Clinical practice. Deep-vein thrombosis of the upper extremities

Evidence-based summary of preventive care for central venous access device-related thrombosis in hospitalized children

PURPOSE

This study aims to summarize the latest and best evidence on central venous access device-related thrombosis (CRT) in hospitalized children, which provides theoretical support for standardizing the preventive care practice of CRT in hospitalized children.

METHODS

Relevant guidelines, systematic reviews and expert consensuses were reviewed through ten guideline websites, six professional association websites and seven databases. The literature evaluation was conducted, and the best evidence from qualified studies was extracted and summarized. Furthermore, the best evidence was summarized through expert consultation and localized for the preventive care practice of CRT in hospitalized children in China.

RESULTS

A total of 14 topics and 68 best evidence were collected, including personnel qualification and quality management, pediatric patient selection, risk assessment, central venous access device (CVAD) selection and use, tip position, catheter maintenance, basic prevention, drug prevention, imaging examination, health education, nursing records, follow-up, CVAD removal and others.

CONCLUSION

In this study, the best evidence based on evidence-based nursing was summarized, and expert consultation was adopted to localize the best evidence collected. It is of great significance to standardize the clinical practice of pediatric nurses and ensure the effectiveness of CRT preventive care for hospitalized children, thus guaranteeing the safety of hospitalized children with CVAD catheterization.

Catheter-related deep vein thrombosis: Where are we at and where are we going? Updates and ongoing unmet clinical needs

BACKGROUND

Catheter-related thrombosis (CRT) is one of the major complications affecting patients with indwelling venous catheters, usually involving the upper extremity deep venous system. This condition can lead to potentially life-threatening complications such as pulmonary embolism and sepsis. The risk of developing CRT varies depending on type of catheters and patient characteristics. Despite advances in materials and technologies, the actual incidence of CRT is still considerable. Available evidence on CRT management remains controversial, and clinical guidelines base their recommendations on data from non-catheter related upper extremity or lower extremity deep venous thromboses.

AIMS

This narrative review aims to describe the epidemiology of CRT, to review the available evidence on its management and to highlight the current unmet needs.

METHODS

No formal search strategy was applied for the revision of the literature. The main sources of information used were Medline and guidelines from international societies.

CONTENT

The management of CRT requires a careful balance between the risk of thrombus progression, recurrent events, and systemic embolization and the increased bleeding risk in often fragile patients. Open issues include the optimal management of the catheter and the type and duration of anticoagulant therapy. Direct oral anticoagulants are increasingly prescribed, representing an important alternative to the standard of care low molecular weight heparins in selected cases. The development of new anticoagulant drugs such as factors XI and XII inhibitors may offer further advantages in this context.

CONCLUSIONS

The management of CRT is still challenging with constant need for updated evidence to support tailored approaches.

Pulmonary embolism following an undiagnosed Paget-Schroetter syndrome: a case report and review of the literature

Paget-Schroetter Syndrome (PSS) is a rare condition characterized by spontaneous thrombosis of the axillary-subclavian vein that occurs predominantly in young athletes engaged in repetitive overhead upper extremity motion, for instance, weightlifting, swimming, baseball, and tennis. PSS is usually a consequence of chronic repetitive microtrauma to the vein intima due to compression of the axillary-subclavian vein by the thoracic outlet structures. This chronic injury can then be acutely exacerbated by vigorous exercise done over a brief period, accelerating thrombus formation. Lack of PSS awareness leads to underdiagnosis, misdiagnosis, or late diagnosis, which can pose life-threatening risks to patients, including pulmonary embolism (PE) and recurrent thrombosis. This case report of a 20-year-old male college athlete exposes a PE caused by PSS, potentially worsened by a delay in diagnosis. Early suspicion and proper management are crucial for optimizing long-term outcomes and facilitating limb rehabilitation. The recommended approach involves early catheter-directed thrombolysis followed by thoracic outlet decompression.

Innominate Vein Thrombosis: A Case Report and Literature Review

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.

A Rare Cause of Deep Vein Thrombosis in a Young Orchestra Conductor

Upper extremity deep vein thrombosis (DVT) of the axillary/subclavian veins is rare (5-10% of DVT). After clinical suspicion and duplex ultrasound, anticoagulation, surgical decompression and sometimes thrombolysis are mandatory due to complications. We discuss the case of a young healthy orchestra conductor with primary DVT of the left upper extremity and concomitant left shoulder musculo-tendinous traumatic injury. Symptoms of both conditions and subtle signs of upper extremity DVT delayed the diagnosis until full-blown DVT occurred. After successful anticoagulation and surgical TOS (thoracic outlet syndrome) decompression, evolution was favorable, without recurrent thrombosis.

While the Incidence of Venous Thromboembolism After Shoulder Arthroscopy Is Low, the Risk Factors Are a Body Mass Index Greater than 30 and Hypertension

Purpose

This study aims to determine the overall incidence of venous thromboembolism (VTE) following shoulder arthroscopy and to define potential risk factors associated with its development that may help define guidelines for the use of thromboprophylaxis.

Methods

A systematic review was performed using PubMed, Embase, Web of Science, CINAHL, and Cochrane databases per PRISMA guidelines. The search terms consisted of variations of "Venous Thromboembolism" and "Shoulder Arthroscopy." Information regarding arthroscopy indication, risk factors, outcomes, and patient demographics was recorded and analyzed, and pooled odds ratios were reported for each variable.

Results

Six hundred eighty-five articles were identified in the initial search, and 35 articles reported DVT, PE, or VTE incidence following shoulder arthroscopy. Seventeen nonoverlapping articles with a unique patient population incidence rates. Four articles were then used for subgroup meta-analysis. The incidence rate of VTE was 0.24%, ranging from 0.01% to 5.7%. BMI >30 (OR = 1.46; 95% CI = [1.22, 1.74]; I2 = 0%) and hypertension (OR = 1.64; 95% CI = [1.03, 2.6]; I2 = 75%) were significant risk factors (P < .05) for developing VTE following shoulder arthroscopy. Diabetes (OR = 1.2; 95% CI = [0.97, 1.48]; I2 = 0%), insulin-dependent diabetes (OR = 5.58; 95% CI = [0.12, 260.19]; I2 = 85%), smoking (OR = 1.04; 95% CI = [0.79, 1.37]; I2 = 12%), male sex (OR = 0.95; 95% CI = [0.49, 1.85]; I2 = 86%) and age over 65 (OR = 4.3; 95% CI = [0.25, 72.83]; I2 = 85%) were not associated with higher VTE risk.

Conclusion

The VTE incidence following shoulder arthroscopy is low at 0.24%. Patients with BMI >30 and hypertension are at a higher risk for VTE after shoulder arthroscopy.

Level of Evidence

Level IV, systematic review and meta-analysis of Level I-IV studies.

Diagnostic trends of preoperative venous thromboembolism and its clinical implications in patients who underwent surgery for degenerative spinal diseases

BACKGROUND CONTEXT

Although the risk of postoperative venous thromboembolism (VTE) in patients who undergo surgery for degenerative spinal disease has received attention, patients experiencing prolonged pain and disability while awaiting or considering surgery have not received adequate attention regarding the risk of VTE.

PURPOSE

To investigate the epidemiology of preoperative VTE in patients undergoing surgery for degenerative spinal disease.

DESIGN

Retrospective cohort study using a nationwide database.

PATIENT SAMPLE

Patients who underwent surgery for degenerative spinal disease.

OUTCOME MEASURES

Preoperative occurrence of VTE.

METHODS

Data from 2014 to 2018 were obtained from the Korean National Health Insurance claims database. The occurrence of preoperative VTE within a 1-year period divided into 12 time intervals of 30 days each was investigated. The patients were categorized into two groups based on the presence of preoperative VTE. Multivariable logistic regression analysis was conducted to identify the factors associated with preoperative VTE. To validate the relationship between degenerative spinal disease and preoperative VTE, the diagnostic trends of preoperative VTE were analyzed in accordance with the identified risk factors.

