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Azygos Vein Central Venous Access in a Patient with Thoracic Central Venous Obstruction. Ann Vasc Surg 2021; 80:392.e1-392.e4. [PMID: 34644629 DOI: 10.1016/j.avsg.2021.07.031] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2021] [Accepted: 07/01/2021] [Indexed: 11/20/2022]
Abstract
This is a report of a 45-year-old female with thoracic central venous obstruction (TCVO) and alpha-1 antitrypsin deficiency requiring an implanted port for infusions. The azygos vein was used for catheter access in the setting of an occluded right internal jugular vein, bilateral innominate, and superior vena cava. A literature review examines the etiology of TCVO and superior vena cava syndrome (SVC), as well as the potential benefits and complications for using the azygos vein in patients with TCVO requiring port or catheter venous access.
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Endovascular port-a-cath rescue in acute thrombotic superior vena cava syndrome. J Vasc Surg Cases Innov Tech 2019; 5:169-173. [PMID: 31193522 PMCID: PMC6535642 DOI: 10.1016/j.jvscit.2019.03.005] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2018] [Accepted: 03/11/2019] [Indexed: 11/24/2022] Open
Abstract
Acute superior vena cava (SVC) syndrome is managed by endovascular recanalization, venoplasty with stenting, and anticoagulation. It is often associated with central venous catheters. We present a case of a 55-year-old woman with acute SVC syndrome due to port-a-cath-associated thrombosis of the SVC and the brachiocephalic and subclavian veins who was treated with catheter-based thrombectomy and local spray thrombolysis, venoplasty, and stent placement. Port-a-cath restoration was achieved in the same session by endovascular snaring and repositioning. This case demonstrates that reoperation with surgical catheter removal and reinsertion of central venous catheters with possible complications (eg, rethrombosis, bleeding) can be avoided by single-session endovascular management.
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Para-Axial Central Venous Stent Placement in Patients with Malignant Central Venous Obstruction with a Venous Port. J Vasc Interv Radiol 2018; 29:1567-1570. [PMID: 30293728 DOI: 10.1016/j.jvir.2018.06.022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2018] [Revised: 06/07/2018] [Accepted: 06/26/2018] [Indexed: 11/21/2022] Open
Abstract
The authors performed a para-axial central venous stent (p-CVS) placement in 38 patients and implanted the stent without having to remove the functioning port. No difficulties were experienced in catheter function with p-CVS. In-stent stenosis was seen in 6 of 24 patients in the p-CVS group and in 6 of 18 patients in the intrastent venous stent placement group (P = .333). No complications occurred in any patient with p-CVS when the venous port was removed. Thus, p-CVS can be an alternative way to insert a CVS in patients who already have a functioning venous port.
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Volpi S, Doenz F, Qanadli SD. Superior Vena Cava (SVC) Endovascular Reconstruction with Implanted Central Venous Catheter Repositioning for Treatment of Malignant SVC Obstruction. Front Surg 2018; 5:4. [PMID: 29435452 PMCID: PMC5790922 DOI: 10.3389/fsurg.2018.00004] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2017] [Accepted: 01/09/2018] [Indexed: 11/24/2022] Open
Abstract
Superior vena cava (SVC) syndrome is a group of clinical signs caused by the obstruction or compression of SVC and characterized by edema of the head, neck, and upper extremities, shortness of breath, and headaches. The syndrome may be caused by benign causes but most of the cases are caused by lung or mediastinal malignant tumors. Stenting of SVC has become widely accepted as the palliative treatment for this condition in malignant diseases, as it offers rapid relief of symptoms and improves the quality of life. Preserving previously placed central venous catheters (CVCs) is a major issue in this population. We report the case of a patient with SVC syndrome caused by tumoral obstruction due to central small-cell lung cancer who had right subclavian implanted CVC and a preferential head and neck venous drainage through the left internal jugular and brachiocephalic vein (BCV). We describe a complex procedure of SVC reconstruction with two different objectives: left recanalization and stent placement to ensure head and neck venous drainage and right BCV stenting for CVC repositioning and subsequent replacement. We also review published cases of SVC obstructions stenting with catheter repositioning. The patient experienced quick relief of symptoms after treatment. Chemotherapy was rapidly delivered through the preserved implanted CVC access. A 3-month follow-up computed tomography showed stents patency.
