UEDVT.ppt

Upper Limb DVT…Upper Limb DVT…It’s not just for legs It’s not just for legs

anymoreanymore

Tress Goodwin, SMSIV

Surgical ICU, October 2007

OutlineOutline

• AnatomyAnatomy• Primary vs. Secondary ULDVTPrimary vs. Secondary ULDVT• Clinical featuresClinical features• DiagnosisDiagnosis• TreatmentTreatment• SequelaeSequelae

Upper vs. Lower DVTsUpper vs. Lower DVTs

• Virchow’s triad (venous stasis, Virchow’s triad (venous stasis, hypercoagulability, endothelial hypercoagulability, endothelial trauma)trauma)

• UL: Higher venous flow, less stasis, UL: Higher venous flow, less stasis, gravitational effectsgravitational effects

• Direct endothelial trauma: effort in Direct endothelial trauma: effort in primary; iatrogenic in secondary primary; iatrogenic in secondary

Spontaneous (Primary) Spontaneous (Primary) ULDVTULDVT

• First described by Paget and First described by Paget and Schroetter Schroetter

• AKA Paget-Schroetter syndrome, AKA Paget-Schroetter syndrome, “effort thrombosis”“effort thrombosis”

• Compressive anatomy at thoracic Compressive anatomy at thoracic outlet—compression of vein b/w outlet—compression of vein b/w first rib and hypertrophied scalene first rib and hypertrophied scalene or tendonsor tendons

• Can occur after strenuous activity Can occur after strenuous activity of arms and shouldersof arms and shoulders

• Central venous cathetersCentral venous catheters• PacemakersPacemakers• Higher incidence: Chemotherapy, Higher incidence: Chemotherapy,

TPN via central lines TPN via central lines • Improper placement of catheter tipImproper placement of catheter tip• Incidence varies: 1-4% of all DVT’sIncidence varies: 1-4% of all DVT’s

Secondary ULDVTSecondary ULDVT

Clinical FeaturesClinical Features

• Arm swelling, pain, heavinessArm swelling, pain, heaviness• Dilated subcutaneous veinsDilated subcutaneous veins• JVDJVD• Upper limb cyanosisUpper limb cyanosis• Can be asymptomaticCan be asymptomatic• DDx: DDx: superficialsuperficial thrombophlebitis thrombophlebitis

Associated ConditionsAssociated Conditions

• Presence of a central venous Presence of a central venous catheter in (72%)catheter in (72%)

• Infection (28%)Infection (28%)• Extrathoracic malignancy (22%)Extrathoracic malignancy (22%)• Thoracic malignancy in (21%)Thoracic malignancy in (21%)• Renal failure (21%)Renal failure (21%)• Prior lower-extremity deep venous Prior lower-extremity deep venous

thrombosis (18%)thrombosis (18%)

Marinella MA, Kathula SK, Markert RJ. Heart Lung. 2000 Mar-Apr;29(2):113-7. Spectrum of upper-extremity deep venous thrombosis in a community teaching hospital.

Spectrum of Spectrum of ManifestationsManifestations

Asymptomatic Massive PEUpper limb complications

ULDVT SequelaeULDVT Sequelae

Sajid, M, et al. Upper Limb Deep Vein Thrombosis: A Literature Review to Streamline the Protocol for Management. Acta Haematol 2007; 118.

DiagnosisDiagnosis

• Duplex ultrasonography Duplex ultrasonography

• Aggressive diagnosis: digital Aggressive diagnosis: digital subtraction venography, MRV, CTV subtraction venography, MRV, CTV

Sajid, M, et al. Upper Limb Deep Vein Thrombosis: A Literature Review to Streamline the Protocol for Management. Acta Haematol 2007; 118.

TreatmentTreatment

• Expectant managementExpectant management• Removal of offending agentRemoval of offending agent• Anticoagulation (standard: heparin Anticoagulation (standard: heparin

x 5-7 days, 3 mos of Coumadin)x 5-7 days, 3 mos of Coumadin)• Thrombolysis (streptokinase, Thrombolysis (streptokinase,

urokinase, TPA)urokinase, TPA)• SurgerySurgery• SVC filterSVC filter

Sajid, M, et al. Upper Limb Deep Vein Thrombosis: A Literature Review to Streamline the Protocol for Management. Acta Haematol 2007; 118.

Treatment Protocol

Thrombolysis v Thrombolysis v AnticoagulationAnticoagulation

Sajid, M, et al. Upper Limb Deep Vein Thrombosis: A Literature Review to Streamline the Protocol for Management. Acta Haematol 2007; 118.

Surgical managementSurgical management

Sajid, M, et al. Upper Limb Deep Vein Thrombosis: A Literature Review to Streamline the Protocol for Management. Acta Haematol 2007; 118.

SVC FiltersSVC FiltersAscher, Enrico, Hingorani, Anil, Mazzariol, Fernanda,

Jacob, Theresa, Yorkovich, William, Gade, PrasadClinical Experience with Superior Vena Caval Greenfield Filters. Journal of Endovascular Surgery 1999 6: 365-369

Ascher E, Hingorani A, Tsemekhin B, Yorkovich W, Gunduz Y.Lessons learned from a 6-year clinical experience with superior vena cava Greenfield filters. J Vasc Surg. 2001 Apr;33(4):907

• Insertion of SVC-GFs is a safe, efficacious, and Insertion of SVC-GFs is a safe, efficacious, and feasible therapy and may prevent reccurent feasible therapy and may prevent reccurent thromboembolism in patients with UEDVT who thromboembolism in patients with UEDVT who are resistant to anticoagulation or have are resistant to anticoagulation or have contraindications to anticoagulationcontraindications to anticoagulation

• Insertion of SVC Greenfield filters is a safe and feasible therapy to prevent recurrent thromboembolism in patients with UEDVT who are refractory to or inappropriate for anticoagulation therapy.

SVC Filters - Indicated? SVC Filters - Indicated?

ConclusionsConclusions• ULDVT: relatively rare but associated with ULDVT: relatively rare but associated with

considerable morbidity and mortality (PE, considerable morbidity and mortality (PE, post-thrombotic syndrome, loss of post-thrombotic syndrome, loss of vascular access)vascular access)

• Duplex ultrasound sufficient for majority Duplex ultrasound sufficient for majority of diagnosesof diagnoses

• Simple anticoagulation suitable for most Simple anticoagulation suitable for most patientspatients

• Thrombolysis/thrombectomy less Thrombolysis/thrombectomy less frequently usedfrequently used

• Surgery, SVC filters (?) for recurrent cases Surgery, SVC filters (?) for recurrent cases or where other tx contraindicatedor where other tx contraindicated

Questions?Questions?