RESULTS

The overall incidence of preoperative VTE was 50 per 10,000 individuals. Multivariable analysis revealed that VTE occurred more frequently in older patients with specific medical comorbidities, particularly in those with a lumbar spinal lesion accompanied by arthritis of the hip, knee, or shoulder. We also found that the incidence rates of preoperative VTE, as well as the gradient of their increase, began to rise approximately 2 to 3 months prior to the index surgery, peaking just before the index surgery. This diagnostic trend was consistently observed in all patients irrespective of the presence of other risk factors.

CONCLUSIONS

The incidence of preoperative VTE in patients with degenerative spinal disease exhibited a sharp increase immediately before surgery, with similar rates to those of postoperative VTE. Clinicians managing patients with degenerative spinal disease should be vigilant for preoperative as well as postoperative VTE.

ESPEN guideline on chronic intestinal failure in adults - Update 2023

BACKGROUND & AIMS

In 2016, ESPEN published the guideline for Chronic Intestinal Failure (CIF) in adults. An updated version of ESPEN guidelines on CIF due to benign disease in adults was devised in order to incorporate new evidence since the publication of the previous ESPEN guidelines.

METHODS

The grading system of the Scottish Intercollegiate Guidelines Network (SIGN) was used to grade the literature. Recommendations were graded according to the levels of evidence available as A (strong), B (conditional), 0 (weak) and Good practice points (GPP). The recommendations of the 2016 guideline (graded using the GRADE system) which were still valid, because no studies supporting an update were retrieved, were reworded and re-graded accordingly.

RESULTS

The recommendations of the 2016 guideline were reviewed, particularly focusing on definitions, and new chapters were included to devise recommendations on IF centers, chronic enterocutaneous fistulas, costs of IF, caring for CIF patients during pregnancy, transition of patients from pediatric to adult centers. The new guideline consist of 149 recommendations and 16 statements which were voted for consensus by ESPEN members, online in July 2022 and at conference during the annual Congress in September 2022. The Grade of recommendation is GPP for 96 (64.4%) of the recommendations, 0 for 29 (19.5%), B for 19 (12.7%), and A for only five (3.4%). The grade of consensus is "strong consensus" for 148 (99.3%) and "consensus" for one (0.7%) recommendation. The grade of consensus for the statements is "strong consensus" for 14 (87.5%) and "consensus" for two (12.5%).

CONCLUSIONS

It is confirmed that CIF management requires complex technologies, multidisciplinary and multiprofessional activity, and expertise to care for the underlying gastrointestinal disease and to provide HPN support. Most of the recommendations were graded as GPP, but almost all received a strong consensus.

Risk and Prognosis of Upper Extremity Deep Vein Thrombosis

Objectives: We aimed to investigate the clinical features of upper extremity deep vein thrombosis (UEDVT). Methods: We retrospectively reviewed the background, thrombus site, treatment, and outcome of 76 UEDVT patients. Results: Of the 76 UEDVT patients, 44 (57.9%) were men, and 51 (67.1%) were complicated by malignancy, 44 (57.9%) had an indwelling central vein (CV) catheter, 8 (10.5%) had concomitant pulmonary embolization (PE), and 33 (43.3%) were symptomatic. Regarding the thrombus site, the right internal jugular vein was the most common, with 30 cases (35.3%). As regards the treatment method, 53 patients (69.7%) received oral anticoagulants. In 2015, when direct oral anticoagulants (DOACs) was covered by insurance, there were 44 UEDVT cases, of which 34 (77.3%) received DOACs. Outcomes at a mean observation period of 37.5±41.5 months included 40 deaths (52.6%) with a mean survival of 16.3±21.3 months. The most common cause of death was malignancy, with 33 cases (82.5%). Conclusion: In the background of UEDVT, the combination of indwelling CV catheter placement and malignancy was frequently observed. While the risk of recurrence or PE complications is low, the prognosis of UEDVT complicated by malignancy is extremely poor.

Causality assessment of circulating Vitamin D level on venous thromboembolism: A Mendelian randomization study

BACKGROUND AND AIMS

The associations of vitamin D level with venous thromboembolism (VTE) reported in observational studies, whereas these causal associations were uncertain in European population. Therefore, we used Mendelian randomization (MR) method to explore the causal associations between 25-hydroxyvitamin D (25(OH)D) concentrations and the risk of VTE and its subtypes [including deep vein thrombosis (DVT) and pulmonary embolism (PE)].

METHODS AND RESULTS

We used three kinds of genetic instruments to proxy the exposure of 25(OH)D, including genetic variants significantly associated with 25(OH)D, expression quantitative trait loci of 25(OH)D target genes, and genetic variants within or nearby 25(OH)D target genes. MR analyses did not provide any evidence for the associations of 25(OH)D levels with VTE and its subtypes (p > 0.05). The summary-data-based MR (SMR) analyses indicated that elevated expression of VDR was associated with decreased risk of VTE (OR = 0.81; 95% CI, 0.65-0.998; p = 0.047) and PE (OR = 0.67; 95% CI, 0.50-0.91; p = 0.011), and expression of AMDHD1 was associated with PE (OR = 0.93; 95% CI, 0.88-0.99; p = 0.027). MR analysis provided a significant causal effect of 25(OH)D level mediated by gene AMDHD1 on PE risk (OR = 0.09; 95% CI, 0.01-0.60; p = 0.012).

CONCLUSION

Our MR analysis did not support causal association of 25(OH)D level with the risk of VTE and its subtypes. In addition, the expression of VDR and AMDHD1 involved in vitamin D metabolism showed a strong association with VTE or PE and might represent targets for these conditions.

Body and Extremity MR Venography: Technique, Clinical Applications, and Advances

Magnetic resonance venography (MRV) represents a distinct imaging approach that may be used to evaluate a wide spectrum of venous pathology. Despite duplex ultrasound and computed tomography venography representing the dominant imaging modalities in investigating suspected venous disease, MRV is increasingly used due to its lack of ionizing radiation, unique ability to be performed without administration of intravenous contrast, and recent technical improvements resulting in improved sensitivity, image quality, and faster acquisition times. In this review, the authors discuss commonly used body and extremity MRV techniques, different clinical applications, and future directions.

Biomarkers Associated with Thrombosis in Patients with Peripherally Inserted Central Catheter: A Systematic Review and Meta-Analysis

BACKGROUND

The measurement and identification of plasma biomarkers can support the estimation of risk and diagnosis of deep vein thrombosis (DVT) associated with the use of a peripherally inserted central catheter (PICC).

OBJECTIVES

This systematic review and meta-analysis aimed to identify the association between the levels of potential biomarkers that reflect the activation of the blood system, long-term vascular complications, inflammatory system, and the occurrence of PICC-related DVT.

METHODS

Seven electronic databases (Embase, Web of Science, Medline, Scopus, Cinahl, Cochrane Central Register of Controlled Trials, and ERIC) were searched to identify literature published until December 2022. Studies were required to report: (I) adult and pediatric patients, outpatient or admitted to clinical, surgical, or ICU with PICC; (II) patients with PICC-related DVT and patients without PICC-related DVT as a comparator; and (III) at least one biomarker available. The Newcastle-Ottawa Scale was used to evaluate the quality of the studies. Study precision was evaluated by using a funnel plot for platelets level. We provided a narrative synthesis and meta-analysis of the findings on the biomarkers' outcomes of the studies. We pooled the results using random effects meta-analysis. The meta-analysis was conducted using Review Manager software v5.4. This systematic review is registered in PROSPERO (CRD42018108871).