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Affiliation(s)
- Stephanie Volpi
- Cardio-Thoracic and Vascular Unit, Department of Radiology, Centre Hospitalier Universitaire Vaudois (CHUV), Lausanne, Switzerland
| | - Francesco Doenz
- Cardio-Thoracic and Vascular Unit, Department of Radiology, Centre Hospitalier Universitaire Vaudois (CHUV), Lausanne, Switzerland
| | - Salah D Qanadli
- Cardio-Thoracic and Vascular Unit, Department of Radiology, Centre Hospitalier Universitaire Vaudois (CHUV), Lausanne, Switzerland
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Clark K, Chick JFB, Reddy SN, Shin BJ, Nadolski GJ, Clark TW, Trerotola SO. Concurrent Central Venous Stent and Central Venous Access Device Placement Does Not Compromise Stent Patency or Catheter Function in Patients with Malignant Central Venous Obstruction. J Vasc Interv Radiol 2017; 28:602-607. [PMID: 28238580 DOI: 10.1016/j.jvir.2016.12.1222] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2016] [Revised: 12/20/2016] [Accepted: 12/21/2016] [Indexed: 11/29/2022] Open
Abstract
PURPOSE To determine if concurrent placement of a central venous stent (CVS) and central venous access device (CVAD) compromises stent patency or catheter function in patients with malignant central venous obstruction. MATERIALS AND METHODS CVS placement for symptomatic stenosis resulting from malignant compression was performed in 33 consecutive patients who were identified retrospectively over a 10-year period; 28 (85%) patients had superior vena cava syndrome, and 5 (15%) had arm swelling. Of patients, 11 (33%) underwent concurrent CVS and CVAD placement, exchange, or repositioning; 22 (67%) underwent CVS deployment alone and served as the control group. Types of CVADs ranged from 5-F to 9.5-F catheters. Endpoints were CVS patency as determined by clinical symptoms or CT and CVAD function, which was determined by clinical performance. RESULTS All procedures were technically successful. There was no difference between the 2 groups in clinically symptomatic CVS occlusion (P = .2) or asymptomatic in-stent stenosis detected on CT (P = .5). None of the patients in the CVS and CVAD group had recurrent clinical symptoms, but 3 (30%) of 10 patients with imaging follow-up had asymptomatic in-stent stenosis. In the control group, 3 (14%) patients had clinically symptomatic CVS occlusion and required stent revision, whereas 4 (21%) of 19 patients with imaging follow-up had asymptomatic in-stent stenosis. During the study, 2 (20%) functional but radiographically malpositioned catheters were identified (0.66 per 1,000 catheter days). CONCLUSIONS Presence of a CVAD through a CVS may not compromise stent patency or catheter function compared with CVS placement alone.
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Affiliation(s)
- Katherine Clark
- Division of Interventional Radiology, Department of Radiology, Hospital of the University of Pennsylvania, Perelman School of Medicine, 1 Silverstein, 3400 Spruce Street, Philadelphia, PA 19104
| | - Jeffrey Forris Beecham Chick
- Division of Interventional Radiology, Department of Radiology, Hospital of the University of Pennsylvania, Perelman School of Medicine, 1 Silverstein, 3400 Spruce Street, Philadelphia, PA 19104; Division of Vascular and Interventional Radiology, Department of Radiology, University of Michigan Medical Center, Ann Arbor, Michigan
| | - Shilpa N Reddy
- Division of Interventional Radiology, Department of Radiology, Hospital of the University of Pennsylvania, Perelman School of Medicine, 1 Silverstein, 3400 Spruce Street, Philadelphia, PA 19104; Division of Vascular and Interventional Radiology, Radiology Associates of the Main Line, Main Line Health System, Bryn Mawr Hospital, Bryn Mawr, Pennsylvania
| | - Benjamin J Shin
- Division of Interventional Radiology, Department of Radiology, Hospital of the University of Pennsylvania, Perelman School of Medicine, 1 Silverstein, 3400 Spruce Street, Philadelphia, PA 19104
| | - Gregory J Nadolski
- Division of Interventional Radiology, Department of Radiology, Hospital of the University of Pennsylvania, Perelman School of Medicine, 1 Silverstein, 3400 Spruce Street, Philadelphia, PA 19104
| | - Timothy W Clark
- Division of Interventional Radiology, Department of Radiology, Hospital of the University of Pennsylvania, Perelman School of Medicine, 1 Silverstein, 3400 Spruce Street, Philadelphia, PA 19104
| | - Scott O Trerotola
- Division of Interventional Radiology, Department of Radiology, Hospital of the University of Pennsylvania, Perelman School of Medicine, 1 Silverstein, 3400 Spruce Street, Philadelphia, PA 19104.
