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Stojanovic N, Ukenenye E, Syed A. Innominate Vein Thrombosis: A Case Report and Literature Review. Cureus 2024; 16:e64145. [PMID: 39119383 PMCID: PMC11309737 DOI: 10.7759/cureus.64145] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/09/2024] [Indexed: 08/10/2024] Open
Abstract
The brachiocephalic vein (BCV), also known as the innominate vein, is a central vein in the upper chest formed by merging the internal jugular and subclavian veins. It plays a crucial role in venous return from the head, neck, and upper extremities and is significant in procedures such as pacemaker and implantable cardioverter-defibrillator (ICD) placement, chemotherapy ports, and central venous catheter insertions. The presence of foreign bodies and local malignancy are major risk factors for thrombosis in the BCV. As part of the deep venous system, BCV thrombosis (BCVT) is a rare condition but can lead to serious complications like superior vena cava syndrome and, rarely, pulmonary embolism. This case report presents an 82-year-old woman with a history of heart failure with reduced ejection fraction, coronary artery disease, atrial fibrillation, HIV, pulmonary embolism, systemic lupus erythematosus, and breast cancer who required an ICD placement due to persistent systolic dysfunction. During the procedure, chronic BCVT leading to the stenosis was incidentally discovered, necessitating urgent vascular intervention to establish venous patency. The patient's complex medical history, including previous chemotherapy through a central venous catheter, contributed to the risk factors for BCVT. The multidisciplinary approach led to successful ICD placement and the reinstatement of anticoagulation therapy. This case underscores the rarity and severity of BCVT and highlights the importance of pre-procedural imaging, such as CT venography, in patients with multiple risk factors. Additionally, the report suggests considering leadless ICD technology for patients with limited venous access to avoid complications. The findings emphasize the critical need for thorough evaluation and planning in complex cases to ensure successful outcomes.
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Affiliation(s)
- Nikola Stojanovic
- Medicine, Brookdale University Hospital and Medical Center, Brooklyn, USA
| | - Emmanuel Ukenenye
- Internal Medicine, Brookdale University Hospital and Medical Center, Brooklyn, USA
| | - Asma Syed
- Electrophysiology and Cardiology, Brookdale University Hospital and Medical Center, Brooklyn, USA
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2
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Davies MG, Hart JP. Endovascular management of acute and subacute venous thoracic outlet syndrome. Front Surg 2024; 11:1302568. [PMID: 38440414 PMCID: PMC10909919 DOI: 10.3389/fsurg.2024.1302568] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2023] [Accepted: 02/05/2024] [Indexed: 03/06/2024] Open
Abstract
Approximately 3% of all patients presenting with Thoracic Outlet Syndrome have a venous etiology (vTOS), which is considered "effort thrombosis". These patients will present with symptomatic deep venous thrombosis or focal subclavian vein (SCV) stenosis. Endovascular management of vTOS occurs in several phases: diagnostic, preoperative therapeutic intervention before decompression, postoperative interventions after decompression, and delayed interventions in the follow-up after decompression. In the diagnostic phase, dynamic SCV venography can establish functional vTOS. Approximately 4,000 patients have been treated for vTOS and reported in the literature since 1970. Declotting of the SCV was followed by surgical decompression in 53% of patients, while in the remainder, surgical decompression alone (18%), endovascular intervention alone (15%), or conservative therapy with anticoagulation (15%) was performed. The initial intervention was predominantly catheter-directed thrombolysis, with <10% of cases undergoing concomitant balloon angioplasty. 93% of cases were successful. In the postoperative phase, balloon angioplasty was performed to correct residual intrinsic SCV disease after vTOS decompression in under 15% of cases. Stents were rarely deployed. Symptom relief was reported as 94 ± 12% (mean ± SD) and 90 ± 23%, respectively for declotting with decompression and declotting alone. In the delayed phase, balloon angioplasty was performed in under 15% of cases to re-establish patency.
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Affiliation(s)
- Mark G. Davies
- Department of Cardiovascular Outcomes, Center for Quality, Effectiveness, and Outcomes in Cardiovascular Diseases, Houston, TX, United States
| | - Joseph P. Hart
- Division of Vascular and Endovascular Surgery, Medical College of Wisconsin, Milwaukee, WI, United States
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3
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Espitia O, Raimbeau A, Planquette B, Katsahian S, Sanchez O, Espinasse B, Bénichou A, Murris J. A systematic review and meta-analysis of the incidence of post-thrombotic syndrome, recurrent thromboembolism, and bleeding after upper extremity vein thrombosis. J Vasc Surg Venous Lymphat Disord 2024; 12:101688. [PMID: 37717788 DOI: 10.1016/j.jvsv.2023.09.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2023] [Revised: 08/26/2023] [Accepted: 09/04/2023] [Indexed: 09/19/2023]
Abstract
BACKGROUND Data on complications after upper extremity vein thrombosis (UEVT) are limited and heterogeneous. METHODS The aim of the present study was to evaluate the pooled proportions of venous thromboembolism (VTE) recurrence, bleeding, and post-thrombotic syndrome (PTS) in patients with UEVT. A systematic literature review was conducted of PubMed, Embase, and the Cochrane Library databases from January 2000 to April 2023 in accordance with the PRISMA (preferred reporting items for systematic reviews and meta-analyses) guidelines. All studies included patients with UEVT and were published in English. Meta-analyses of VTE recurrence, bleeding, and of PTS after UEVT were performed to compute pooled estimates and associated 95% confidence intervals (CIs). Subgroup analyses of cancer-associated UEVT and catheter-associated venous thrombosis were conducted. Patients with Paget-Schroetter syndrome or effort thrombosis were excluded. RESULTS A total of 55 studies with 15,694 patients were included. The pooled proportions for VTE recurrence, major bleeding, and PTS were 4.8% (95% CI, 3.8%-6.2%), 3.0% (95% CI, 2.2%-4.0%), and 23.8% (95% CI, 17.0%-32.3%), respectively. The pooled proportion of VTE recurrence was 2.7% (95% CI, 1.6%-4.6%) for patients treated with direct oral anticoagulants (DOACs), 1.7% (95% CI, 0.8%-3.7%) for patients treated with low-molecular-weight heparin (LMWH), and 4.4% (95% CI, 1.5%-11.8%) for vitamin K antagonists (VKAs; P = .36). The pooled proportion was 6.3% (95% CI, 4.3%-9.1%) for cancer patients compared with 3.1% (95% CI, 2.1%-4.6%) for patients without cancer (P = .01). The pooled proportion of major bleeding for patients treated with DOACs, LMWH, and VKAs, was 2.1% (95% CI, 0.9%-5.1%), 3.2% (95% CI, 1.4%-7.2%), and 3.4% (95% CI, 1.4%-8.4%), respectively (P = .72). The pooled proportion of PTS for patients treated with DOACs, LMWH, and VKAs was 11.8% (95% CI, 6.5%-20.6%), 27.9% (95% CI, 20.9%-36.2%), and 24.5% (95% CI, 17.6%-33.1%), respectively (P = .02). CONCLUSIONS The results from this study suggest that UEVT is associated with significant rates of PTS and VTE recurrence. Treatment with DOACs might be associated with lower PTS rates than treatment with other anticoagulants.
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Affiliation(s)
- Olivier Espitia
- Department of Vascular Medicine, Nantes Université, CHU Nantes, l'institut du Thorax, INSERM UMR1087/CNRS UMR 6291, Team III Vascular & Pulmonary Diseases, Nantes, France; UNAV, Nantes Vascular Access Unit, Nantes Université, CHU Nantes, Nantes, France.
