# Use of Direct Oral Anticoagulants in Patients With Upper Extremity Deep Vein Thrombosis: A Meta-Analysis of Efficacy and Safety

## TL;DR

This study finds that direct oral anticoagulants may be more effective than heparin for treating upper extremity blood clots, but they carry a higher bleeding risk.

## Contribution

First meta-analysis comparing direct oral anticoagulants and heparin specifically for upper extremity deep vein thrombosis.

## Key findings

- DOACs showed significantly lower mortality and thrombotic complications compared to historical LMWH data.
- Major bleeding rates were higher with DOACs than with LMWH.
- Most UEDVT cases were cancer-related or catheter-associated, with rivaroxaban being the most used DOAC.

## Abstract

Upper extremity deep vein thrombosis (UEDVT), distinct in etiology from lower limb DVT, often arises from catheter use, malignancy, or thoracic outlet syndrome. While direct oral anticoagulants (DOACs) are established for lower limb DVT, their role in UEDVT remains understudied. This meta-analysis evaluates the efficacy and safety of DOACs compared to low-molecular-weight heparin (LMWH) in UEDVT. A systematic PubMed search identified nine studies (643 DOAC-treated patients). Outcomes included mortality, venous thromboembolism (VTE) recurrence, pulmonary embolism (PE), and major bleeding.

DOACs demonstrated significantly lower mortality (2.49% vs. 16.5-27.5%; p<0.001), VTE recurrence (0.93% vs. 5%; p<0.001), and PE incidence (0.31% vs. 5-8%; p<0.001) compared to historical LMWH data. However, major bleeding rates were higher with DOACs (2.02% vs. 0.25%; p<0.001). Patient cohorts predominantly had cancer-related (66.7%) or catheter-associated (64.5%) UEDVT, with rivaroxaban being the most used DOAC (70.9%). Median treatment duration was three months, with a six-month follow-up.

These findings suggest DOACs may offer superior efficacy in reducing mortality and thrombotic complications in UEDVT, though with an increased bleeding risk. Limitations include reliance on historical LMWH comparisons, heterogeneity in study designs, and small event counts for PE. Standardized imaging and extended follow-up are needed to assess long-term outcomes. While DOACs present a promising alternative, cautious use in high-bleeding-risk patients is warranted. Further randomized trials are essential to validate these results and refine clinical guidelines.