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Quaretti P, Galli F, Moramarco LP, Corti R, Leati G, Fiorina I, Maestri M. Dialysis catheter-related superior vena cava syndrome with patent vena cava: long term efficacy of unilateral Viatorr stent-graft avoiding catheter manipulation. Korean J Radiol 2014; 15:364-9. [PMID: 24843241 PMCID: PMC4023055 DOI: 10.3348/kjr.2014.15.3.364] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2013] [Accepted: 02/23/2014] [Indexed: 11/17/2022] Open
Abstract
Central venous catheters are the most frequent causes of benign central vein stenosis. We report the case of a 79-year-old woman on hemodialysis through a twin catheter in the right internal jugular vein, presenting with superior vena cava (SVC) syndrome with patent SVC. The clinically driven endovascular therapy was conducted to treat the venous syndrome with a unilateral left brachiocephalic stent-graft without manipulation of the well-functioning catheter. The follow-up was uneventful until death 94 months later.
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Affiliation(s)
- Pietro Quaretti
- Unit of Interventional Radiology - Radiology Department, IRCCS Policlinico San Matteo Foundation, Pavia 27100, Italy
| | - Franco Galli
- Nephrology and Dialysis, IRCCS Fondazione Salvatore Maugeri, Pavia 27100, Italy
| | - Lorenzo Paolo Moramarco
- Unit of Interventional Radiology - Radiology Department, IRCCS Policlinico San Matteo Foundation, Pavia 27100, Italy
| | - Riccardo Corti
- Unit of Interventional Radiology - Radiology Department, IRCCS Policlinico San Matteo Foundation, Pavia 27100, Italy
| | - Giovanni Leati
- Unit of Interventional Radiology - Radiology Department, IRCCS Policlinico San Matteo Foundation, Pavia 27100, Italy
| | - Ilaria Fiorina
- Unit of Interventional Radiology - Radiology Department, IRCCS Policlinico San Matteo Foundation, Pavia 27100, Italy
| | - Marcello Maestri
- Department of General Surgery, IRCCS Policlinico San Matteo Foundation, Pavia 27100, Italy
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El Hammoumi M, El Ouazni M, Arsalane A, El Oueriachi F, Mansouri H, Kabiri EH. Incidents and complications of permanent venous central access systems: a series of 1,460 cases. THE KOREAN JOURNAL OF THORACIC AND CARDIOVASCULAR SURGERY 2014; 47:117-23. [PMID: 24782960 PMCID: PMC4000867 DOI: 10.5090/kjtcs.2014.47.2.117] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/29/2013] [Revised: 10/02/2013] [Accepted: 10/07/2013] [Indexed: 12/24/2022]
Abstract
BACKGROUND Implanted venous access devices or permanent central venous access systems (PCVASs) are routinely used in oncologic patients. Complications can occur during the implantation or use of such devices. We describe such complications of the PCVAS and their management. METHODS Our retrospective study included 1,460 cases in which PCVAS was implanted in the 11 years between January 2002 and January 2013, including 810 women and 650 men with an average age of 45.2 years. We used polyurethane or silicone catheters. The site of insertion and the surgical or percutaneous procedure were selected on the basis of clinical data and disease information. The subclavian and cephalic veins were our most common sites of insertion. RESULTS About 1,100 cases (75%) underwent surgery by training surgeons and 360 patients by expert surgeons. Perioperative incidents occurred in 33% and 12% of these patients, respectively. Incidents (28%) included technical difficulties (n=64), a subcutaneous hematoma (n=37), pneumothoraces (n=15), and an intrapleural catheter (n=1). Complications in the short and medium term were present in 14.2% of the cases. Distortion and rupture of the catheter (n=5) were noted in the costoclavicular area (pinch-off syndrome). There were 5 cases of catheter migration into the jugular vein (n=1), superior vena cava (n=1), and heart cavities (n=3). No patient died of PCVAS insertion or complication. CONCLUSION PCVAS complications should be diagnosed early and treated with probable removal of this material for preventing any life-threatening outcome associated with complicated PVCAS.