| | - Alizée Raimbeau
- Department of Vascular Medicine, Nantes Université, CHU Nantes, l'institut du Thorax, INSERM UMR1087/CNRS UMR 6291, Team III Vascular & Pulmonary Diseases, Nantes, France; UNAV, Nantes Vascular Access Unit, Nantes Université, CHU Nantes, Nantes, France
| | - Benjamin Planquette
- Service de Pneumologie et Soins Intensifs, Hôpital Européen Georges Pompidou, AP-HP, Centre - Université Paris Cité, INSERM UMR S1140, Innovative Therapies in Hemostasis, Paris, France, F-CRIN INNOVTE, Université Paris Cité, St-Etienne, France
| | - Sandrine Katsahian
- INSERM, Centre d'Investigation Clinique 1418 (CIC1418) Epidémiologie Clinique, AP-HP, Hôpital Européen Georges Pompidou, Unité de Recherche Clinique, Service d'Informatique Médicale, Biostatistiques et Santé Publique, AP-HP Centre, Paris, France; Inserm, Centre de Recherche des Cordeliers, Université de Paris, Sorbonne Université, Paris, France; HeKA, Inria, Paris, France
| | - Olivier Sanchez
- Service de Pneumologie et Soins Intensifs, Hôpital Européen Georges Pompidou, AP-HP, Centre - Université Paris Cité, INSERM UMR S1140, Innovative Therapies in Hemostasis, Paris, France, F-CRIN INNOVTE, Université Paris Cité, St-Etienne, France
| | | | - Antoine Bénichou
- Department of Vascular Medicine, Nantes Université, CHU Nantes, l'institut du Thorax, INSERM UMR1087/CNRS UMR 6291, Team III Vascular & Pulmonary Diseases, Nantes, France; UNAV, Nantes Vascular Access Unit, Nantes Université, CHU Nantes, Nantes, France
| | - Juliette Murris
- Inserm, Centre de Recherche des Cordeliers, Université de Paris, Sorbonne Université, Paris, France; HeKA, Inria, Paris, France; RWE and Data, Pierre Fabre, Boulogne-Billancourt, France
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4
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Jenab Y, Tofighi S, Ayati A, Rezvanimehr A, Moosavi NS, Jalaie H, Barbati ME. Single-center experience with catheter-directed thrombolysis and balloon angioplasty for acute upper-extremity deep vein thrombosis: a case series study. BMC Cardiovasc Disord 2023; 23:351. [PMID: 37460994 DOI: 10.1186/s12872-023-03389-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2023] [Accepted: 07/11/2023] [Indexed: 07/20/2023] Open
Abstract
BACKGROUND Effective treatment of upper extremity deep vein thrombosis (UEDVT) is crucial to prevent further complications. Various treatments, including percutaneous mechanical thrombectomy (PMT), catheter-directed thrombolysis (CDT), decompression surgery, and venoplasty are suggested for UEDVT. However, no prospective study has yet favored any of these treatments. This study presents a review of our experience with CDT followed by balloon venoplasty in patients with acute primary UEDVT. METHODS We enrolled all patients diagnosed with acute UEDVT from January 2020 to June 2021. Subjects with UEDVT due to secondary causes like malignancies, indwelling catheters, or leads were excluded. CDT was performed through brachial vein access, using a perfusion catheter, and rt-PA administration. Balloon venoplasty was performed if the treated segment had remaining stenosis after CDT. Patients were followed up at the vein clinic for any signs and symptoms in the upper extremity and lifestyle changes. Follow-up ultrasonography was done 12 months after discharge. RESULTS Twelve patients with a mean age of 41.08 ± 14.0 years were included in the study. The mean duration of CDT was 25.00 ± 10.56 h. After CDT, all patients had remaining occlusions, with seven having more than 50% remaining stenosis. However, after balloon venoplasty, no patient had significant (more than 50%) stenosis. There was no serious complication after both procedures. Patients were followed up for a mean duration of twelve months after their admission, with a mean time of maintenance anticoagulation was 10.73 ± 5.77 months. Only one patient had recurrent symptoms in his target limb which required a decompression surgery, while the rest were free of symptoms in their treated extremity. No subject developed pulmonary emboli (PE) during admission or the follow-up period. There was no evidence of hospital readmission for any reason. Upper extremity color-doppler sonography of the patients at twelve months after their procedure showed normal venous flow without any significant stenosis in 8 (66.7%), and partially normal flow with patent target vein in 4 (33.3%) patients. CONCLUSIONS CDT followed by balloon venoplasty may be an effective treatment for selected patients with acute primary UEDVT, providing desirable long-term results and potentially avoiding the need for decompression surgery in the short or long term.
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Affiliation(s)
- Yaser Jenab
- Cardiovascular Diseases Research Institute, Tehran Heart Center, Tehran University of Medical Sciences, Tehran, Iran
| | - Saeed Tofighi
- Cardiovascular Diseases Research Institute, Tehran Heart Center, Tehran University of Medical Sciences, Tehran, Iran.
| | - Aryan Ayati
- Cardiovascular Diseases Research Institute, Tehran Heart Center, Tehran University of Medical Sciences, Tehran, Iran
| | - Ali Rezvanimehr
- Faculty of Medicine, Tehran Medical Sciences Branch, Islamic Azad University, Tehran, Iran
| | - Najme-Sadat Moosavi
- Cardiovascular Diseases Research Institute, Tehran Heart Center, Tehran University of Medical Sciences, Tehran, Iran
| | - Houman Jalaie
- Department of Vascular and Endovascular Surgery, University Hospital Aachen, Aachen, Germany
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Discalzi A, Cignini V, Ciferri F, Nardelli F, Rossato D, Calandri M, Fonio P. Successful endovascular thrombectomy with the ClotTriever System for acute subclavian vein thrombosis in venous thoracic outlet syndrome. CVIR Endovasc 2023; 6:32. [PMID: 37284970 PMCID: PMC10247914 DOI: 10.1186/s42155-023-00378-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2023] [Accepted: 05/11/2023] [Indexed: 06/08/2023] Open
Abstract
BACKGROUND The case describes a successful endovascular thrombectomy using the ClotTriever System for an acute subclavian thrombosis in venous thoracic outlet syndrome. To the best of our knowledge, this is the first case report on use of Inari ClotTriever for acute upper extremity deep venous thrombosis due to venous thoracic outlet syndrome. The rapid technical and clinical success of our intervention may be an interesting cue for interventional radiologist colleagues. CASE PRESENTATION Upper extremity deep vein thrombosis in the setting of venous thoracic outlet syndrome generally occurs in young adults after excessive arm activity and can sometimes be managed with anticoagulation. In this case, a 29-year-old male diagnosed with acute effort-induced thrombosis of the left subclavian vein and persistent symptoms following low-molecular-weight heparin therapy underwent mechanical thrombectomy. Successful thrombectomy was completed with > 90% thrombus burden reduction and no complication. The patient experienced immediate symptom relief and vein patency was confirmed via imaging 3 months post procedure. CONCLUSIONS Mechanical thrombectomy is a promising treatment technique for thrombosis associated with venous thoracic outlet syndrome.
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Affiliation(s)
- Andrea Discalzi
- Department of Surgical Sciences, Radiology Unit, University of Turin, Molinette Hospital, Via Genova 3, 10126, Turin, Italy
| | - Valentina Cignini
- Department of Surgical Sciences, Radiology Unit, University of Turin, Molinette Hospital, Via Genova 3, 10126, Turin, Italy.
| | - Fernanda Ciferri
- Department of Surgical Sciences, Radiology Unit, University of Turin, Molinette Hospital, Via Genova 3, 10126, Turin, Italy
| | - Floriana Nardelli
- Department of Surgical Sciences, Radiology Unit, University of Turin, Molinette Hospital, Via Genova 3, 10126, Turin, Italy
| | - Denis Rossato
- Department of Surgical Sciences, Radiology Unit, University of Turin, Molinette Hospital, Via Genova 3, 10126, Turin, Italy
| | - Marco Calandri
- Department of Surgical Sciences, Radiology Unit, University of Turin, Molinette Hospital, Via Genova 3, 10126, Turin, Italy
| | - Paolo Fonio
- Department of Surgical Sciences, Radiology Unit, University of Turin, Molinette Hospital, Via Genova 3, 10126, Turin, Italy
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Catheter-related thrombosis (CRT) in patients with solid tumors: a narrative review and clinical guidance for daily care. Support Care Cancer 2022; 30:8577-8588. [PMID: 35932317 DOI: 10.1007/s00520-022-07297-8] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2021] [Accepted: 07/24/2022] [Indexed: 10/16/2022]
Abstract
Central venous access devices (CVADs) including central venous catheters and peripherally inserted central catheters (PICCs) are essential in the treatment of cancer. Catheter-related thrombosis (CRT) is the most frequent non-infectious complication associated with the use of central lines. The development of CRT may cause to delays in oncologic treatment and increase morbidity leading to potentially life-threatening complications. Several local and systemic risk factors are associated with the development of CRT and should be taken into account to prevent CRT by standardizing appropriate catheter placement and maintenance. The use of primary pharmacological thromboprophylaxis in order to avoid CRT is not routinely recommended, although it can be considered in selected cases. Recommendations for the management of established CRT are based on the extrapolation of anticoagulation for lower limb venous thrombosis. The present review summarizes the current evidence and recommendations for the prevention and management of CRT and identifies areas that require further research.
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7
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Huang Y, Abad-Santos M, Iyer RS, Monroe EJ, Malone CD. Imaging to intervention: Thoracic outlet syndrome. Clin Imaging 2022; 89:23-36. [PMID: 35689965 DOI: 10.1016/j.clinimag.2022.06.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2022] [Revised: 05/21/2022] [Accepted: 06/06/2022] [Indexed: 11/03/2022]
Abstract
Thoracic outlet syndrome (TOS) is a clinical disorder resulting from compression of the neurovascular bundle of the lower neck and upper chest. TOS can be categorized into neurogenic, venous, and arterial subtypes which result from anatomical compression of the brachial plexus, subclavian vein, and subclavian artery, respectively. This can lead to neurogenic pain as well as vascular injury with thrombosis and thromboembolism. Interventional and diagnostic radiologists play a critical role in the imaging diagnosis and treatment of vascular TOS. Prompt imaging and endovascular management with surgical collaboration has been shown to provide the most successful and long-lasting clinical outcomes, from vessel patency to symptom relief. In this article, we review the anatomy and clinical presentations of TOS as well as the initial imaging modalities used for diagnosis. Furthermore, we detail the role of the diagnostic and interventional radiologist in the management of TOS, including pre-procedure and endovascular interventions, along with medical and surgical treatments. PRECIS: Diagnostic and Interventional Radiologists play a key role in diagnosis and management of vascular thoracic outlet syndromes and are critical for timely and successful outcomes.