RESULTS

Of the 3564 studies identified (after duplication removal), 28 were included. PICC-related DVT was associated with higher D-dimers (0.37 μg/mL, 95% CI 0.02, 0.72; p = 0.04, I² = 92%; p for heterogeneity < 0.00001) and with higher platelets (8.76 × 10⁹/L, 95% CI 1.62, 15.91; p = 0.02, I² = 41%; p for heterogeneity = 0.06).

CONCLUSIONS

High levels of D-dimer and platelet were associated with DVT in patients with PICC. However, biomarkers such as APTT, fibrinogen, FDP, glucose, hemoglobin, glycated hemoglobin, INR, prothrombin time, prothrombin fragment 1.2, the thrombin-antithrombin complex, and WBC were not related to the development of DVT associated with PICC.

Upper extremity deep vein thrombosis: An intensivist’s perspective

Upper extremity deep vein thrombosis (UEDVT) is less common than lower extremity DVT but is a cause of significant morbidity and mortality in intensive care unit patients. Increasing cancer incidence, prolonged life expectancy and increasing use of intravascular catheters and devices has led to an increased incidence of UEDVT. It is also associated with high rates of complications like pulmonary embolism, post-thrombotic syndrome and recurrent thrombosis. Clinical prediction scores and D-dimer may not be as useful in identifying UEDVT; hence, a high suspicion index is required for diagnosis. Doppler ultrasound is commonly employed for diagnosis, but other tests like computed tomography and magnetic resonance imaging venography may also be required in some patients. Contrast venography is rarely used in patients with clinical and ultrasound findings discrepancies. Anticoagulant therapy alone is sufficient in most patients, and thrombolysis and surgical decompression is seldom indicated. The outcome depends on the cause and underlying comorbidities.

Left brachiocephalic venous occlusion with spontaneous arteriovenous fistula presenting with severe edema in left upper extremity and face: A case report

INTRODUCTION AND IMPORTANCE

The coexistence of central venous occlusion and arteriovenous fistulas (AVF) is rare among non-dialysis patients. Herein, we describe a case of left brachiocephalic venous occlusion with spontaneous AVF, presenting with severe edema in left upper extremity and face.

CASE PRESENTATION

A 90-year-old woman presented to our hospital with gradually worsening edema in her left arm and face for eight years. Contrast-enhanced computed tomography revealed left brachiocephalic venous occlusion and severe edema in her left upper extremity and face. Computed tomography also revealed abundant collateral veins; thus, it seemed unnatural for severe edema to occur with such well-developed collateral pathways. Therefore, the presence of AVF was suspected. After careful re-examination of the patient, a continuous murmur was heard in the post-auricular region. Magnetic resonance imaging and angiogram revealed a dural AVF. Considering the patient's age and treatment difficulty for the dural AVF, we performed a stent insertion into the left brachiocephalic vein. After the procedure, edema in her left upper extremity and face improved dramatically.

CLINICAL DISCUSSION

In cases of persistent swelling of the upper extremities or face, there could be a factor that increases venous inflow. Therefore, any condition that may increase venous inflow must be aggressively investigated and therapeutic interventions should be applied to treat such conditions.

CONCLUSION

Central venous occlusion and AVF is a possible underlying cause for severe refractory edema in the upper extremity and face. Therefore, both AVF and brachiocephalic occlusion should be assessed for treatment indications under these conditions.

Prevention and treatment of catheter-related venous thrombosis in long-term parenteral nutrition: A SINuC position statement

The implementation of long-term parenteral nutrition (PN) often requires the placement of central venous access, a procedure that carries a considerable risk of catheter-related venous thrombosis (CRT). The occurrence of CRT represents a major event in the natural history of patients in PN since it can lead to central venous access loss and PN failure. Despite the importance of this topic in clinical nutrition, the prevention and treatment of CRT in PN represents one of the "gray areas" of the literature of the presence of few randomized controlled clinical trials and the generally low level of evidence of published scientific papers. Through a narrative review of the literature and a Delphi consensus, the Italian Society of Clinical Nutrition and Metabolism (SINuC) aimed to collect some practical recommendations regarding the current state-of-the-art in the prevention, diagnosis, and treatment of CRT in patients undergoing long-term PN.

Upper extremity deep venous thrombosis after BNT162b2 mRNA COVID-19 vaccine case report

We describe a case of an otherwise healthy 60-year-old female patient who presented 6 days after receipt of the second dose of the BNT162b2 mRNA COVID-19 (Pfizer/BioNTech) vaccine and was found to have upper extremity deep venous thrombosis.

Percutaneous thrombectomy of upper extremity and thoracic central veins using Inari ClotTriever System: Experience in 14 patients

Objective

In the present report, we have described the technical and clinical outcomes of percutaneous thrombectomy in the deep veins of the upper extremity and thorax using the ClotTriever system (Inari Medical, Irvine, CA).

Methods

Fourteen patients with symptomatic deep venous occlusive disease in the upper extremity deep veins and thoracic central veins who had undergone thrombectomy using the ClotTriever system between October 2020 and January 2022 were reviewed. The technical results, adverse events, imaging follow-up data, and clinical outcomes were recorded.

Results

Fourteen patients (seven men and seven women; mean age, 53.6 ± 13.3 years) constituted the study cohort. Of the 14 patients, 9 (64.3%) had had DVT due to intravascular invasion or external compression from known malignancy, 2 (14.3%) had had infected thrombi and/or vegetation due to Staphylococcus aureus refractory to intravenous antibiotic therapy, and 3 (21.4%) had had a benign etiology for thrombus formation. The presenting symptoms included upper extremity and/or facial swelling (n = 14), upper extremity pain (n = 6), fever (n = 2), and dyspnea (n = 1). Thrombectomy with the ClotTriever system was successfully completed in all 14 patients. Seven patients (50.0%) had required additional venous stent reconstruction after thrombectomy to address the underlying stenosis. No major adverse events were noted. All the patients had experienced resolution of the presenting symptoms.

Conclusions

For the management of symptomatic deep venous occlusive disease of the upper extremity deep veins and thoracic central veins, thrombectomy using the ClotTriever system was feasible with excellent technical and clinical success.

Venous thrombosis: a mimic of musculoskeletal injury on MR imaging

Clinical signs and symptoms of venous thrombosis and musculoskeletal pathologies frequently overlap. Sometimes, patients with venous thrombosis undergo MR examinations under an equivocal suspicion of muscle, tendon or articular injury. A low pretest clinical suspicion and lack of familiarity with the conventional MR imaging signs of venous thrombosis may result in failure to diagnose venous thrombosis, delaying treatment and raising morbimortality. In MR imaging, thrombosis presents as venous ectasia with intraluminal heterogeneous content. Small vein thrombosis is often identified as having a branching aspect. Perivenous edema and inflammatory soft tissue changes may be the most prominent findings. The purpose of this paper is to illustrate MR findings of venous thrombosis in patients who underwent MR examinations due to suspected musculoskeletal pathologies. Cases of venous thrombosis in different sites of the body diagnosed through MR are presented.

Perioperative Challenges in a Septic Shock Patient With Extensive Splanchnic and Extra-Splanchnic Vein Thrombosis Up to the Right Atrium

Venous thromboembolism (VTE) has a significant disease burden worldwide and comprises deep vein thrombosis (DVT) and pulmonary embolism (PE). DVT most commonly occurs in the lower extremities, very rarely it can present in the splanchnic venous circulation or inferior vena cava or both. We report an unusual presentation of a 68-year-old woman with septic shock secondary to ischemic bowel, complicated by non-tumor related, extensive right hepatic vein thrombosis extending up to the inferior vena cava (IVC) and right atrium. She underwent bowel resection surgery emergently and was started on systemic anticoagulation in the perioperative period after an extensive evaluation and resuscitation. She was managed by a multidisciplinary team during her admission and was discharged after four weeks. This case poses an interesting therapeutic challenge to the team as there is little literature to guide treatment in a critically ill patient with ischemic bowel, septic shock with extensive splanchnic and IVC thrombosis who also had likely pseudo-heparin resistance with artifactual activated partial thromboplastin time (aPTT) values. This case report seeks to share our experience of a multidisciplinary and patient-centric approach in this rare presentation of a disease spectrum.

