Upper extremities deep vein thrombosis and DOAC treatment: a prospective cohort study

Abstract Background Data on the use of direct oral anticoagulants (DOACs) in patients with upper extremities deep vein thrombosis (UEDVT) are limited. Purpose To assess the effectiveness and safety of DOACs in the treatment of UEDVT. Methods Data on patients with an objective diagnosis of acute UEDVT treated with DOACs were merged from prospective cohorts of patients with venous thromboembolism (VTE). Study outcomes were recurrent VTE and major bleeding (MB) occurring during DOAC treatment. Results Overall, 132 patients were included: mean age was 47.7±18.0 years (range 18 to 97), males were 42.4%. Twenty-seven percent of patients had 2 or more risk factors for VTE, 29.5% had UEDVT complicating a central venous line or after pacemaker implantation (Table). Ninety-two patients (70%) were managed as outpatients. Increased age (OR 1.03, 95% CI 1.0–1.05) and anemia (OR 1.35, 95% CI 1.07–1.70) were associated with in-patient management. Among patients treated with apixaban (40) or rivaroxaban (85) loading dose was used in 72%; in patients treated with dabigatran (5) or edoxaban (2) mean heparin pre-treatment was 8 days. DOACs were started after 1 month from UEDVT diagnosis in 12.9% of patients; active cancer was a main predictor for delayed initiation (OR 22.2, 95% CI 5.8–84.4). Mean treatment duration in patients with a scheduled stop was 4.9 months, while mean followup in those who continued DOACs was 9.3 months. No recurrence of VTE nor MBs occurred during DOAC treatment; one patient had acute limb ischemia (1.38% patient-year), 7 clinically relevant non-MBs (3 genital, 2 epistaxis, 1 gingival, 1 genital bleeding plus epistaxis; 10.51% patient-year), 5 deaths (4 cancer, 1 advanced age; 9.69% patient-year). Conclusions Our data support the effectiveness and safety of DOACs for the treatment of acute UEDVT. Further studies are required to confirm these findings. Features of the study population Overall (n=132) Active cancer (n=34) Non-cancer risk factor (n=62) Unprovoked (n=36) Age, years (mean ± SD) 47.7±18.0 55.4±13.2 46.1±18.1 43.3±19.9 Male, n (%) 56 (42.4) 14 (41.2) 23 (37.1) 19 (52.8) Concomitant pulmonary embolism, n (%) 11 (8.3) 3 (8.8) 5 (8.1) 3 (8.3) Weight, kg (mean ± SD) 71.6±14.9 67.3±10.5 74.8±16.0 69.6±15.6 CVC, PICC or PMK, n (%) 39 (29.5) 19 (55.9) 20 (32.3) – Recent surgery or trauma, n (%) 19 (14.4) 2 (5.9) 17 (27.4) – Effort thrombosis or thoracic outlet syndrome, n (%) 12 (9.1) 0 12 (19.4) – Thrombophilia or estrogen-progestin therapy, n (