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Affiliation(s)
- Massine El Hammoumi
- Department of Thoracic Surgery, Mohamed V Military University Hospital, Morocco
| | | | - Adil Arsalane
- Department of Thoracic Surgery, Mohamed V Military University Hospital, Morocco
| | - Fayçal El Oueriachi
- Department of Thoracic Surgery, Mohamed V Military University Hospital, Morocco
| | - Hamid Mansouri
- Department of Radiotherapy, Mohamed V Military University Hospital, Morocco
| | - El Hassane Kabiri
- Department of Thoracic Surgery, Mohamed V Military University Hospital, Morocco
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Isfort P, Penzkofer T, Goerg F, Mahnken AH. Stenting of the superior vena cava and left brachiocephalic vein with preserving the central venous catheter in situ. Korean J Radiol 2011; 12:629-33. [PMID: 21927566 PMCID: PMC3168806 DOI: 10.3348/kjr.2011.12.5.629] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2010] [Accepted: 03/10/2011] [Indexed: 12/02/2022] Open
Abstract
Stenting of the central veins is well established for treating localized venous stenosis. The techniques regarding catheter preservation for central venous catheters in the superior vena cava have been described. We describe here a method for stent implantation in the superior vena cava and the left brachiocephalic vein, and principally via a single jugular venous puncture, while saving a left sided jugular central venous catheter in a patient suffering from central venous stenosis of the superior vena cava and the left brachiocephalic vein.
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Affiliation(s)
- Peter Isfort
- Department of Diagnostic and Interventional Radiology, University Hospital RWTH Aachen, 52074 Aachen, Germany.
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Allaqaband S, Kirvaitis R, Jan F, Bajwa T. Endovascular treatment of peripheral vascular disease. Curr Probl Cardiol 2009; 34:359-476. [PMID: 19664498 DOI: 10.1016/j.cpcardiol.2009.05.001] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Peripheral arterial disease (PAD) affects about 27 million people in North America and Europe, accounting for up to 413,000 hospitalizations per year with 88,000 hospitalizations involving the lower extremities and 28,000 involving embolectomy or thrombectomy of lower limb arteries. Many patients are asymptomatic and, among symptomatic patients, atypical symptoms are more common than classic claudication. Peripheral arterial disease also correlates strongly with risk of major cardiovascular events, and patients with PAD have a high prevalence of coexistent coronary and cerebrovascular disease. Because the prevalence of PAD increases progressively with age, PAD is a growing clinical problem due to the increasingly aged population in the United States and other developed countries. Until recently, vascular surgical procedures were the only alternative to medical therapy in such patients. Today, endovascular practice, percutaneous transluminal angioplasty with or without stenting, is used far more frequently for all types of lower extremity occlusive lesions, reflecting the continuing advances in imaging techniques, angioplasty equipment, and endovascular expertise. The role of endovascular intervention in the treatment of limb-threatening ischemia is also expanding, and its promise of limb salvage and symptom relief with reduced morbidity and mortality makes percutaneous transluminal angioplasty/stenting an attractive alternative to surgery and, as most endovascular interventions are performed on an outpatient basis, hospital costs are cut considerably. In this monograph we discuss current endovascular intervention for treatment of occlusive PAD, aneurysmal arterial disease, and venous occlusive disease.
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Endovascular stenting for the management of port-a-cath associated superior vena cava syndrome. Emerg Radiol 2008; 16:143-6. [PMID: 18322718 DOI: 10.1007/s10140-008-0714-5] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2008] [Accepted: 02/14/2008] [Indexed: 10/22/2022]
Abstract
Port-a-cath systems are often essential for the administration of long-term chemotherapy in the treatment of malignancies because they improve venous access, but they are associated with complications, mainly thrombosis of central veins. In the present report, we describe a case of right subclavian and superior vena cava port-a-cath-related thrombosis causing superior vena cava syndrome (SVCS) in a patient affected by Hodgkin's disease. The patient underwent percutaneous revascularization with stent positioning, experiencing immediate relief of symptoms. Endovascular procedures for the treatment of nonmalignant SVCS seem to represent a challenging therapeutic option.
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Hasskarl J, Köberich S, Frydrychowicz A, Illerhaus G, Waller CF. Complete caval thrombosis secondary to an implanted venous port--a case study. DEUTSCHES ARZTEBLATT INTERNATIONAL 2008; 105:18-21. [PMID: 19578449 DOI: 10.3238/arztebl.2008.0018] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/25/2007] [Accepted: 08/08/2007] [Indexed: 11/27/2022]
Abstract
HISTORY AND CLINICAL FINDINGS We report the case of a woman who presented to the medical emergency room with upper thoracic inlet syndrome six months after being treated for cancer of the left breast with surgery, radiation, and chemotherapy. A port-related occlusion of the superior vena cava was diagnosed on the basis of the history, physical findings, and diagnostic images. METHODS The local standards for the handling of port systems are presented. DISCUSSION Implanted port systems facilitate the treatment of the chronically ill by enabling easy and safe venous access. As the number of patients with such systems is growing, there is an increased need for optimized handling and care, awareness of the risks (such as catheter occlusion, thrombosis, and infection), and recognition of complications when they arise.