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Affiliation(s)
- Yijin Huang
- Emory University, Atlanta, GA, United States of America
| | - Matthew Abad-Santos
- Department of Radiology, University of Washington School of Medicine, Seattle, WA, United States of America
| | - Ramesh S Iyer
- Department of Radiology, University of Washington School of Medicine, Seattle, WA, United States of America
| | - Eric J Monroe
- Department of Radiology, University of Wisconsin-Madison, Madison, WI, United States of America
| | - Christopher D Malone
- Mallinckrodt Institute of Radiology at Washington University School of Medicine, St. Louis, MO, United States of America.
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8
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Habibollahi P, Zhang D, Kolber MK, Pillai AK. Venous thoracic outlet syndrome. Cardiovasc Diagn Ther 2021; 11:1150-1158. [PMID: 34815966 DOI: 10.21037/cdt-20-168] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2020] [Accepted: 06/04/2020] [Indexed: 11/06/2022]
Abstract
Venous thoracic outlet syndrome (vTOS) is a spectrum of disease caused by external compression of the subclavian vein as it passes through the costoclavicular space. Paget-Schroetter's Syndrome (PSS) or effort thrombosis is a subtype of vTOS where compression and microtrauma to subclavian vein from repetitive arm movements results in venous thrombosis. PSS or effort thrombosis mostly affects young otherwise healthy active individuals, and this further highlights the importance of this condition. Early diagnosis and aggressive early intervention aimed at complete resolution of acute symptoms and minimizing the risk of recurrence is ultimately important and increases the likelihood of the full restoration of limb function. Several noninvasive imaging techniques are currently available to confirm the initial diagnosis including Doppler ultrasound, contrast-enhanced computed tomography, and magnetic resonance imaging. Following diagnosis, multiple algorithms exist for the management of PSS and almost all require a multidisciplinary approach. Like any other condition involving the thrombosis of deep venous system, initial step in the management is anticoagulation. Catheter-directed therapies (CDT) have also a pivotal role as the initial treatment to resolve the acute thrombosis and establish venous patency. CDT combined with medical anticoagulation and surgical decompression are the components of most treatment algorithms for the management of patients suffering from PSS.
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Affiliation(s)
- Peiman Habibollahi
- Division of Vascular and Interventional Radiology, Department of Radiology, University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Dianbo Zhang
- Division of Vascular and Interventional Radiology, Department of Radiology, University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Marcin K Kolber
- Division of Vascular and Interventional Radiology, Department of Radiology, University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Anil K Pillai
- Division of Vascular and Interventional Radiology, Department of Radiology, University of Texas Southwestern Medical Center, Dallas, TX, USA
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Fuller T, Neville E, Shapiro J, Muck AE, Broering M, Kulwicki A, Kuhn B, Recht M, Muck P. Comparison of Aspiration Thrombectomy to other endovascular therapies for Proximal Upper Extremity Deep Venous Thrombosis. J Vasc Surg Venous Lymphat Disord 2021; 10:300-305. [PMID: 34438088 DOI: 10.1016/j.jvsv.2021.07.017] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2021] [Accepted: 07/27/2021] [Indexed: 11/26/2022]
Abstract
OBJECTIVE Catheter-directed thrombolysis (CDT) provides an effective method for clearing deep venous thrombosis (DVT). Unfortunately, CDT is associated with hemorrhagic complications. This study evaluated the technical success of the various endovascular therapies including a new mechanical aspiration thrombectomy (AT) device for the treatment of acute upper extremity deep venous thrombosis (UEDVT). METHODS This was a single-center retrospective review of patients with acute symptomatic proximal UEDVT secondary to venous thoracic outlet syndrome. Undergoing endovascular therapy from December 2013 to June 2019. Patients were treated with a variety of methods including CDT, ultrasound assisted thrombolysis (USAT), rheolytic thrombectomy (RT) and aspiration thrombectomy (AT). We evaluated outcomes for patients undergoing AT compared to non-aspiration thrombectomy (NAT) techniques. The primary outcome was technical success, defined as resolution of >70% of thrombus. The secondary endpoint was the ability to complete the therapy in a single session. RESULTS There were 22 patients who had endovascular management of their symptomatic proximal UEDVT. All 22 (100%) patients were successfully treated with greater than 70% thrombus resolution. 10 patients underwent AT, of which 50% (5/10) had single session therapies. 12 patients underwent NAT (3 had CDT or USAT alone; 3 had USAT with RT; and 6 had CDT followed by RT), with single session therapy occurring in only 8.3% (1/12) of the NAT group. The average total dose of thrombolytics was 12.6mg (SD= 9.65) in the AT group compared to 19.0mg (SD= 5.78) in the NAT group (mean difference -6.4; 95% CI -1.1, 13.9). All but one of the patients in the AT group went on to have successful first rib resections. All NAT patients had successful first rib resections. Venogram was not performed at the time of decompression. All patients except one underwent resection via the infraclavicular approach, with rib removal posterior to the brachial plexus, a median of 8.0 [IQR 6.0, 12.0] days following DVT therapy. CONCLUSIONS In this study, technical success of 100% was achieved for acute symptomatic proximal UEDVT therapies. AT technology allows for higher rates of treatment in a single session thereby minimizing a patient's risks of bleeding complications. Further research is needed to further define the role of this new technology in the treatment paradigm of UEDVT management.
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Affiliation(s)
- Tim Fuller
- Department of Vascular Surgery, Good Samaritan Hospital & Bethesda North Hospital, Cincinnati, OH
| | - Evan Neville
- Department of Vascular Surgery, Good Samaritan Hospital & Bethesda North Hospital, Cincinnati, OH
| | - Jacob Shapiro
- Department of Vascular Surgery, Good Samaritan Hospital & Bethesda North Hospital, Cincinnati, OH.
| | - Audrey E Muck
- Department of Vascular Surgery, Good Samaritan Hospital & Bethesda North Hospital, Cincinnati, OH
| | - Mark Broering
- Department of Vascular Surgery, Good Samaritan Hospital & Bethesda North Hospital, Cincinnati, OH
| | - Aaron Kulwicki
- Department of Vascular Surgery, Good Samaritan Hospital & Bethesda North Hospital, Cincinnati, OH
| | - Brian Kuhn
- Department of Vascular Surgery, Good Samaritan Hospital & Bethesda North Hospital, Cincinnati, OH
| | - Matthew Recht
- Department of Vascular Surgery, Good Samaritan Hospital & Bethesda North Hospital, Cincinnati, OH
| | - Patrick Muck
- Department of Vascular Surgery, Good Samaritan Hospital & Bethesda North Hospital, Cincinnati, OH
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Potere N, Candeloro M, Porreca E, DI Nisio M. Management of upper extremity deep vein thrombosis: an updated review of the literature. Minerva Med 2021; 112:746-754. [PMID: 33969964 DOI: 10.23736/s0026-4806.21.07578-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
Upper extremity deep vein thrombosis (UEDVT) represents about 5-10% of all cases of deep vein thrombosis (DVT) with a steadily increasing incidence mostly due to the high prevalence of cancer and frequent use of intravascular devices such as central venous catheters and pacemaker. In primary UEDVT, the venous outflow obstruction and subsequent thrombosis are related to congenital or acquired anatomical abnormalities, whereas secondary UEDVT is often associated with malignancy or indwelling lines. A considerable proportion of patients with UEDVT develops serious complications such as recurrent thrombosis, post-thrombotic syndrome, and pulmonary embolism, therefore timely diagnosis and adequate treatment are of crucial importance. Despite sharing many similarities with lower extremity DVT, UEDVT has distinctive features requiring specific diagnostic and therapeutic approaches. The present review discusses the latest evidence on the epidemiology, diagnosis, and treatment of UEDVT, and provides management indications which may help guide clinical decision making.