Systematic review of venous thromboembolism risk categories derived from Caprini score

OBJECTIVE

Hospital-acquired venous thromboembolism (VTE, including pulmonary embolism [PE] and deep vein thrombosis [DVT]) is a preventable cause of hospital death. The Caprini risk assessment model (RAM) is one of the most commonly used tools to assess VTE risk. The RAM is operationalized in clinical practice by grouping several risk scores into VTE risk categories that drive decisions on prophylaxis. A correlation between increasing Caprini scores and rising VTE risk is well-established. We assessed whether the increasing VTE risk categories assigned on the basis of recommended score ranges also correlate with increasing VTE risk.

METHODS

We conducted a systematic review of articles that used the Caprini RAM to assign VTE risk categories and that reported corresponding VTE rates. A Medline and EMBASE search retrieved 895 articles, of which 57 fulfilled inclusion criteria.

RESULTS

Forty-eight (84%) of the articles were cohort studies, 7 (12%) were case-control studies, and 2 (4%) were cross-sectional studies. The populations varied from postsurgical to medical patients. There was variability in the number of VTE risk categories assigned by individual studies (6 used 5 risk categories, 37 used 4, 11 used 3, and 3 used 2), and in the cutoff scores defining the risk categories (scores from 0 alone to 0-10 for the low-risk category; from ≥5 to ≥10 for high risk). The VTE rates reported for similar risk categories also varied across studies (0%-12.3% in the low-risk category; 0%-40% for high risk). The Caprini RAM is designed to assess composite VTE risk; however, two studies reported PE or DVT rates alone, and many of the other studies did not specify the types of DVTs analyzed. The Caprini RAM predicts VTE at 30 days after assessment; however, only 17 studies measured outcomes at 30 days; the remaining studies had either shorter or longer follow-ups (0-180 days).

CONCLUSIONS

The usefulness of the Caprini RAM is limited by heterogeneity in its implementation across centers. The score-derived VTE risk categorization has significant variability in the number of risk categories being used, the cutpoints used to define the risk categories, the outcome being measured, and the follow-up duration. This factor leads to similar risk categories being associated with different VTE rates, which impacts the clinical and research implications of the results. To enhance generalizability, there is a need for studies that validate the RAM in a broad population of medical and surgical patients, identify standardized risk categories, define risk of DVT and PE as distinct end points, and measure outcomes at standardized follow-up time points.

Upper Extremity Deep Venous Thrombosis: Etiologies, Diagnosis, and Updates in Therapeutic Strategies

Upper extremity deep vein thrombosis (UEDVT) is responsible for 4 to 10% of all deep vein thrombosis (DVT). Untreated UEDVT can lead to significant disability secondary to the postthrombotic syndrome. To date, there are no randomized trials specifically comparing different therapeutic strategies. Ultimately, optimal management of UEDVT depends on the underlying etiology, patient symptoms, and degree of thrombosis, with supporting evidence primarily extrapolated from lower extremity DVT data. This article will review the classification, presentation, and diagnosis of both primary and secondary UEDVT. In addition, it will discuss updates in clinical guidelines, anticoagulation, endovascular and surgical treatment strategies.

Diagnosis of Internal Jugular Vein Septic Thrombophlebitis by Point-of-Care Ultrasound

ABSTRACT

Septic thrombophlebitis represents a rare but serious collection of diseases, which carry a high risk of morbidity and mortality requiring prompt and aggressive treatment. Diagnosis centers on identification of thrombus along with clinical and microbiologic data. We present a case where point-of-care ultrasound was used to diagnose septic thrombophlebitis of the internal jugular vein and expedite appropriate therapy. We further review the technique and literature for ultrasound diagnosis of venous thrombosis and associated thrombophlebitis.

Anticoagulants decrease the risk for catheter-related venous thrombosis in patients with chronic intestinal failure: A long-term cohort study

BACKGROUND

Catheter-related venous thrombosis (CRVT) is a severe complication of home parental nutrition. Although primary prevention of CRVT is crucial, there is no consensus on anticoagulant use to prevent this adversity. The aim was to compare CRVT risk in patients with chronic intestinal failure (CIF) in the presence or absence of anticoagulants, and to identify CRVT risk factors.

METHODS

This retrospective cohort study comprised adult patients with CIF with a central venous access device (CVAD) between 2010 and 2020 that were treated at our national CIF referral center. Analyses were performed at a CVAD level.

RESULTS

Overall, 1188 CVADs in 389 patients were included (540.800 CVAD days). Anticoagulants were used in 403 CVADs. In total, 137 CRVTs occurred in 98 patients, resulting in 0.25 CRVTs/1000 CVAD days (95% CI, 0.22-0.29). Anticoagulant use was associated with a decreased CRVT risk (odds ratio [OR] = 0.53; 95% CI, 0.31-0.89; P = 0.02). Left-sided CVAD insertion (OR = 2.00; 95% CI, 1.36-2.94), a history of venous thrombosis (OR = 1.73; 95% CI, 1.05-2.84), and a shorter period postinsertion (OR = 0.78; 95% CI, 0.65-0.92) were independently associated with an increased CRVT risk.

CONCLUSION

Anticoagulants decreased the CRVT risk. In addition, we identified left-sided vein insertion, a history of venous thrombosis, and a shorter period post-CVAD insertion as CRVT risk factors. Further prospective studies should provide guidance whether prophylactic anticoagulant use, especially in higher-risk patients with a left-sided CVAD or a history of venous thrombosis, is justified.

[Arm Swelling with a Camouflaged Cause]

Arm Swelling with a Camouflaged Cause Abstract. We report on a 72-year-old patient who presented to the emergency department due to a proximal multiple-fragment humeral fracture on the left. Despite correct therapeutic approaches, there was no improvement in the left arm swelling. Further investigations showed a provoked arm vein thrombosis on the left with a post-humeral fracture on the left. After therapeutic anticoagulation, the swelling regressed immediately, but with persistent lymphedema of the left hand.

Early Diagnosis of Pulmonary Embolism Related to Clinical Presentation and Vital Signs in the Emergency Department at King Saud Medical City

Background: Pulmonary embolism (PE) is a common acute life-threatening cardiovascular disorder. It is the third most common cause of hospital-related death and early detection and management of PE are crucial. The study aimed to evaluate the association between vital signs and laboratory investigations with PE.

Methods: This is a retrospective, hospital records-based, observational study, conducted among patients who were admitted to the emergency department of King Saud Medical City in Riyadh, Saudi Arabia with a suspected diagnosis of PE during the period of March 2021 to March 2022. Data were collected by searching patients’ files and recording demographic data, and information about the clinical presentation, workup, and outcome. Data were entered and analyzed using SPSS version 26 (IBM, Armonk, NY), utilizing Chi-square statistics to test differences between groups, and logistic regression analyses to identify predictors of PE.

Results: The study included 92 patients, with a preponderance of females (70.7%), and those aged 40-60 years (51.1%). Diabetes mellitus (44.6%), and hypertension (30.4%) were the most common comorbidities among others, while shortness of breath (SOB) (83.7%), and chest pain (44.6%) were among the most commonly reported symptoms. A majority of patients had tachycardia (64.1%), while about half had low oxygen saturation (51.5%), and nearly one-third had tachypnea (29.3%), which was more predominant among those not diagnosed with PE. Logistic regression analysis revealed that SOB, respiratory rate, and oxygen saturation were the only significant predictors of PE.

