We would like to thank Prof. Kröger for his comment on the therapy of deep vein thrombosis of the upper extremity (DVT-UE). Not only the German S2k guideline but also the more current, English-language recommendations and guidelines list direct oral anticoagulants (DOAC) as a therapy option for deep vein thrombosis without distinguishing between upper and lower extremities. It was pointed out that these substances have not been tested separately for the therapy of DVT-UE (1, 2). In February 2017, a phase IV study was initiated that explicitly assesses using Apixaban for the treatment of DVT-UE with respect to the endpoints “thromboembolism-related deaths,” “symptomatic recurrences,” and “bleeding complications.” Results are expected for 2019 (Apixaban for Routine Management of Upper Extremity Deep Venous Thrombosis [ARM-DVT]; NCT02945280).
DOACs cannot currently be recommended as a therapy for mesenteric vein thrombosis or Budd–Chiari syndrome: the efficacy of these substance classes has not been investigated, and the alterations of the liver function that are frequently associated with these diseases can lead to pharmacological problems (3).
Dr. Maibaum rightly points out that vitamin K antagonists (VKA) are not listed in the Table in our article. We mention this drug group in the text and have in no way made a judgement for or against VKAs in the treatment of DVT-UE. We believe that the anticoagulation therapy for DVT-UE must be individually adapted to the clinical circumstances of each patient, and that VKA is an important treatment option. Regarding the licensing conditions of low-molecular-weight heparins, we point out in the footnotes to the Table that the pertinent licensing conditions of substances need to be considered.
The question posed by Prof. Matzdorff regarding the duration of anticoagulation in the presence of foreign bodies (for example, a port system) and DVT-UE is frequently asked in the everyday clinical practice. According to the current recommendations, published by Streiff and Rajasekhar, we carry out anticoagulation until the removal of the foreign body, but for at least three months (4, 5). For indispensable foreign bodies, such as heart pacemakers, we stop anticoagulation after three months. On the other hand, we would not leave in a port system for DVT-UE in case of tumor recurrence but rather would remove it and stop the anticoagulation therapy. Prolonged maintenance therapy may be indicated, following the criteria published in the S2k guideline. Here, no distinction is made between leg and arm vein thrombosis (2).
The indication for thrombosis prophylaxis follows the S3 guideline “Prophylaxis of venous thromboembolism (VTE).” This recommends thrombosis prophylaxis for specific risk factors for non-immobilized cancer outpatients. For example, patients who are discharged following abdominal tumor surgery receive a drug-based thrombosis prophylaxis for about 4 weeks postoperatively. In the absence of contraindications and side effects, low-molecular-weight heparins are used for this (6).
In his contribution, Dr. Hertting explicitly mentions again thrombosis of the upper limb caused by compression syndromes or overexertion and their treatment. This is important to note. Due to the size limitations for the printed edition of our article, we included these points as part of the eSupplement of the article (7).
On behalf of the authors:
Dr. med. Alexander Reinisch
University Hospital Frankfurt am Main
Department of General and Visceral Surgery, Germany
Conflict of interest statement
The author declares that no conflict of interest exists.
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|2.||AWMF: S2k-Diagnostik und Therapie der Venenthrombose und der Lungenembolie. http://www.awmf.org/leitlinien/detail/ll/065-002.html (last accessed on 26 May 2017).|
|3.||Harding DJ, Thamara M, Perera PR, Chen F, Olliff S, Tripathi D: Portal vein thrombosis in cirrhosis: controversies and latest developments. World J Gastroenterol 2015; 21: 6769–8 MEDLINE PubMed Central|
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|5.||Rajasekhar A, Streiff MB: How I treat central venous access device-related upper extremity deep vein thrombosis. Blood 2017; 129: 2727–36 CrossRef MEDLINE|
|6.||AWMF: S3-Leitlinie Prophylaxe der venösen Thromboembolie (VTE). http://www.awmf.org/leitlinien/detail/ll/003-001.html (last accessed on 26 May 2017).|
|7.||Heil J, Miesbach W, Vogl T, Bechstein WO, Reinisch A: Deep vein thrombosis of the upper extremity—a systematic review. Dtsch Arztebl Int 2017; 114: 244–9 VOLLTEXT|