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Affiliation(s)
- Nicola Potere
- Department of Innovative Technologies in Medicine and Dentistry, University G. d'Annunzio of Chieti-Pescara, Chieti, Italy
| | - Matteo Candeloro
- Department of Medicine and Ageing Sciences, University G. d'Annunzio of Chieti-Pescara, Chieti, Italy
| | - Ettore Porreca
- Department of Innovative Technologies in Medicine and Dentistry, University G. d'Annunzio of Chieti-Pescara, Chieti, Italy
| | - Marcello DI Nisio
- Department of Medicine and Ageing Sciences, University G. d'Annunzio of Chieti-Pescara, Chieti, Italy -
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11
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Karaolanis G, Antonopoulos CN, Koutsias SG, Giosdekos A, Metaxas EK, Tzimas P, de Borst GJ, Geroulakos G. A systematic review and meta-analysis for the management of Paget-Schroetter syndrome. J Vasc Surg Venous Lymphat Disord 2021; 9:801-810.e5. [PMID: 33540134 DOI: 10.1016/j.jvsv.2021.01.011] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2020] [Accepted: 01/21/2021] [Indexed: 10/22/2022]
Abstract
OBJECTIVE There is currently no general agreement on the optimal treatment of Paget-Schroetter syndrome. Most centers have advocated an interventional approach that is based on the results of small institutional series. The purpose of our meta-analysis was to focus on the safety and efficacy of thrombolysis or anticoagulation with decompression therapy. A detailed description of the epidemiologic, etiologic, and clinical characteristics, along with radiologic findings and treatment option details, was also performed. METHODS The current meta-analysis was conducted using the PRISMA guidelines. Studies reporting on spontaneous thrombosis or thrombosis after strenuous activities of axillary-subclavian vein were considered eligible. Analyses of all retrospective studies were conducted, and pooled proportions with 95% confidence intervals of outcome rates were calculated. RESULTS Twenty-five studies with 1511 patients were identified. Among these patients, 1177 (77.9%) had thrombolysis, 658 (43.5%) had anticoagulation, and 1293 (85.6%) patients had decompression therapy of the thoracic outlet. Complete thrombus resolution was estimated at 78.11% of the patients after thrombolysis, and the respective pooled proportion for partial resolution of thrombus was 23.72%. Despite thrombolytic therapy, 212 patients underwent additional balloon angioplasty for residual stenosis, although only 36 stents were implanted. After anticoagulation, a total of 40.70% of the patients had complete thrombus resolution, whereas partial resolution was occurred in 29.13% of the patients. During follow-up, a total of 51.75% of the patients with any initial treatment modality had no remaining thrombus, and 84.87% of these patients were free of symptoms. We also estimated that 76.88% of the patients had a Disabilities of the Arm, Shoulder and Hand score of <20, indicating no or mild symptoms after treatment. A subgroup meta-analysis with 20 studies and 1309 patients, showed significantly improved vein patency and symptom resolution in patients who had first rib resection with or without venoplasty, compared with those who had only thrombolysis. CONCLUSIONS Although no randomized controlled data are available, our analysis strongly suggested higher rates of thrombus and symptoms resolution with thrombolysis, followed by first rib resection. A prospective randomized trial comparing anticoagulants with thrombolysis and decompression of thoracic outlet is required.
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Affiliation(s)
- Georgios Karaolanis
- Vascular Unit, Department of Surgery, University Hospital of Ioannina and School of Medicine, Ioannina, Greece.
| | - Constantine N Antonopoulos
- Cardiothoracic and Vascular Surgery Department, General Hospital of Athens "Evangelismos", Athens, Greece; Department of Vascular Surgery, Athens University Medical School, Athens, Greece
| | - Stylianos G Koutsias
- Vascular Unit, Department of Surgery, University Hospital of Ioannina and School of Medicine, Ioannina, Greece
| | - Alexandros Giosdekos
- Department of Vascular Surgery, Athens University Medical School, Athens, Greece
| | | | - Petros Tzimas
- Department of Anesthesiology, University Hospital of Ioannina and School of Medicine, Ioannina, Greece
| | - Gert J de Borst
- Department of Vascular Surgery, UMC, Utrecht, The Netherlands
| | - George Geroulakos
- Department of Vascular Surgery, Athens University Medical School, Athens, Greece
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Isolated Pectoralis Minor Tendon Rupture with Subclavian Vein Thrombosis. Case Rep Orthop 2021; 2021:8865592. [PMID: 33575052 PMCID: PMC7857928 DOI: 10.1155/2021/8865592] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2020] [Revised: 11/07/2020] [Accepted: 01/12/2021] [Indexed: 11/17/2022] Open
Abstract
Isolated insertional ruptures of the pectoralis minor tendon at the coracoid process are a rare condition. Hitherto, very few cases have been reported in the literature. A precise diagnosis is often difficult to obtain and commonly requires advanced imaging to confirm the suspicion and rule out concomitant injuries. All cases reported in the literature to date have been treated conservatively, with excellent results and no further complications. Here, however, we present the case of a patient who had developed a subclavian vein thrombosis. Furthermore, we provide an overview over and draw comparisons to the cases described in the literature. Despite the effectiveness of the conservative treatment, physicians should be aware that adverse events may occur.
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Effort Thrombosis Presenting as Unilateral "Pumped" Arm in a Climber. Wilderness Environ Med 2020; 31:344-349. [PMID: 32773353 DOI: 10.1016/j.wem.2020.05.001] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2019] [Revised: 04/24/2020] [Accepted: 05/06/2020] [Indexed: 01/03/2023]
Abstract
Upper extremity injuries are common among the growing population of climbers. Although conditions affecting musculoskeletal structures are the most common causes of symptoms, a comprehensive differential diagnosis is necessary to avoid the misdiagnosis of high-morbidity conditions in this patient population. We present a case of a climber with acute edema, erythema, and pain of the entire right upper extremity. After confirmation of an upper extremity deep vein thrombosis by ultrasound, and in the absence of secondary causes for his thrombotic process, he was diagnosed with effort thrombosis. The patient was treated acutely with anticoagulation, catheter thrombectomy, direct thrombolysis, and balloon angioplasty followed by surgical decompression of the subclavian vein. Owing to the importance of early diagnosis and initiation of treatment, it is critical to keep disorders affecting the upper thoracic vascular structures in consideration.
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Bosch FTM, Nisio MD, Büller HR, van Es N. Diagnostic and Therapeutic Management of Upper Extremity Deep Vein Thrombosis. J Clin Med 2020; 9:jcm9072069. [PMID: 32630244 PMCID: PMC7408847 DOI: 10.3390/jcm9072069] [Citation(s) in RCA: 30] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2020] [Revised: 06/25/2020] [Accepted: 06/29/2020] [Indexed: 12/21/2022] Open
Abstract
Upper extremity deep vein thrombosis (UEDVT) accounts for 5% of all deep vein thromboses (DVTs). UEDVT may be complicated by post thrombotic syndrome and pulmonary embolism, and early recognition and prompt start of anticoagulant treatment are key. Primary UEDVT, also known as Paget-von Schrötter syndrome, is associated with repeated or sudden physical activity of the upper arm and venous outflow obstruction due to anatomical variations. Secondary UEDVT is often associated with malignancy or use of intravenous devices, such as central venous catheters or pacemaker leads. Although the diagnosis and treatment of UEDVT have many similarities with DVT of the lower extremities, knowledge of specific aspects regarding UEDVT is important to guide optimal management. In this review, we will discuss the epidemiology, diagnosis, and treatment of UEDVT based on the current literature.
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Affiliation(s)
- Floris T. M. Bosch
- Department of Internal Medicine, Tergooi Hospitals, 1213 XZ Hilversum, The Netherlands
- Department of Vascular Medicine, Amsterdam Cardiovascular Science, Amsterdam UMC, University of Amsterdam, 1105 AZ Amsterdam, The Netherlands; (H.R.B.); (N.v.E.)
- Correspondence: ; Tel.: +31-20-566-8791
| | - Marcello Di Nisio
- Department of Medicine and Ageing Sciences, Gabriele D′Annunzio University, Via dei Vestini 31, 66100 Chieti, Italy;
| | - Harry R. Büller
- Department of Vascular Medicine, Amsterdam Cardiovascular Science, Amsterdam UMC, University of Amsterdam, 1105 AZ Amsterdam, The Netherlands; (H.R.B.); (N.v.E.)
| | - Nick van Es
- Department of Vascular Medicine, Amsterdam Cardiovascular Science, Amsterdam UMC, University of Amsterdam, 1105 AZ Amsterdam, The Netherlands; (H.R.B.); (N.v.E.)
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15
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Cai TY, Rajendran S, Saha P, Dubenec S. Paget-Schroetter syndrome: A contemporary review of the controversies in management. Phlebology 2020; 35:461-471. [DOI: 10.1177/0268355519898920] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Aim To assess the current evidence, controversies and technologies behind the various approaches and steps in the management of Paget-Schroetter syndrome. Materials and methods We performed a narrative review based on a literature search in Embase, Medline, Pubmed and Google Scholar through keyword searching related to upper extremity deep vein thrombosis, Paget-Schroetter syndrome and venous thoracic outlet syndrome. Results There is a paucity of high-quality evidence assessing the efficacy of contemporary approaches for the management of acute upper extremity deep vein thrombosis which, though promising, is largely limited to single institution case studies and small series. As a result, a formal systematic review could not be performed. Conclusions Paget-Schroetter syndrome is a rare condition, whose management approaches are largely guided by the accumulated expertise and clinical experience of vascular specialists. In the absence of randomized controlled trials, current practice has been guided by retrospective reviews and experience. Modern approaches and protocols appear to remain distinct between health care facilities, but have common features including early clot lysis, surgical decompression with first rib resection, followed by adjunctive open or endovascular procedures. Further high-quality level 1 evidence and research are required in order to standardize treatment for this condition.