Conclusion: Although being an integral part of the initial assessment in the hospital, measuring the vital signs is not always reflective of the likelihood of PE, and they should not be the only metric relied upon to make decisions about treatment approaches in patients with PE. Physicians should ensure the employment of evidence-based clinical prediction rules and guidelines when diagnosing and managing PE.

Management of Contraception in Adolescent Females With Hormone-Related Venous Thromboembolism

PURPOSE

Management of contraception in adolescent females with hormone-related venous thromboembolism (VTE) is challenging. We examined the characteristics of this patient population and outcomes, including recurrent VTE, heavy menstrual bleeding, and pregnancy.

METHODS

We performed a single-institution retrospective cohort study of adolescents with a new diagnosis of VTE and concurrent use of estrogen- and/or progestin-containing medication (N = 89). We collected data on additional risk factors for thrombosis, management of hormone therapy, and anticoagulation. We compared outcomes between patients with prescribed contraception within the year after their VTE diagnosis (n = 52) with those without (n = 37).

RESULTS

At least one additional risk factor for thrombosis was identified in 92% of patients, and 73% had two or more. The most common additional thrombosis risk factors were obesity (35%), family history (33%), and recent immobility (33%). Ninety-seven percent of patients were receiving combined hormonal medications, and 42% of patients had their medication stopped and not replaced with an alternative. Heavy menstrual bleeding was reported while on anticoagulation in 46% of patients with a documented menstrual history. Recurrent VTE occurred in 9.0% of patients. The group without prescribed contraception had a significantly higher rate of pregnancy in the two years after VTE diagnosis (18% vs. 1.9%, p = .04). Two pregnancies occurred while on warfarin.

DISCUSSION

Early assessment of contraceptive needs and menstrual bleeding symptoms are needed after diagnosis of hormone-related VTE in adolescent females. Access to contraceptive methods associated with low thrombosis risk is important for the prevention of unplanned pregnancy in this patient population.

Subclavian Effort Thrombosis: Pathophysiology, Diagnosis, and Management

Subclavian vein (SCV) effort thrombosis, also known as Paget-Schroetter syndrome or venous thoracic outlet syndrome, is an uncommon condition that affects individuals with an irregularly narrow thoracic outlet who engage in repetitive overhead motions of the affected arm. Venous injury arises from microtraumas that occur from the repetitive compression of the SCV between the first rib and the overlying clavicle. Additional sources of extrinsic compression can be due to the anterior scalene muscle, subclavius muscle, and costoclavicular ligament. SCV effort thrombosis is a distinct entity from other forms of deep venous thrombosis and requires unique diagnostic and treatment considerations. Early catheter-directed therapy in the form of pharmacomechanical or catheter-directed thrombolysis combined with prompt surgical thoracic outlet decompression offers patients the best chances for early and durable symptom relief.

Study on the correlation between high density lipoprotein and lower extremities deep venous thrombosis in patients undergoing hip arthroplasty

OBJECTIVE

To explore the relationship between high density lipoprotein (HDL) and lower extremities deep venous thrombosis (DVT) in patients undergoing hip arthroplasty.

METHODS

A total of 348 patients undergoing hip arthroplasty in our hospital were enrolled, and divided into observation (n = 154, 44.25%) and control (n = 194, 55.75%) groups according to the occurrence of lower extremities DVT. The presence of DVT was assessed 1 day before surgery and routinely every 2 days after surgery. The factors of DVT were analyzed by single factor analysis, multivariate logistic regression analysis, and Pearson correlation.

RESULTS

The age and body mass index in the observation group were significantly higher (p = .045, p = .041, respectively), while HDL-C was significantly lower (p = .032) than the control group. Increase age, high BMI, low apolipoprotein-A1 level and low HDL-C level were risk factors for lower extremities DVT. The mean HDL-C in the observation and control groups was 0.91 ± 0.27 and 1.19 ± 0.37, respectively, the adjusted odds ratio was 1.050; 95% CI 1.010-1.092, p = .014.

CONCLUSION

Elderly patients with high BMI and low HDL-C level undergoing hip arthroplasty are at risk of lower extremities DVT, and should be paid attention to clinically.

Upper-extremity deep venous thrombosis and bilateral pulmonary embolism in a patient with COVID-19 under prophylactic anticoagulation: A case report

The COVID-19 infection induces coagulation dysfunction resulting in an increased incidence of pulmonary embolism (PE) and deep venous thrombosis (DVT), mostly in the lower extremities. While upper-extremity DVT is less frequent than lower-extremity DVT, the thrombosis of internal jugular vein or brachiocephalic (innominate) vein is an uncommon presentation. All the current studies concerning the thrombotic risk linked to hospital COVID-19 indicate that therapeutic anticoagulation does not improve the clinical prognosis in the intensive care unit. Standard prophylactic anticoagulation is therefore recommended. But again, thrombotic complications of COVID-19 infection are still frequently reported nowadays despite anticoagulation therapy, as we can see in this case report. Here we report a rare case of a 50-year-old woman with a previous history of dyslipidemia, admitted for COVID-19 related acute respiratory failure. The patient developed during hospitalization an acute bilateral PE, with upper-extremity DVT including thrombosis of the left brachiocephalic vein extended to the left internal jugular vein, while under prophylactic anticoagulation since hospital admission, leading finally to the patient's death from respiratory failure. At present, the pathophysiology of the hypercoagulable state related to COVID-19 infection is poorly understood. The significant rate of thrombosis despite preventive and therapeutic dosage anticoagulation raises the possibility of a pathophysiology unique to COVID-19. This rare case highlights the importance of thrombotic morbidity and mortality associated with the SARS-CoV-2 epidemic, and the need for further studies to better understand the physiopathology behind the thrombotic state of COVID 19 infection and establish a more efficient way to deal with these complications.

•

Thromboembolic complications are commonly associated with COVID-19 infection.

•

Thrombosis can occur at different location, requiring minutious examination and close interpretation of imaging.

•

Current recommendations indicate prophylactic anticoagulation for the thrombotic risk linked to hospital COVID-19 patients.

•

Thromboembolic complications of COVID-19 infection are frequently reported despite anticoagulation therapy.

•

The thrombotic state of COVID-19 infection may be related to a unique pathophysiology, wich may require specific therapy that is more effective than standard heparin anticoagulation.

Incidence of upper extremity deep vein thrombosis in the retrosternal reconstruction after esophagectomy

Background

Upper extremity deep vein thrombosis (UEDVT) is relatively rare but cannot be negligible because it can cause fatal complications. Although it is reported that the occurrence rate of UEDVT has increased due to central venous catheter (CVC), cancer, and surgical invasion, there is still limited information for esophagectomy. The aim of this study was to evaluate the clinical factors, including CVC placement and thromboprophylaxis approach, as well as retrosternal space’s width as a predictive factor for UEDVT in patients receiving esophagectomy.

Methods

This study included 66 patients who underwent esophagectomy with retrosternal reconstruction using a gastric tube. All patients routinely underwent contrast-enhanced computed tomography (CT) on the 4th postoperative day. Low-molecular-weight-heparin (LMWH) was routinely administered by the 2nd postoperative day. To evaluate retrosternal space’s width, (a) The distance from sternum to brachiocephalic artery and (b) the distance from sternum to vertebra were measured by preoperative CT, and the ratio of (a) to (b) was defined as the width of retrosternal space.

Results

Among all patients, 11 (16.7%) suffered from UEDVT, and none was preoperatively received CVC placement, while 7 were inserted in non-UEDVT cases. Retrosternal space’s width in patients with UEDVT was significantly smaller than that in patients without UEDVT (0.17 vs. 0.26; P < 0.0001). A cutoff value of the width was 0.21, which has high sensitivity (87%) and specificity (82%) for UEDVT prediction, respectively.

