if they represent reconsider diagnosis)
    • High Risk Constans’ (≥2) OR Low Risk and High Age Adjusted D-Dimer – Go to Step 2
  2. Exclusions to Outpatient/Ambulatory Pathway: > MAU/AMU
    • Unable to Go home and return for U/S
    • CKD 5 – Creatinine  Clearance <15 (eGFR <30 calculate CrCl – HERE)
    • Liver Failure
    • Bleed Risk (e.g. Oesophageal varices, major surgery, major trauma, intracranial bleed <4/52, grade 3 hypertensionetc.)
    • NSTEMI/Unstable angina
  3. Outpatient Pathway:
    • Order Lower leg Ultrasound: (Side, Constans’ and D-Dimer are required)
    • Treatment
      • First line – Apixaban – 7 day
      • Second Line – Tinzaparin – 7 day OR  [BNF]
        • First Line in Pregnancy/Lactating
    • Patient advice leaflet [PDF pg:2]
    • Give patient details to AAU/SDEC – for follow up
  4. Inpatient Pathway:
    • Commence Tinzaparin – if not contraindicated; [BNF]
    • Ref to AMU/MAU

References.