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Affiliation(s)
- Tommy Y Cai
- Department of Vascular Surgery, Royal Prince Alfred Hospital, Camperdown, NSW, Australia
- School of Medicine, University of Sydney, Sydney, NSW, Australia
| | - Saissan Rajendran
- Department of Vascular Surgery, Royal Prince Alfred Hospital, Camperdown, NSW, Australia
- Faculty of Medicine, University of New South Wales, Kensington, NSW, Australia
| | - Prakash Saha
- Department of Vascular Surgery, Royal Prince Alfred Hospital, Camperdown, NSW, Australia
- Academic Department of Vascular Surgery, St Thomas’ Hospital, King’s College London, London, UK
| | - Steven Dubenec
- Department of Vascular Surgery, Royal Prince Alfred Hospital, Camperdown, NSW, Australia
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Rajendran S, Cai TY, Loa J, Saha P, Dubenec S. Early outcomes using dedicated venous stents in the upper limb of patients with venous thoracic outlet syndrome: A single centre experience. CVIR Endovasc 2019; 2:22. [PMID: 32026125 PMCID: PMC6966406 DOI: 10.1186/s42155-019-0066-0] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2019] [Accepted: 07/09/2019] [Indexed: 11/10/2022] Open
Abstract
INTRODUCTION Surgical management of Venous Thoracic Outlet Syndrome (vTOS) is based upon resection of the first rib. The optimal method to treat any residual venous scarring however remains unclear. The purpose of this study was to evaluate a single quaternary centre's early and mid-term outcomes following endovascular reconstruction of the axillo-subclavian vein using dedicated venous stents in patients with VTOS. METHODOLOGY A retrospective analysis of patients at Royal Prince Alfred Hospital, who underwent upper limb deep venous stenting as an adjunct in the treatment of vTOS was performed. All patients between 2012 and 2017 were included. Stent patency was assessed with duplex ultrasonography. All re-interventions and their indications were recorded. RESULTS A total of 24 limbs in 21 patients (13 female, median age 44 yrs) were treated with dedicated venous stents between 2012 and 2017. All patients had resection of their first rib using a transaxillary approach. Nine patients initially presented with an acute DVT and underwent thrombolysis. In three of these patients a venous stent was placed before rib resection following completion of lysis. In the remainder, the median time for stent placement following surgery was 64 days. Median follow-up from stent insertion was 50 months. Primary, primary-assisted and secondary patency at 24 months was 55%, 95% and 100% respectively with one patient lost during follow-up. There were no major complications. A total of 14 re-interventions were performed on these patients. Three patients reported residual symptoms following stenting including heaviness (n = 1), bluish discolouration (n = 1) and prominent veins on the chest (n = 1) with the remainder asymptomatic. CONCLUSION In this single centre study, endovascular reconstruction using dedicated venous stents appears to be an effective and safe method to reconstruct a damaged subclavian vein following rib resection in patients with vTOS.
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Affiliation(s)
- Saissan Rajendran
- Department of Vascular Surgery, Royal Prince Alfred Hospital, 50 Missenden Road, Camperdown, NSW, 2066, Australia. .,Faculty of Medicine, University of New South Wales, Wallace Wurth Building, 18 High St, Kensington, NSW, 2052, Australia.
| | - Tommy Y Cai
- Department of Vascular Surgery, Royal Prince Alfred Hospital, 50 Missenden Road, Camperdown, NSW, 2066, Australia.,School of Medicine, University of Sydney, Edward Ford Building (A27) Fisher Road, Sydney, NSW, 2006, Australia
| | - Jacky Loa
- Department of Vascular Surgery, Royal Prince Alfred Hospital, 50 Missenden Road, Camperdown, NSW, 2066, Australia
| | - Prakash Saha
- Department of Vascular Surgery, Royal Prince Alfred Hospital, 50 Missenden Road, Camperdown, NSW, 2066, Australia.,Academic Department of Vascular Surgery, St Thomas' Hospital, King's College London, Westminster Bridge Rd, London, SE1 7EH, UK
| | - Steven Dubenec
- Department of Vascular Surgery, Royal Prince Alfred Hospital, 50 Missenden Road, Camperdown, NSW, 2066, Australia
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Agrawal A, Bajaj D, Ruben M, George J. Idiopathic Internal Jugular Vein and Subclavian Vein Thrombosis: A Rare Case Report. Cureus 2019; 11:e4005. [PMID: 31001459 PMCID: PMC6450591 DOI: 10.7759/cureus.4005] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Abstract
Venous thrombosis is a vascular disorder which is a consequence of Virchow's triad: hypercoagulability, venous stasis, and endothelial injury. While lower extremity deep venous thrombosis is common, upper torso thrombosis is a rare clinical condition and usually a complication of central venous catheterization or malignancy-related paraneoplastic syndromes. Herein, we present a rare case of a 64-year-old male who presented with right upper extremity and right facial swelling who was found to have a thrombus in the right internal jugular vein and right subclavian vein with no predisposing factors. He was successfully treated with anticoagulation without any complications.
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Affiliation(s)
- Ankit Agrawal
- Internal Medicine, Rutgers Robert Wood Johnson Medical School / Saint Peter's University Hospital, New Brunswick, USA
| | - Divyansh Bajaj
- Internal Medicine, Saint Vincent Medical Center, Bridgeport, USA
| | - Megan Ruben
- Internal Medicine, Rutgers Robert Wood Johnson Medical School / Saint Peter's University Hospital, New Brunswick, USA
| | - John George
- Internal Medicine, Bridgeport Hospital, Milford, USA
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Thiyagarajah K, Ellingwood L, Endres K, Hegazi A, Radford J, Iansavitchene A, Lazo-Langner A. Post-thrombotic syndrome and recurrent thromboembolism in patients with upper extremity deep vein thrombosis: A systematic review and meta-analysis. Thromb Res 2019; 174:34-39. [DOI: 10.1016/j.thromres.2018.12.012] [Citation(s) in RCA: 37] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2018] [Revised: 11/13/2018] [Accepted: 12/07/2018] [Indexed: 10/27/2022]
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19
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Rajasekhar A, Streiff MB. Etiology and Management of Upper-Extremity Catheter-Related Thrombosis in Cancer Patients. Cancer Treat Res 2019; 179:117-137. [PMID: 31317484 DOI: 10.1007/978-3-030-20315-3_8] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2023]
Abstract
Central venous access devices are a critical instrument in the treatment and supportive care delivery for oncology patients. Catheter-related thrombosis (CRT) is a common complication of central venous access devices in oncology patients. Risk factors for CRT include patient-, device-, and treatment-related risk factors. Treatment of CRT is indicated to reduce symptoms, prevent catheter malfunction, prevent recurrent DVT or thromboembolic pulmonary embolism, and minimize the risk of post-thrombotic syndrome. Minimal prospective data exist on the prevention and treatment of catheter-related thromboses in cancer patients. As such recommendations largely are derived from data in the lower-extremity DVT and PE studies in cancer and non-cancer patients. Based on the available literature, primary pharmacologic prophylaxis against CRT is not recommended in cancer patients. Treatment options for CRT include catheter removal, anticoagulation, catheter-directed thrombolysis, or surgical thrombectomy. Current evidence-based guidelines recommend LMWH as the anticoagulant of choice. However, recent data showing efficacy and safety of DOACs in cancer-related VTE may be extrapolated to treatment of CRT in cancer patients. In patients with CRT, catheter removal should be pursued if continued vascular access is no longer needed, the catheter is dysfunctional, a catheter-associated infection is present, or if CRT symptoms do not resolve with anticoagulation alone. Catheter-directed thrombolysis is reserved for rare severe cases of CRT. Herein we discuss the pathophysiology, clinical presentation, diagnosis, and general management of CRT in cancer patients.
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Affiliation(s)
- Anita Rajasekhar
- Division of Hematology/Oncology, Department of Medicine, University of Florida, PO Box 100278, 1600 SW Archer Rd, Gainesville, FL, 32610, USA.
| | - Michael B Streiff
- Division of Hematology, Department of Medicine, Johns Hopkins University School of Medicine, 1830 East Monument Street, Suite 7300, Baltimore, MD, 21205, USA
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Miller MJ, Stokes LS, Abboud R, Bhatti Z, Pillai AK. Percutaneous Venous Interventions in The Pulmonary Vascular, Central and Peripheral Venous Systems: How to Recognize, Avoid and Treat Complications. Tech Vasc Interv Radiol 2018; 21:228-241. [PMID: 30545501 DOI: 10.1053/j.tvir.2018.07.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
Endovascular treatment of venous disease encompasses a broad range of interventions. Both central and peripheral venous interventions can range from the simple to the complex which increases the need for proper patient selection, procedural planning and technical proficiency. The following article will discuss the importance of avoiding, recognizing and addressing complications associated with venous interventions. Our goal is to raise awareness and educate to help the reader improve performance.