Conclusion

The existence of CVC may not affect the development of UEDVT, but preoperative evaluation of retrosternal ratio may predict the occurrence of UEDVT.

Anticoagulant treatment for upper extremity deep vein thrombosis: A systematic review and meta-analysis

BACKGROUND

Data on anticoagulant treatment for upper extremity deep vein thrombosis (UEDVT) are largely derived from studies on usual site venous thromboembolism (VTE).

OBJECTIVES

The objective of this meta-analysis was to evaluate the efficacy and safety of anticoagulant therapy for UEDVT.

PATIENTS/METHODS

A systematic search of MEDLINE and EMBASE was conducted for studies including patients with UEDVT. Primary outcomes were recurrent VTE and major bleeding. Secondary outcomes included clinically-relevant non-major bleeding and all-cause mortality. Summary estimates with 95% confidence intervals (CIs) were calculated by random-effect meta-analysis.

RESULTS

A total of 1473 patients from 11 prospective and nine retrospective studies were included. Sixty percent of patients had an indwelling catheter and 56.1% had cancer. Anticoagulant treatment consisted of direct oral anticoagulants, low molecular weight heparin followed by vitamin K antagonists, and low molecular weight heparin alone in 45.1%, 35.0%, and 19.9% of patients, respectively. During a median follow-up of 13 months, recurrent VTE occurred in 3% of patients (95% CI: 2-4; 21/1334 patients), major bleeding in 3% (95% CI: 2%-5%; 29/1235 patients), clinically-relevant non-major bleeding in 4% (95% CI: 3-6; 40/1075 patients), and all-cause mortality in 9% (95% CI: 5-15; 108/1084 patients). Rates of these outcomes were not significantly different between patients with or without cancer, patients with or without an indwelling catheter, and among those receiving different anticoagulant treatments.

CONCLUSIONS

In patients with UEDVT, anticoagulant treatment is associated with a low risk of recurrent VTE and a nonnegligible risk of major bleeding.

Duration of anticoagulation for upper extremity deep vein thrombosis associated with cancer and central venous catheter: Outcome of a cohort study

INTRODUCTION

In cancer patients with catheter-associated upper extremity deep vein thrombosis, 3 months of anticoagulation is recommended. The main objective of this study was to compare the incidence of thrombosis recurrence in these patients in case of continuation or discontinuation of anticoagulation, at the end of 3 months and after catheter has been removed. The secondary objectives were the incidence of major bleeding and death.

MATERIAL AND METHODS

We conducted a retrospective cohort study including patients with a cancer and a catheter-associated upper extremity deep vein thrombosis.

RESULTS

About 60 patients included, 44 stopped anticoagulation after the first 3 months and 16 continued it. The median time between catheter insertion and deep vein thrombosis was 26±83 days. Three recurrences occurred during the one-year follow-up: 2 in the group who stopped anticoagulation, with a cumulative incidence at 1 year of 4,8% (95%IC 1.2-18.1) and 1 in the group who continued anticoagulation, with a cumulative incidence at 1 year of 14.3% (95%IC 2.1-66.6). No major bleeding event occurred in anticoagulation discontinued group. The group who stopped anticoagulation was significantly associated with a lower risk of death (HR 0.21-95%IC 0.09-0.48, P<0.001).

CONCLUSION

The risk of recurrence in cancer patients with a catheter-associated upper extremity deep vein thrombosis was low and statistically comparable between the group who stopped anticoagulation and the group who continued it. These results suggest that anticoagulation after the first 3 months deserves to be considered when catheter is removed.

Upper extremity deep vein thrombosis in COVID-19: Incidence and correlated risk factors in a cohort of non-ICU patients

Background

Venous thromboembolism is a frequent complication of COVID-19 infection. Less than 50% of pulmonary embolism (PE) is associated with the evidence of deep venous thrombosis (DVT) of the lower extremities. DVT may also occur in the venous system of the upper limbs especially if provoking conditions are present such as continuous positive airway pressure (CPAP). The aim of this study was to evaluate the incidence of UEDVT in patients affected by moderate-severe COVID-19 infection and to identify potential associated risk factors for its occurrence.

Methods

We performed a retrospective analysis of all patients affected by moderate-severe COVID-19 infection admitted to our unit. In accordance with the local protocol, all patients had undergone a systematic screening for the diagnosis of UEDVT, by vein compression ultrasonography (CUS). All the patients were receiving pharmacological thromboprophylaxis according to international guidelines recommendations. Univariate and multivariate analyses were used to identify risk factors associated with UEDVT.

Results

257 patients were included in the study, 28 patients were affected by UEDVT with an incidence of 10.9% (95% CI, 7.1–14.7). At univariate analysis UEDVT appeared to be significantly associated (p< 0.05) with pneumonia, ARDS, PaO2/FiO2, D-dimer value higher than the age adjusted cut off value and need for CPAP ventilation. Multivariate analysis showed a significant association between UEDVT and the need for CPAP ventilation (OR 5.95; 95% IC 1.33–26.58). Increased mortality was found in patients affected by UEDVT compared to those who were not (OR 3.71; 95% CI, 1.41–9.78).

Conclusions

UEDVT can occur in COVID-19 patients despite adequate prophylaxis especially in patients undergoing helmet CPAP ventilation. Further studies are needed to identify the correct strategy to prevent DVT in these patients.

A prospective cohort study of catheter-related thrombosis in cancer patients treated with 1 month of anticoagulation after catheter removal

The duration of anticoagulation in patients with catheter-related thrombosis (CRT) is not standardized. This is a multiinstitutional prospective pilot study in patients with cancer and upper extremity CRT. Patients received therapeutic enoxaparin for 1 month after catheter removal. Incidence of recurrent thrombosis, hemorrhage, and postthrombotic syndrome (PTS) using the modified Villalta scale, and functional limitation using the Disabilities of the Arm, Shoulder and Hand (DASH) questionnaire were assessed at months 1, 3, and 6 after catheter removal. Clopper-Pearson exact 95% confidence intervals (CI), Pearson correlations, and Skillings-Mack, and Wilcoxon signed ranks tests were done. Twenty-seven patients from three institutions were enrolled. Feasibility outcomes were not met. Seventy percent (n = 19) of the cohort had hematologic malignancies. Excluding two patients who were still on enoxaparin at study withdrawal, the median total duration of therapeutic enoxaparin was 32 [interquartile range (IQR) 30-52] days in the remaining 25 patients. During the 6 months after catheter removal, the incidence of recurrent thrombosis was 0% (n = 0/20, 95% CI 0-17%) and major hemorrhage was 5% (n = 1/20, 95% CI 0.13-25%). One patient (5%, 95% CI 0.13-25%) had PTS in the affected arm at any visit, and none had severe PTS. Higher PTS scores were associated with higher DASH scores. DASH scores at month 6 were significantly lower compared with month 1 (P = 0.0066). No deaths occurred. A multicenter pilot study of treatment with anticoagulation for 1 month after catheter removal did not meet feasibility outcomes but we found no recurrent thrombosis and a low incidence of PTS.

Prevalence and clinical outcomes of hospitalized patients with upper extremity deep vein thrombosis

OBJECTIVE

Upper extremity (UE) deep vein thrombosis (DVT) is a common and increasing complication in hospitalized patients. The objective of the present study was to determine the prevalence, treatment strategies, complications, and outcomes of UE-DVT.

METHODS

We performed a retrospective single-institution study of patients with a diagnosis of UE-DVT from January 2016 through February 2018 (26 months). Patients aged ≥18 years who had been admitted to the hospital and who had had positive UE duplex ultrasound findings for acute UE-DVT were included in the present study. The outcomes were in-hospital mortality, major bleeding, pulmonary embolism (PE), and recurrent UE-DVT.

