Approach to treatment of VTE at sites other than the lower limb

Axillary and subclavian vein thromboses are associated with pulmonary embolism (PE) in 30% of cases and therefore require anticoagulant therapyPrandoni, 2004—see direct-acting anticoagulants (DOACs), warfarin or parenteral anticoagulants for dosages. Some axillary and subclavian thromboses are associated with compression from an extra (supernumerary) rib or intrathoracic lesions; consider computed tomography (CT) of the chest and seek specialist advice.

An axillary or subclavian thrombosis can develop as a complication of an implanted cardiac device. The optimal duration of anticoagulant therapy is uncertain in this situation. The harm–benefit balance for risk of further thrombosis and of bleeding must be weighed up individually. Patients with an implanted cardiac device who developed an axillary or subclavian thrombosis were excluded from most studies; however, long-term low-intensity anticoagulation is sometimes recommended. See Extended low-intensity anticoagulant therapy for VTE for dosages.

Splanchnic vein thrombosis includes portal, mesenteric or splanchnic vein thrombosis, and Budd–Chiari syndrome (hepatic vein thrombosis). This may be complicated by ischaemic bowel; investigate or refer patients who have significant abdominal pain. Patients with symptomatic acute splanchnic vein thrombosis should be anticoagulated for at least 3 to 6 months. Low molecular weight heparin, warfarin or a DOAC are appropriate options. However, liver dysfunction can prevent the safe use of a DOACDi Nisio, 2020—see Anticoagulation in patients with cirrhosis.

Other venous thromboses (eg cerebral vein thrombosis, gonadal vein thrombosis) are rare. Seek specialist advice.