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Affiliation(s)
- Michael J Miller
- Wake Forest School of Medicine, Medical Center Boulevard, Winston-Salem, NC.
| | - LeAnn S Stokes
- Department of Radiology, Vanderbilt University Medical Center, TN.
| | - Rayan Abboud
- Wake Forest School of Medicine, Medical Center Boulevard, Winston-Salem, NC.
| | - Zagum Bhatti
- Department of Diagnostic Imaging and Intervention, University of Texas, Houston, TX.
| | - Anil K Pillai
- University of Texas, Health Science Center, Houston, TX.
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Shaw CM, Shah S, Kapoor BS, Cain TR, Caplin DM, Farsad K, Knuttinen MG, Lee MH, McBride JJ, Minocha J, Robilotti EV, Rochon PJ, Strax R, Teo EYL, Lorenz JM. ACR Appropriateness Criteria ® Radiologic Management of Central Venous Access. J Am Coll Radiol 2018; 14:S506-S529. [PMID: 29101989 DOI: 10.1016/j.jacr.2017.08.053] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2017] [Accepted: 08/23/2017] [Indexed: 01/15/2023]
Abstract
Obtaining central venous access is one of the most commonly performed procedures in hospital settings. Multiple devices such as peripherally inserted central venous catheters, tunneled central venous catheters (eg, Hohn catheter, Hickman catheter, C. R. Bard, Inc, Salt Lake City UT), and implantable ports are available for this purpose. The device selected for central venous access depends on the clinical indication, duration of the treatment, and associated comorbidities. It is important for health care providers to familiarize themselves with the types of central venous catheters available, including information about their indications, contraindications, and potential complications, especially the management of catheters in the setting of catheter-related bloodstream infections. The American College of Radiology Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision include an extensive analysis of current medical literature from peer reviewed journals and the application of well-established methodologies (RAND/UCLA Appropriateness Method and Grading of Recommendations Assessment, Development, and Evaluation or GRADE) to rate the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances where evidence is lacking or equivocal, expert opinion may supplement the available evidence to recommend imaging or treatment.
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Affiliation(s)
| | - Colette M Shaw
- Principal Author, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania.
| | - Shrenik Shah
- Research Author, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania
| | | | | | - Drew M Caplin
- Hofstra Northwell School of Medicine, Manhasset, New York
| | | | | | - Margaret H Lee
- David Geffen School of Medicine at UCLA, Los Angeles, California
| | | | - Jeet Minocha
- University of California San Diego, San Diego, California
| | - Elizabeth V Robilotti
- Memorial Sloan Kettering Cancer Center, New York, New York; Infectious Diseases Society of America
| | - Paul J Rochon
- University of Colorado Denver, Anschutz Medical Campus, Aurora, Colorado
| | | | - Elrond Y L Teo
- Emory University School of Medicine, Atlanta, Georgia; Society of Critical Care Medicine
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Mahmoud O, Sihvo E, Räsänen J, Vikatmaa L, Vikatmaa P, Venermo M. Treatment of Paget-Schroetter syndrome with a three-stage approach including thoracoscopic rib resection at the second stage. J Vasc Surg Venous Lymphat Disord 2018; 6:75-82. [DOI: 10.1016/j.jvsv.2017.07.010] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2016] [Accepted: 07/28/2017] [Indexed: 11/30/2022]
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Recurrent Upper Extremity Thrombosis Associated with Overactivity: A Case of Delayed Diagnosis of Paget-Schroetter Syndrome. Case Rep Vasc Med 2017; 2017:8764903. [PMID: 28775908 PMCID: PMC5523535 DOI: 10.1155/2017/8764903] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2017] [Revised: 05/23/2017] [Accepted: 06/13/2017] [Indexed: 11/18/2022] Open
Abstract
Paget-Schroetter syndrome is thrombosis of the axillary-subclavian vein that is associated with strenuous and repetitive activity of the upper extremities. Overuse of the arm coupled with external compression results in microtrauma in the intima of the subclavian vein, resulting in the activation of the coagulation cascade. Diagnosis is usually made by Doppler ultrasound and the treatment involves thrombolysis, while routine surgical decompression of the thoracic outlet is controversial. In this report, we present a case of a patient who presented with a second episode of spontaneous right upper extremity deep venous thrombosis. The first episode was inadequately treated with oral anticoagulation alone. During the second episode, Paget-Schroetter syndrome was diagnosed, after careful review of his occupational history. He subsequently underwent angioplasty and decompression of thoracic outlet with no recurrence of thrombosis in a 12-month follow-up period.
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How I treat central venous access device-related upper extremity deep vein thrombosis. Blood 2017; 129:2727-2736. [PMID: 28373261 DOI: 10.1182/blood-2016-08-693671] [Citation(s) in RCA: 49] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/20/2016] [Accepted: 02/04/2017] [Indexed: 12/26/2022] Open
Abstract
Central venous access device (CVAD)-related thrombosis (CRT) is a common complication among patients requiring central venous access as part of their medical care. Complications of CRT include pulmonary embolism, recurrent deep venous thrombosis, loss of central venous access, and postthrombotic syndrome. Patient-, device-, and treatment-related factors can influence the risk of CRT. Despite numerous randomized controlled trials, the clinical benefit of pharmacologic thromboprophylaxis for the prevention of CRT remains to be established. Therefore, minimizing patient exposure to known risk factors is the best available approach to prevent CRT. Venous duplex is recommended for the diagnosis of CRT. Anticoagulation for at least 3 months or the duration of the indwelling CVAD is recommended for treatment of CRT. Thrombolysis should be considered for patients at low risk for bleeding who have limb-threatening thrombosis or whose symptoms fail to resolve with adequate anticoagulation. CVAD removal should be consider for patients with bacteremia, persistent symptoms despite anticoagulation, and if the CVAD is no longer needed. Superior vena cava filters should be avoided. Prospective studies are needed to define the optimal management of patients with or at risk for CRT.
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Casanegra AI, McBane RD, Bjarnason H. Intervention radiology for venous thrombosis: early thrombus removal using invasive methods. Br J Haematol 2017; 177:173-184. [PMID: 28369771 DOI: 10.1111/bjh.14581] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
The post thrombotic syndrome is one of the most dreaded complications of proximal deep vein thrombosis. This syndrome leads to pain and suffering with leg swelling, recalcitrant ulceration and venous claudication which greatly impairs mobility and quality of life. The prevalence can be high in patients with iliofemoral venous involvement particularly in the setting of a proximal venous stenosis, such as occurs in May Thurner syndrome. Anticoagulation alone does not reduce the likelihood of this outcome. Compression therapy may be effective but garment discomfort limits its implementation. Pharmacomechanical thrombectomy, which combines catheter-directed thrombolysis with mechanical thrombus dissolution, provides an attractive treatment strategy for such patients. The rationale and delivery of pharmacomechanical thrombectomy, including patient selection and adjunctive antithrombotic therapy, will be reviewed in addition to tips and tricks for managing difficult patient scenarios.
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Clinical course of upper extremity deep vein thrombosis in patients with or without cancer: a systematic review. Thromb Res 2017; 140 Suppl 1:S81-8. [PMID: 27067985 DOI: 10.1016/s0049-3848(16)30104-9] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
BACKGROUND The incidence of upper extremity deep vein thrombosis (UEDVT) is increasing. Information on the clinical course of UEDVT is scarce, especially in cancer patients. AIM To summarize the clinical evidence regarding long-term clinical outcomes of UEDVT, in terms of recurrent venous thromboembolism (VTE), mortality, and anticoagulant-related bleeding, in patients with or without concomitant cancer. METHODS A systematic search of the literature was conducted in MEDLINE, EMBASE and BIOSIS Previews. Incidence rates for all outcome variables were calculated. RESULTS In total, 45 studies comprising 4580 patients were included. No randomized controlled trials were identified. In most studies, patients were treated solely with anticoagulants. Among the prospective studies, the incidences of recurrent VTE and bleeding complications averaged 5.1% and 3.1% respectively, during 3 to 59months of follow-up. In the retrospective studies these figures were 9.8% and 6.7% respectively. Among the prospective studies, the mortality rate was 24% after one year. In the retrospective studies this rate was 35%. Cancer patients were found to have a 2- to 3-fold higher risk of recurrent VTE, an 8-fold increased risk of mortality, and a 4-fold increased risk of bleeding during anticoagulant therapy, compared to non-cancer patients. CONCLUSIONS Studies were very heterogeneous in terms of study design, study populations and treatment approaches. Follow-up durations varied greatly, hampering combined analyses of average incidence rates. There is a need for large prospective studies to provide information on the best management of this disease, especially in high risk groups such as those with cancer.