RESULTS

Among 63,045 patients admitted to the hospital, 1000 (1.6%) had been diagnosed with UE-DVT. Of 3695 UE venous duplex ultrasound examinations performed during the study period, almost one third (27.0%) were positive for acute UE-DVT. The mean age was 55.0 ± 17.2 years, and most patients were men (58.3%), white (49.2%), and overweight (mean body mass index, 29.4 ± 10.3 kg/m²). The most affected vein was the right internal jugular vein (54.8%). Most of the patients (96.9%) has been receiving venous thromboembolism prophylaxis or anticoagulation therapy at the diagnosis. Most patients (77.8%) had had an intravenous device (IVD) in place at the diagnosis. Most of the patients (84.4%) were treated with anticoagulation therapy in the hospital but only one half (54.5%) were discharged with anticoagulation therapy. In-hospital mortality was 12.1% unrelated to UE-DVT, major bleeding occurred in 47.6% of the patients during hospitalization (fatal bleeding, 1%), PE was diagnosed in 4.8% of the patients, and 0.7% were fatal. Recurrent UE-DVT occurred in 6.1% of the patients. On multivariable analysis, the risk of death was increased by older age, cancer, intensive care unit admission, concomitant lower extremity DVT, and bleeding before the UE-DVT diagnosis. The presence of an IVD increased the risk of PE and the risk of recurrent UE-DVT. The risk of major bleeding was increased by the presence of an IVD, female sex, and concomitant lower extremity DVT.

CONCLUSIONS

UE-DVT is a common complication in hospitalized patients (1.6%). Consequent acute PE and recurrent DVT remain important complications, as does bleeding. It is unclear whether standard thromboprophylaxis effectively protects against UE-DVT. More studies dedicated to UE-DVT are required to provide appropriate guidance on prophylaxis and treatment.

Upper-Extremity Venous Thromboembolism Following Operative Treatment of Distal Radius Fractures: An Uncommon but Dangerous Complication

PURPOSE

Distal radius fractures are the most common long bone fracture in the United States, with an estimated incidence of 640,000 cases per year. Operative fixation presents a theoretical risk factor for the development of upper-extremity venous thromboembolism (UE-VTE). Additionally, patients presenting with distal radius fracture commonly have preexisting comorbidities that further increase the risk of UE-VTE. Finally, UE-VTE is considered the highest risk for eventual development of pulmonary embolism. Despite this, scant attention has been paid to studying UE-VTE in this population. The purpose of this study was to measure the incidence of this complication and to identify possible medical factors that increased the risk of developing UE-VTE.

METHODS

We queried the Truven MarketScan Commercial Claims and Encounters Database for all patients who experienced a distal radius fracture and were subsequently treated with open reduction and internal fixation between 2012 and 2016. Patients were identified using relevant Common Procedural Terminology codes. Demographic and medical variables were tabulated. Our primary outcome was the development of ipsilateral UE-VTE or pulmonary embolism in the first 60 days after surgery.

RESULTS

The study included 24,494 patients. The mean age was 50.7 years (range, 18-91), and 58% were women. There were 79 cases (0.3%) of UE-VTE and 19 cases of pulmonary embolism in the study population (24.1% of all UE-VTE cases; 0.08% of total sample). Multivariable logistic regression showed that coexisting heart failure and estrogen use were associated with increased risk of UE-VTE.

CONCLUSIONS

Although uncommon, the development of UE-VTE after open reduction and internal fixation for distal radius fractures is a concerning complication. Coexisting heart failure and estrogen use are associated with increased risk of UE-VTE.

TYPE OF STUDY/LEVEL OF EVIDENCE

Prognostic II.

Neurological Complications of Pulmonary Embolism: a Literature Review

PURPOSE OF REVIEW

The present review discusses in-depth about neurological complications following acute venous thromboembolism (VTE).

RECENT FINDINGS

Intracranial hemorrhage, acute ischemic cerebrovascular events, and VTE in brain tumors are described as central nervous system (CNS) complications of PE, while peripheral neuropathy and neuropathic pain are reported as peripheral nervous system (PNS) sequelae of PE. Syncope and seizure are illustrated as atypical neurological presentations of PE. Mounting evidence suggests higher risk of venous thromboembolism (VTE) in patients with neurological diseases, but data on reverse, i.e., neurological sequelae following VTE, is underexplored. The present review is an attempt to explore some of the latter issues categorized into CNS, PNS, and atypical complications following VTE.

Paget-Schroetter syndrome in a non athlete - a case report

A young male waiter presented with left shoulder pain, with ultrasound showing thrombosis of the left subclavian vein. After exclusion of hypercoagulability, a dynamic MRI upper limb venogram was performed, confirming Paget-Schroetter syndrome (PSS). Our case is unusual as Paget Schroetter syndrome are seldom reported in non athletes. This is also the first report to show dynamic MRI images of PSS.

Low awareness of venous thromboembolism among the general population: a call for increased public enlightenment programs

BACKGROUND

Venous thromboembolism (VTE) is a notable but often ignored cause of disability and death. Improved public awareness of the symptoms and risks associated with VTE reduces the burden of disease.

AIM

We aimed to determine the awareness of VTE among the general population.

METHODS

We conducted a population-based study using a pre-tested, pre-validated Ipsos-Reid questionnaire between October 2019 to March 2020. The questionnaire was distributed to consenting adults in the capital cities of Enugu and Ebonyi states of South-Eastern Nigeria to determine their awareness and knowledge of the symptoms and risk factors of VTE.

RESULTS

A total of 284 adults participated with a mean age of 32.73 ± 10.33 years and majority (70.8%) had a post-secondary education. While majority were aware of other medical conditions like a heart attack (96.1%), stroke (97.2%), diabetes (98.2%), HIV/AIDS (98.6%), cancer (97.2%) and malaria (98.2), just a few of the subjects were aware of thrombosis (41.5%) and DVT (33.8%). Less than half (42.4%) correctly described DVT as a blood clot in the vein and 13.7% of the respondents knew what PE feels like. A minority of them knew the risk factors of VTE included hospital stay (19.0%), surgery (37.2%), cancer (31.6%), pregnancy (31.6%) and old age (29.6%). Age and gender showed no statistically significant association with awareness of VTE, p value, 0.491 and 0.287, respectively.

CONCLUSION

The awareness of VTE in the general population is low. Public awareness programs should be a public health priority to reduce morbidity and mortality associated with VTE.

Upper extremity deep venous thrombosis prevalence in the NHS Grampian Medical Ambulatory clinic: diagnostic, therapeutic, and prognostic considerations in oncology patients

Introduction

Whilst upper extremity deep vein thromboses (UEDVT) account for approximately 5 to 10% of all cases of DVT, rigorous guidelines regarding diagnosis and management of presenting patients remain to be developed. The association of UEDVT with concurrent asymptomatic pulmonary embolism as well as the first presentation of malignancy deems essential rigorous research and clinical guideline development to ensure optimal patient care.

Methods

This retrospective audit study is the first to provide estimates of UEDVT prevalence in the North-East Deanery main hospital centre, Aberdeen Royal Infirmary (ARI).

Results

Of the 605 patients attending the ARI Ambulatory Emergency Care (AEC) clinic with clinical suspicion of UEDVT, 38 (6.2%) had a confirmatory diagnosis. Underlying malignancy, presence of PICC line, and cardiovascular co-morbidities were identified as common confounding factors. Subclavian vein with concurrent extension to primarily the cephalic vein thrombosis was identified as the most commonly thrombosed venous territories. Importantly, oncology patients were found to have poorer survival outcomes following an UEDVT, in comparison to patients with other significant co-morbidities (cardiovascular, chronic renal disease, inflammatory bowel disease): HR 5.814 (95%CI 1.15, 29.25), p 0.012. Lastly, genetic associations were drawn between patient genetic status as tested for other co-morbidities and prothrombotic cellular cascades, suggesting rigorous VTE assessment in patients identified with congenital or acquired mutations, namely, in CALR, JAK, MSH 2/6, MYC, and FXN.