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Affiliation(s)
- Jens Hasskarl
- Medizinische Universitätsklinik Freiburg, Hämatologie/Onkologie Abteilung I, Hugstetter Strasse 55, Freiburg, Germany
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Pires e Albuquerque M. A Modified Internal Jugular Vein Access for Long-Term Catheter Placement in Cancer Patients. Ann Surg Oncol 2006; 14:937-41. [PMID: 17103072 DOI: 10.1245/s10434-006-9140-7] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2006] [Revised: 06/20/2006] [Accepted: 06/26/2006] [Indexed: 11/18/2022]
Abstract
BACKGROUND Placement, handling, and maintenance of indwelling central venous access devices may be difficult due to anatomical, clinical, or hematologic conditions in many cancer patients needing chemotherapy. An alternative approach technique is suggested joining surgical dissection to venipuncture, assisted by fluoroscopy, as a secure way to avoid complications of long-term indwelling catheters. Although ultrasound guided puncture is a safe procedure, it is not always available or familiar to most surgeons. METHODS At the National Cancer Institute (INCA) in Rio de Janeiro, Brazil, 1750 long-term catheter placements were performed between the years 1997 and 2005. Among those, 160 were done through an alternative technical procedure consisting of an anterior cervical cutdown approach to the internal jugular vein (IJV) followed by percutaneous visual puncture of the vein. This modified internal jugular vein access (MIJVA) was employed when other access techniques were not feasible or if other underlying conditions increase the risk of bleeding complications. RESULTS The MIJVA procedure was successful in all 160 patients. Although it was used only as an exceptional option in difficult venous accesses, further prospective trials must be conducted, however, for comparison with other technical approaches. CONCLUSION The MIJVA is an option that provides successful IJV dissection and safe percutaneous visual puncture overcoming anatomical pitfalls in placement of long-term venous access for chemotherapy in cancer patients.
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Affiliation(s)
- Marcos Pires e Albuquerque
- Bone Marrow Transplantation Center of the National Cancer Institute (INCA), Ministry of Health, Rio de Janeiro, Brazil.
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Caruselli M, Pieroni G, Franceschi A, Santelli F, Bechi P, Pagni R. Secondary migration of a central venous catheter: a rare complication. J Vasc Access 2006; 5:36-8. [PMID: 16596538 DOI: 10.1177/112972980400500108] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
The Authors describe a case of spontaneous migration in the right jugular vein of a central venous catheter tip, properly positioned in the right atrium through the right subclavian vein two days before.
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Affiliation(s)
- M Caruselli
- Department of Anesthesia and Intensive Care, G. Salesi Children's and Mother's Hospital, Ancona, Italy.
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Sharafuddin MJ, Sun S, Hoballah JJ. Endovascular management of venous thrombotic diseases of the upper torso and extremities. J Vasc Interv Radiol 2002; 13:975-90. [PMID: 12397118 DOI: 10.1016/s1051-0443(07)61861-2] [Citation(s) in RCA: 39] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
Central venous thrombosis in the upper torso can be either primary, occurring as a result of longstanding extrinsic compression, or secondary, resulting from an acquired intrinsic occlusive disease or foreign body. As in lower extremity deep vein thrombosis (DVT), anticoagulation therapy is the mainstay of therapy in upper torso and upper extremity DVT. However, in the presence of severely symptomatic acute thrombosis, pharmacologic and/or mechanical thrombolytic therapy represent the main invasive form of therapy for these conditions. After clearance of the acute thrombotic component, definitive management in patients with underlying anatomic abnormalities can be undertaken. Primary subclavian axillary vein thrombosis caused by extrinsic obstruction at the thoracic outlet is treated with thrombolytic therapy and anticoagulation followed by surgical decompression, whereas secondary causes of central venous obstruction and thrombosis are usually amenable to endovascular treatment with balloon angioplasty and stent placement. Postoperative interval anticoagulation is usually recommended. In addition to clinical follow-up, imaging follow-up with duplex sonography or conventional venography is usually recommended to assess the presence of restenosis and/or residual compression.
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Affiliation(s)
- Melhem J Sharafuddin
- Department of Radiology, University of Iowa College of Medicine, 3889 JPP, 200 Hawkins Drive, Iowa City, Iowa 52242-1077, USA.
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