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Stuck AK, Engelberger RP, Saengprakai W, Kucher N. Pharmacomechanical or ultrasound-assisted thrombolysis, balloon angioplasty and provisional surgical decompression for upper extremity deep vein thrombosis due to thoracic outlet syndrome. Thromb Res 2016; 145:109-11. [DOI: 10.1016/j.thromres.2016.08.006] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2016] [Revised: 08/02/2016] [Accepted: 08/04/2016] [Indexed: 01/08/2023]
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Tichelaar VYIG, Brodin EE, Vik A, Isaksen T, Skjeldestad FE, Kumar S, Trasti NC, Singh K, Hansen JB. A Retrospective Comparison of Ultrasound-Assisted Catheter-Directed Thrombolysis and Catheter-Directed Thrombolysis Alone for Treatment of Proximal Deep Vein Thrombosis. Cardiovasc Intervent Radiol 2016; 39:1115-21. [PMID: 27250354 PMCID: PMC4923095 DOI: 10.1007/s00270-016-1367-5] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/07/2016] [Accepted: 05/11/2016] [Indexed: 11/16/2022]
Abstract
Background Recent studies have suggested that catheter-directed thrombolysis (CDT) reduces development of post-thrombotic syndrome (PTS). Ultrasound-assisted CDT (USCDT) might enhance the efficiency of thrombolysis. We aimed to compare USCDT with CDT on efficacy, safety, development of PTS, and quality of life after long-term follow-up. Methods We describe a retrospective case series of 94 consecutive patients admitted with iliofemoral or more proximal deep vein thrombosis (DVT) to the University Hospital from 2002 to 2011, treated either with CDT or USCDT. Scheduled follow-up visits took place between April 2013 and January 2014. Venography measured the degree of residual luminal obstruction of the affected veins. Each patient completed the Short Form 36-item health survey assessment and the Venous Insufficiency Epidemiological and Economic Study-Quality of Life/Symptoms questionnaires. PTS was assessed using the Villalta scale. Results Risk factors of DVT were equally distributed between groups. In the USCDT group, we observed a significant decline in the duration of thrombolytic treatment (<48 h: 27 vs. 10 %), shortened hospital stay (median 6.0 days (IQR 5.0–9.0) vs. 8.0 (IQR 5.8–12.0)), and less implantation of (intravenous) stents (30 vs. 55 %). There was no difference in patency (76 vs. 79 % fully patent), prevalence of PTS (52 vs. 55 %), or quality of life between groups after long-term follow-up (median 65 months, range: 15–141). Conclusions In this observational study, USCDT was associated with shortened treatment duration, shorter hospital stay, and less intravenous stenting, compared to CDT alone without affecting the long-term prevalence of PTS or quality of life.
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Affiliation(s)
- Vladimir Y I G Tichelaar
- K. G. Jebsen - Thrombosis Research and Expertise Centre (TREC), Department of Clinical Medicine, UiT - The Arctic University of Norway, 9037, Tromsø, Norway. .,Division of Hemostasis and Thrombosis, Department of Hematology, University Medical Center Groningen, Groningen, The Netherlands.
| | - Ellen E Brodin
- K. G. Jebsen - Thrombosis Research and Expertise Centre (TREC), Department of Clinical Medicine, UiT - The Arctic University of Norway, 9037, Tromsø, Norway.,Division of Internal Medicine, University Hospital of North Norway, Tromsø, Norway
| | - Anders Vik
- K. G. Jebsen - Thrombosis Research and Expertise Centre (TREC), Department of Clinical Medicine, UiT - The Arctic University of Norway, 9037, Tromsø, Norway.,Division of Internal Medicine, University Hospital of North Norway, Tromsø, Norway
| | - Trond Isaksen
- K. G. Jebsen - Thrombosis Research and Expertise Centre (TREC), Department of Clinical Medicine, UiT - The Arctic University of Norway, 9037, Tromsø, Norway.,Division of Internal Medicine, University Hospital of North Norway, Tromsø, Norway
| | - Finn Egil Skjeldestad
- Research Group Epidemiology of Chronic Diseases, Department of Community Medicine, UiT - The Arctic University of Norway, 9037, Tromsø, Norway
| | - Satish Kumar
- Department of Radiology, University Hospital of North Norway, Tromsø, Norway
| | - Nora C Trasti
- Department of Radiology, University Hospital of North Norway, Tromsø, Norway
| | - Kulbir Singh
- Department of Radiology, University Hospital of North Norway, Tromsø, Norway
| | - John-Bjarne Hansen
- K. G. Jebsen - Thrombosis Research and Expertise Centre (TREC), Department of Clinical Medicine, UiT - The Arctic University of Norway, 9037, Tromsø, Norway.,Division of Internal Medicine, University Hospital of North Norway, Tromsø, Norway
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Isaksen T, Tichelaar YIGV, Skjeldestad FE, Brodin EE, Vik A, Singh K, Hansen JB. Inter-rater agreement between professional-rated and patient-rated scores of the Villalta scale for evaluation of the post-thrombotic syndrome. Thromb Res 2016; 141:175-7. [PMID: 27058275 DOI: 10.1016/j.thromres.2016.03.027] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2015] [Revised: 03/21/2016] [Accepted: 03/23/2016] [Indexed: 11/28/2022]
Affiliation(s)
- Trond Isaksen
- K. G. Jebsen - Thrombosis Research and Expertise Center (TREC), Department of Clinical Medicine, UiT - The Arctic University of Norway, Tromsø, Norway; Division of Internal Medicine, University Hospital of North Norway, Tromsø, Norway
| | - Y I G Vladimir Tichelaar
- K. G. Jebsen - Thrombosis Research and Expertise Center (TREC), Department of Clinical Medicine, UiT - The Arctic University of Norway, Tromsø, Norway; Division of Hemostasis and Thrombosis, Department of Hematology, University Medical Center Groningen, Groningen, the Netherlands.
| | - Finn E Skjeldestad
- Research Group Epidemiology of Chronic Diseases, Department of Community Medicine, UiT - The Arctic University of Norway, Tromsø, Norway
| | - Ellen E Brodin
- K. G. Jebsen - Thrombosis Research and Expertise Center (TREC), Department of Clinical Medicine, UiT - The Arctic University of Norway, Tromsø, Norway; Division of Internal Medicine, University Hospital of North Norway, Tromsø, Norway
| | - Anders Vik
- K. G. Jebsen - Thrombosis Research and Expertise Center (TREC), Department of Clinical Medicine, UiT - The Arctic University of Norway, Tromsø, Norway; Division of Internal Medicine, University Hospital of North Norway, Tromsø, Norway
| | - Kulbir Singh
- Department of Radiology, University Hospital of North Norway, Tromsø, Norway
| | - John-Bjarne Hansen
- K. G. Jebsen - Thrombosis Research and Expertise Center (TREC), Department of Clinical Medicine, UiT - The Arctic University of Norway, Tromsø, Norway; Division of Internal Medicine, University Hospital of North Norway, Tromsø, Norway
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Skervin AL, Onida S, Davies AH. Upper extremity deep vein thrombosis - The venous thromboembolism Cinderella? Phlebology 2016; 32:76-77. [PMID: 27000146 DOI: 10.1177/0268355516635959] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Affiliation(s)
- Alicia L Skervin
- Academic Section of Vascular Surgery, Department of Surgery and Cancer, Charing Cross Hospital, Imperial College London, London, UK
| | - Sarah Onida
- Academic Section of Vascular Surgery, Department of Surgery and Cancer, Charing Cross Hospital, Imperial College London, London, UK
| | - Alun H Davies
- Academic Section of Vascular Surgery, Department of Surgery and Cancer, Charing Cross Hospital, Imperial College London, London, UK
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Kahn SR, Comerota AJ, Cushman M, Evans NS, Ginsberg JS, Goldenberg NA, Gupta DK, Prandoni P, Vedantham S, Walsh ME, Weitz JI. The Postthrombotic Syndrome: Evidence-Based Prevention, Diagnosis, and Treatment Strategies. Circulation 2014; 130:1636-61. [DOI: 10.1161/cir.0000000000000130] [Citation(s) in RCA: 349] [Impact Index Per Article: 34.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
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Abstract
Key Points
Upper limb PTS in children depends on DVT pathogenesis (primary vs secondary) and on the age of the patient (neonates vs non-neonates). DVT pathogenesis and thrombus resolution are independent predictors of upper limb PTS in children.
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Wadhawan A, Laage Gaupp FM, Sista AK. Automatic implantable cardiac defibrillator implantation may precipitate effort-induced thrombosis in young athletes: a case report and literature review. Clin Imaging 2014; 38:510-514. [PMID: 24794202 DOI: 10.1016/j.clinimag.2014.03.014] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2013] [Revised: 03/18/2014] [Accepted: 03/25/2014] [Indexed: 11/30/2022]
Abstract
Upper extremity deep vein thrombosis (DVT) is a common finding after implantation of an automatic implantable cardiac defrillator (AICD). We describe the case of a patient who developed a left upper extremity DVT 4.5 months after implantation of an AICD and was found to have a lead-induced stenosis with possible underlying Paget-Schroetter syndrome (PSS) in the midbrachiocephalic vein on venography. While his symptoms resolved after the combination of pharmacomechanical thrombolysis, angioplasty, and anticoagulation, his long-term management is complicated by the presence of both PSS and lead-induced stenosis. Herein, we discuss his presentation, treatment, and future management options.