Conclusions

Overall, this study offers the first report of UEDVT presentations in the UK with no restrictions of patient performance status or underlying co-morbidities and provides a rounded clinical picture of patient characteristics, diagnosis, management, and prognostic associations in view of rigorous guideline development.

Supplementary Information

The online version contains supplementary material available at 10.1007/s11845-021-02775-0.

Comparison of Aspiration Thrombectomy to other endovascular therapies for Proximal Upper Extremity Deep Venous Thrombosis

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.

D-dimer level for ruling out peripherally inserted central catheter-associated upper extremity deep vein thrombosis and superficial vein thrombosis

AIMS

To examine the effectiveness of D-dimer values to be used as an independent diagnostic marker for excluding peripherally inserted central catheter-associated upper extremity deep vein thrombosis and superficial vein thrombosis.

DESIGN

This was a retrospective case-cohort study.

METHODS

Records were reviewed for 281 patients who underwent peripherally inserted central catheter insertion between 1 October 2017 and 1 October 2019. According to the modified Wells score after peripherally inserted central catheter insertion, the patients who had low vein thrombosis risk underwent a D-dimer test and colour Doppler ultrasound.

RESULTS

Among 281 patients, 180 patients (64%, 95% CI: 58.2%-69.4%) had negative D-dimer results and 39 of 180 patients had vein thrombosis despite having a negative D-dimer result, resulting in a failure rate of 21.7% (95% CI: 16.3%-28.3%). The negative predictive value of peripherally inserted central catheter-associated vein thrombosis in the cancer group (80.0%, 95% CI: 73.2%-85.4%) was higher than that of the non-cancer group (60.0%, 95% CI: 35.7%-80.2%). The negative predictive value of peripherally inserted central catheter-associated deep venous thrombosis (84.9%, 95% CI: 78.7%-89.6%) was lower than that of the PICC-associated superficial venous thrombosis (91.0%, 95% CI: 85.4%-94.6%).

CONCLUSION

The D-dimer levels maybe should not be used as a diagnostic index to rule out peripherally inserted central catheter-associated upper extremity vein thrombosis.

Invited Review: Optimal Management of Upper Extremity DVT: Is Venous Thoracic Outlet Syndrome Underrecognized?

BACKGROUND

UEDVT accounts for approximately 10% of all cases of deep vein thrombosis. In the most widely referenced general review of deep vein thrombosis (DVT the American Academy of Chest Physicians essentially recommend that upper extremity DVT (UEDVT) essentially be treated identically to that of lower extremity DVT, with anticoagulation being the default therapy. Unfortunately, the medical literature does not well differentiate between DVT in the arm and the leg, and does not emphasize the effects of the costoclavicular junction (CCJ) and the lack of effect of gravity, to the point where UEDVT due to extrinsic bony compression at the CCJ is classified as "primary."

METHODS

Comprehensive literature review, beginning with both Medline and Google Scholar searches in addition to collected references, then following relevant citations within the initial manuscripts studied. Both surgical and medical journals were explored RESULTS: It is proposed that effort thrombosis be classified as a secondary cause of UEDVT, limiting the definition of primary to that which is truly idiopathic. Other causes of secondary UEDVT include catheter- and pacemaker-related thrombosis (the most common cause, but often asymptomatic), thrombosis related to malignancy and hypercoagulable conditions, and the rare case of thrombosis due to compression of the vein by a focal malignancy or other space-occupying lesion. In true primary UEDVT and in those secondary cases where no mechanical cause is present or can be corrected, anticoagulation remains the treatment of choice, usually for three months or the duration of a needed catheter. However, evidence suggests that many cases of effort thrombosis are likely missed by a too-narrow adherence to this protocol.

CONCLUSIONS

Because proper treatment of effort thrombosis drops the long-term symptomatic status rate from 50% to almost zero and these are healthy patients with a long lifespan ahead, it is proposed that a more aggressive attitude toward thrombolysis be followed in any patient who has a reasonable degree of suspicion for venous thoracic outlet syndrome.

Second consensus document on diagnosis and management of acute deep vein thrombosis: updated document elaborated by the ESC Working Group on aorta and peripheral vascular diseases and the ESC Working Group on pulmonary circulation and right ventricular function

This consensus document is proposed to clinicians to provide the whole spectrum of deep vein thrombosis management as an update to the 2017 consensus document. New data guiding clinicians in indicating extended anticoagulation, management of patients with cancer, and prevention and management of post-thrombotic syndrome are presented. More data on benefit and safety of non-vitamin K antagonists oral anticoagulants are highlighted, along with the arrival of new antidotes for severe bleeding management.

Upper extremities deep vein thrombosis treated with oral direct anticoagulants: A prospective cohort study

BACKGROUND

Limited data are available on the role of direct oral anticoagulants (DOACs) for the treatment of upper extremities deep vein thrombosis (UEDVT).

OBJECTIVES

The aim of this study was to assess the effectiveness and safety of DOACs in the treatment of UEDVT.

METHODS

Patients with an objectively confirmed acute UEDVT treated with DOACs were merged from prospective cohorts to a collaborative database. Primary study outcomes were recurrent venous thromboembolism (VTE) and major bleeding occurring during DOAC treatment.

RESULTS

Overall, 188 patients were included in the study: mean age 52.4 ± 20.4 years, males 43.6%, patients with active cancer 29.2%. Twenty-nine percent of patients had 2 or more risk factors for VTE, 33.0% had catheter-related or pacemaker-related UEDVT. In 13.8% of patients, DOACs were started one month after UEDVT diagnosis or later. Active cancer was an independent predictor for delayed initiation of DOACs (OR 8.1, 95% CI 3.0-22.2). Mean duration of treatment with DOACs was 5.1 ± 2.8 months. During treatment with DOACs, recurrent VTE occurred in 0.9 per 100 patient-year, major bleeding in 1.7 and all-cause deaths in 6.0 per 100 patient-year. No fatal bleeding or fatal VTE recurrence were observed. During 232.1 patient-years of follow-up after DOAC withdrawal, recurrent VTE occurred in 3.0 per 100 patient-year. The 2019 ESC categories for risk of VTE recurrences were able to discriminate patient groups at different risk of events in the on and off-treatment periods.

CONCLUSIONS

Our data support the feasibility as well as the effectiveness and safety of DOACs for the treatment of acute UEDVT.

Upper extremity deep vein thrombosis treated with direct oral anticoagulants: a multi-center real world experience

Upper-extremity deep vein thrombosis (UEDVT) accounts for about 5-10% of all cases of deep vein thrombosis (DVT). It is often associated with cancer and/or presence of a central venous catheter (CVC), but it may also occur in the absence of these favoring conditions. The safety and efficacy of using direct oral anticoagulants (DOACs) in subjects with UEDVT has not been systematically evaluated and the only data available in the literature derive from anecdotal evidence, analysis of registries, and small single-centre studies. In addition, a specific analysis of UEDVT not associated with cancer and/or CVC has never been made. In this study, we specifically focused on patients with no cancer and without a CVC who were diagnosed with a first episode of UEDVT and were treated with a DOAC. We studied 61 patients, treated in six Italian centres between January 2014 and December 2018. Treatment lasted at least 3 months in all patients. In terms of efficacy, no recurrence of thrombosis or pulmonary embolism were recorded, while Doppler ultrasonography, performed after at least three months of treatment, documented in all cases either partial or complete recanalization of obstructed veins. In terms of safety, no cases of major bleedings were recorded. This is the only series available in the literature of patients treated with DOACs for UEDVT not associated with cancer and/or CVC. This small multicenter real world experience supports the concept that DOACs might be safe and effective for treating UEDTV. Further studies are required to better understand the role of DOACs in these patients.