UEDVT - Upper Limb DVT… Upper Limb DVT… It’s not just...

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Unformatted text preview: Upper Limb DVT… Upper Limb DVT… It’s not just for legs anymore Tress Goodwin, SMSIV Surgical ICU, October 2007 Outline Outline • • • • • • Anatomy Primary vs. Secondary ULDVT Clinical features Diagnosis Treatment Sequelae Upper vs. Lower DVTs Upper vs. Lower DVTs • • • Virchow’s triad (venous stasis, hypercoagulability, endothelial trauma) UL: Higher venous flow, less stasis, gravitational effects Direct endothelial trauma: effort in primary; iatrogenic in secondary Spontaneous (Primary) ULDVT Spontaneous (Primary) ULDVT • • • • First described by Paget and Schroetter AKA Paget­Schroetter syndrome, “effort thrombosis” Compressive anatomy at thoracic outlet— compression of vein b/w first rib and hypertrophied scalene or tendons Can occur after strenuous activity of arms and shoulders Secondary ULDVT • • • • • Central venous catheters Pacemakers Higher incidence: Chemotherapy, TPN via central lines Improper placement of catheter tip Incidence varies: 1­4% of all DVT’s Clinical Features Clinical Features • • • • • • Arm swelling, pain, heaviness Dilated subcutaneous veins JVD Upper limb cyanosis Can be asymptomatic DDx: superficial thrombophlebitis Associated Conditions Associated Conditions • • • • • • Presence of a central venous catheter in (72%) Infection (28%) Extrathoracic malignancy (22%) Thoracic malignancy in (21%) Renal failure (21%) Prior lower­extremity deep venous thrombosis (18%) Marinella MA, Kathula SK, Markert RJ. Heart Lung. 2000 Mar­Apr;29(2):113­7. Spectrum of upper­extremity deep venous thrombosis in a community teaching hospital. Spectrum of Manifestations Spectrum of Manifestations Asymptomatic Upper limb complications Massive PE ULDVT Sequelae ULDVT Sequelae Sajid, M, et al. Upper Limb Deep Vein Thrombosis: A Literature Review to Streamline the Protocol for Management. Acta Haematol 2007; 118. Diagnosis Diagnosis • Duplex ultrasonography • Aggressive diagnosis: digital 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. Treatment Treatment • • • • • • Expectant management Removal of offending agent Anticoagulation (standard: heparin x 5­7 days, 3 mos of Coumadin) Thrombolysis (streptokinase, urokinase, TPA) Surgery SVC filter Treatment Protocol Sajid, M, et al. Upper Limb Deep Vein Thrombosis: A Literature Review to Streamline the Protocol for Management. Acta Haematol 2007; 118. Thrombolysis v Anticoagulation Thrombolysis v Anticoagulation Sajid, M, et al. Upper Limb Deep Vein Thrombosis: A Literature Review to Streamline the Protocol for Management. Acta Haematol 2007; 118. Surgical management Surgical management Sajid, M, et al. Upper Limb Deep Vein Thrombosis: A Literature Review to Streamline the Protocol for Management. Acta Haematol 2007; 118. SVC Filters SVC Filters Ascher, Enrico, Hingorani, Anil, Mazzariol, Fernanda, Jacob, Theresa, Yorkovich, William, Gade, Prasad Clinical Experience with Superior Vena Caval Greenfield Filters. Journal of Endovascular Surgery 1999 6: 365­369 • 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. 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 SVC­GFs is a safe, efficacious, and feasible therapy and may prevent reccurent thromboembolism in patients with UEDVT who are resistant to anticoagulation or have contraindications to anticoagulation SVC Filters ­ Indicated? SVC Filters ­ Indicated? Conclusions Conclusions • • • • • ULDVT: relatively rare but associated with considerable morbidity and mortality (PE, post­ thrombotic syndrome, loss of vascular access) Duplex ultrasound sufficient for majority of diagnoses Simple anticoagulation suitable for most patients Thrombolysis/thrombectomy less frequently used Surgery, SVC filters (?) for recurrent cases or where other tx contraindicated Questions? Questions? ...
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