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Affiliation(s)
- Abhishek Wadhawan
- Government Medical College, Amritsar, India; Department of Radiology, Weill Cornell Medical College
| | - Fabian M Laage Gaupp
- Department of Radiology, Weill Cornell Medical College; Ludwig-Maximilians-University Munich, Germany
| | - Akhilesh K Sista
- Division of Interventional Radiology, Weill Cornell Medical College.
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Tsekouras N, Comerota AJ. Current trends in the treatment of venous thoracic outlet syndrome: a comprehensive review. Interv Cardiol 2014. [DOI: 10.2217/ica.13.91] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
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Bachand MP, Hébuterne X, Schneider SM. Les thromboses veineuses en nutrition parentérale à domicile : de la prévention au traitement. NUTR CLIN METAB 2013. [DOI: 10.1016/j.nupar.2013.07.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
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Pharmacomechanical thrombolysis in the management of paget-schroetter syndrome. Case Rep Radiol 2013; 2013:214804. [PMID: 23476869 PMCID: PMC3582099 DOI: 10.1155/2013/214804] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2012] [Accepted: 01/16/2013] [Indexed: 11/22/2022] Open
Abstract
Paget-Schroetter syndrome (PSS) is a rare form of thoracic outlet syndrome caused
by axillosubclavian vein thrombosis which typically presents in healthy young adults. Prompt therapy, traditionally by means of catheter-directed thrombolysis (CDT) prior to definitive surgery, can prevent the subsequent onset of postthrombotic syndrome (PTS) and considerable disability. As CDT is associated with major haemorrhage and high overall treatment cost, pharmacomechanical thrombectomy (PMT) seems to be an attractive alternative which combines pharmacological thrombolysis with mechanical clot disruption. The Trellis-8 peripheral infusion catheter is an example of such a treatment which provides topical thrombolysis in an isolated zone. We describe the use of the Trellis-8 PMT system in the successful management of three patients with PSS.
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Abstract
A 56-year-old female, recently (3 months) diagnosed with chronic kidney disease (CKD), on maintenance dialysis through jugular hemodialysis lines with a preexisting nonfunctional mature AV fistula made at diagnosis of CKD, presented to the hospital for a peritoneal dialysis line. The recently inserted indwelling dialysis catheter in left internal jugular vein had no flow on hemodialysis as was the right-sided catheter which was removed a day before insertion of the left-sided line. The left-sided line was removed and a femoral hemodialysis line was cannulated for maintenance hemodialysis, and the next day, a peritoneal catheter was inserted in the operation theater. However, 3 days later, there was progressive painful swelling of the left hand and redness with minimal numbness. The radial artery pulsations were felt. There was also massive edema of forearm, arm and shoulder region on the left side. Doppler indicated a steal phenomena due to a hyperfunctioning AV fistula for which a fistula closure was done. Absence of relief of edema prompted a further computed tomography (CT) angiogram (since it was not possible to evaluate the more proximal venous segments due to edema and presence of clavicle). Ct angiogram revealed central vein thrombosis for which catheter-directed thrombolysis and venoplasty was done resulting in complete resolution of signs and symptoms. Upper extremity DVT (UEDVT) is a very less studied topic as compared to lower extremity DVT and the diagnostic and therapeutic modalities still have substantial areas that need to be studied. We present a review of the present literature including incidences, diagnostic and therapeutic modalities for this entity. Data Sources: MEDLINE, MICROMEDEX, The Cochrane database of Systematic Reviews from 1950 through March 2011.
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Affiliation(s)
- Sanjith Saseedharan
- Department of Critical Care, Sevenhills Hospital, Andheri, Mumbai, Maharashtra, India
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38
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Bamford RF, Holt PJE, Hinchliffe RJ, Thompson MM, Loftus IM. Modernizing the treatment of venous thoracic outlet syndrome. Vascular 2012; 20:138-44. [DOI: 10.1258/vasc.2011.oa0325] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
This study aims to quantify the management and outcomes of patients treated for venous thoracic outlet syndrome (vTOS) over a seven-year period. A retrospective case-note review of all patients undergoing first rib resection at a regional vascular unit between January 1, 2002 and December 31, 2009 was performed. Treatment pathways and outcomes recorded as freedom from symptoms and venous patency were analyzed. Thirty-five patients were identified with vTOS. Ninety-one percent of patients had patent veins at discharge from clinical follow-up and were symptom-free at a median of 44 months. Patients treated within seven days of symptoms (94.7 versus 85.7, P = 0.060), with catheter-directed thrombolysis (94 versus 87.5% P = 0.702) and excision of first rib in less than 30 days (100 versus 85.7%, P = 0.002), had improved symptom-free rates. In conclusion, early referral, immediate catheter-directed thrombolysis, perioperative balloon venoplasty and early thoracic outlet decompression may provide a suitable model for improving outcomes in vTOS.
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Bosma J, Vahl AC, Coveliers HME, Rauwerda JA, Wisselink W. Primary subclavian vein thrombosis and its long-term effect on quality of life. Vascular 2011; 19:327-32. [DOI: 10.1258/vasc.2011.oa0308] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
We aimed to compare the long-term results of three different strategies for treatment of patients with primary (spontaneous or effort related) subclavian vein thrombosis (PSVT). We followed 45 consecutive patients who had been treated for PSVT receiving either oral anticoagulant therapy only ( n = 14, group 1); thrombolysis followed by anticoagulant therapy ( n = 14, group 2); or thrombolysis, transaxillary first rib resection and anticoagulant therapy ( n = 17, group 3). Endpoints were persisting symptoms and quality of life (QoL). The latter was assessed with the EuroQol (EQ-5D) questionnaire at the end of follow-up. The design is a case-control study with three different groups. Predictors for residual symptoms and QoL were analyzed with logistic and linear regression analysis. Patients in groups 2 and 3 had significantly less pain, swelling and fatigue in the afflicted limb at six weeks. There was no difference in pain ( P = 0.90), swelling ( P = 0.58), fatigue ( P = 0.61), functional impairment ( P = 0.61), recurrence ( P = 0.10) or QoL ( P = 0.25) between groups at the end of follow-up (mean follow-up 57 months [range 2–176, SD ± 46]). Treatment strategy was not predictive of QoL ( P = 0.91, analysis of variance). No differences in long-term symptoms or QoL between patients with successful and unsuccessful thrombolysis were present. In conclusion, thrombolysis with or without first rib resection does not appear to contribute to lasting symptom reduction and improvement of QoL in this study. The effect of thrombolysis may be limited to short-term symptom relief. Transaxillary first rib resection was not associated with improved late outcome (symptoms, QoL) and did not reduce recurrence rate.
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Affiliation(s)
- J Bosma
- Department of Vascular Surgery, Onze Lieve Vrouwe Gasthuis
| | - A C Vahl
- Department of Vascular Surgery, Onze Lieve Vrouwe Gasthuis
| | - H M E Coveliers
- Department of Vascular Surgery, VU University Medical Centre, Amsterdam, The Netherlands
| | - J A Rauwerda
- Department of Vascular Surgery, VU University Medical Centre, Amsterdam, The Netherlands
| | - W Wisselink
- Department of Vascular Surgery, VU University Medical Centre, Amsterdam, The Netherlands
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Marder VJ. Historical perspective and future direction of thrombolysis research: the re-discovery of plasmin. J Thromb Haemost 2011; 9 Suppl 1:364-73. [PMID: 21781273 DOI: 10.1111/j.1538-7836.2011.04370.x] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
Two issues have held the focus of thrombolysis research for over 50 years, namely, choosing between a plasminogen activator (PA) or plasmin as the best therapeutic agent and choosing between systemic or local administration. The original plasmin product of the 1950s was both ineffective and contaminated with PA, and catheter technology was not yet developed for routine clinical use. For decades, clinical practice has focused on PA and systemic administration, but today, PAs are often administered by catheter into thrombosed vessels, notably for peripheral arterial and graft occlusion and deep vein thrombosis, and increasingly for acute ischaemic stroke. Despite using catheter-delivered therapy, bleeding complications still occur, most severely expressed as symptomatic intracranial haemorrhage. New experimental data indicate that we should now reconsider plasmin as a viable, even preferable, thrombolytic agent. Plasmin requires catheter delivery to achieve thrombolysis, but this technical issue has been solved with modern technology and widespread presence of interventional suites. After local administration, plasmin will lyse thrombi; thereafter, any plasmin in the circulation will be rapidly neutralised. Pre-clinical studies confirm that plasmin has marked haemostatic safety advantage over t-PA. After more than 50 years, the field has come full circle, and plasmin as the thrombolytic agent and catheter use for local delivery of agent may represent a step forward in thrombolytic therapy.
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Affiliation(s)
- V J Marder
- Division of Hematology and Medical Oncology, Department of Medicine, David Geffen School of Medicine at UCLA, Los Angeles, CA, USA.
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Affiliation(s)
- Nils Kucher
- Department of Angiology, Cardiovascular Division, Inselspital, University Hospital Bern, Bern, Switzerland.
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