A review of upper extremity deep vein thrombosis

To explore the application value of nursing staff involved multidisciplinary continuous nursing in stroke patients with limb dysfunction

BACKGROUND

Stroke patients often experience limb dysfunction, which can significantly impact their quality of life and daily living abilities. This study aimed to explore the effectiveness of nursing programs that incorporate multidisciplinary continuing care with the participation of nursing staff for patients with stroke and limb dysfunction.

METHODS

This was a randomized controlled trial (RCT) conducted from August 2021 to August 2023. Ninety stroke patients were randomly assigned to a control group (n = 45) and an observation group (n = 45). The control group received routine discharge care, while the observation group received multidisciplinary continuing care with the participation of nursing staff. Outcomes measured included Fugl-Meyer Assessment (FMA) scores for upper and lower limb function, quality of life, daily living ability (Barthel Index, MBI), and adverse reactions.

RESULTS

The FMA scores for upper and lower limbs were significantly higher in the observation group compared to the control group. The observation group also had significantly higher scores in all quality of life dimensions and MBI scores compared to the control group. There were 10 adverse reactions reported in the observation group and 22 in the control group.

CONCLUSIONS

Implementing multidisciplinary continuing care with the participation of nursing staff for stroke patients with limb dysfunction has a positive effect on improving limb function, quality of life, and daily living abilities, while also being relatively safe.

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.

Two cases of vertebral perfusion disturbances in computer tomography imitating metastatic lesions in the course of superior vena cava thrombosis

Skeletal metastases are frequently observed in various malignancies. In some cases, they are asymptomatic and can be found incidentally in various imaging methods in patients without known malignant tumors. In this case study 2 cases of vertebral perfusion disturbances are presented that imitate vertebral metastatic lesions in computer tomography in the course of superior vena cava thrombosis. The first patient was referred to our clinic for chest and abdominal computer tomography (CT) for staging due to a known tumor in the anterior mediastinum. The second patient was referred for chest CT due to swelling in the upper extremity and neck, with the suspected diagnosis of a tumor or pulmonary embolism. In both cases, CT scans showed metastases suspected lesions in the upper thoracic vertebral bodies. In both cases, additionally, the thrombosis of superior vena cava (SVC) and vena brachiocephalica was confirmed (in the first case due to tumor compression in the upper mediastinum, in the second case due to the presence of pacemaker leads). In control CT scans after anticoagulation treatment, there were no suspected lesions in the vertebral bodies, which confirmed the diagnosis of vertebral perfusion disturbances in the course of SVC thrombosis in both patients. In conclusion, in rare cases of metastases suspected lesions of thoracic vertebral bodies in contrast-enhanced computer tomography among patients with a diagnosis of superior vena cava thrombosis vertebral perfusion disturbances should be included in differential diagnosis protocol.

Upper Extremity Deep Vein Thrombosis in the Setting of Ductal Carcinoma In Situ: A Case Report

Deep vein thrombosis (DVT) is a type of venous thromboembolism that usually involves a clot formation in the deep veins of the lower extremities. Its formation is linked to Virchow's Triad which factors in venous stasis, endothelial damage, and hypercoagulability. Venous stasis is the primary factor contributing to the development of DVT and it refers to varicosity, external pressure placed on the extremity, or immobilization due to bed rest or long flights. Clinical presentation of DVT depends on the extent and location of the thrombus with common signs including localized swelling, pain, warmth, and edema. The Wells criteria are typically applied to assess the likelihood of thrombus formation alongside D-dimer assay, ultrasound, or CT imaging. As previously mentioned, these mostly occur in the lower extremities. However, upper extremity DVT has been noted and has been linked to inherited issues with coagulation and autoimmune disorders. This report will discuss a case of left-arm DVT in a patient who underwent bilateral mastectomy with sentinel node biopsy for a diagnosis of ductal carcinoma in situ in the left breast.

Single-center experience with catheter-directed thrombolysis and balloon angioplasty for acute upper-extremity deep vein thrombosis: a case series study

BACKGROUND

Effective treatment of upper extremity deep vein thrombosis (UEDVT) is crucial to prevent further complications. Various treatments, including percutaneous mechanical thrombectomy (PMT), catheter-directed thrombolysis (CDT), decompression surgery, and venoplasty are suggested for UEDVT. However, no prospective study has yet favored any of these treatments. This study presents a review of our experience with CDT followed by balloon venoplasty in patients with acute primary UEDVT.

METHODS

We enrolled all patients diagnosed with acute UEDVT from January 2020 to June 2021. Subjects with UEDVT due to secondary causes like malignancies, indwelling catheters, or leads were excluded. CDT was performed through brachial vein access, using a perfusion catheter, and rt-PA administration. Balloon venoplasty was performed if the treated segment had remaining stenosis after CDT. Patients were followed up at the vein clinic for any signs and symptoms in the upper extremity and lifestyle changes. Follow-up ultrasonography was done 12 months after discharge.

RESULTS

Twelve patients with a mean age of 41.08 ± 14.0 years were included in the study. The mean duration of CDT was 25.00 ± 10.56 h. After CDT, all patients had remaining occlusions, with seven having more than 50% remaining stenosis. However, after balloon venoplasty, no patient had significant (more than 50%) stenosis. There was no serious complication after both procedures. Patients were followed up for a mean duration of twelve months after their admission, with a mean time of maintenance anticoagulation was 10.73 ± 5.77 months. Only one patient had recurrent symptoms in his target limb which required a decompression surgery, while the rest were free of symptoms in their treated extremity. No subject developed pulmonary emboli (PE) during admission or the follow-up period. There was no evidence of hospital readmission for any reason. Upper extremity color-doppler sonography of the patients at twelve months after their procedure showed normal venous flow without any significant stenosis in 8 (66.7%), and partially normal flow with patent target vein in 4 (33.3%) patients.

CONCLUSIONS

CDT followed by balloon venoplasty may be an effective treatment for selected patients with acute primary UEDVT, providing desirable long-term results and potentially avoiding the need for decompression surgery in the short or long term.

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.

Upper extremity deep vein thrombosis following BBIBP-CorV COVID-19 vaccine (Sinopharm vaccine): A case report

Key Clinical Message

In patients with acute symptoms such as pain, swelling, and erythema of the upper extremities shortly after receiving COVID-19 vaccines, even inactivated virus vaccines, these symptoms may indicate thrombosis, which may be due to the vaccination.

Abstract

BBIBP-CorV COVID-19 vaccine (Sinopharm vaccine) is an inactivated whole virus vaccine to control the COVID-19 pandemic. Studies concluded that inactivated COVID-19 vaccines do not increase the risk of thrombosis. This report presents a 23-year-old man with the chief complaint of severe pain, swelling, and erythema of the right upper extremity following his second dose of the Sinopharm vaccine. Duplex ultrasound of the right upper extremity revealed upper extremity deep vein thrombosis, and treatment started with oral anticoagulation. It is probably the first upper extremity deep vein thrombosis case following inactivated COVID-19 vaccines.

Quantitative analysis of venous outflow with photo-plethysmography in patients with suspected thoracic outlet syndrome

Background

Venous compression is the second most frequent form of thoracic outlet syndrome (TOS). Although venous photo-plethysmography (PPG) has been largely used to estimate the consequences of chronic thromboses (Paget Schroetter syndrome), systematic direct quantitative recording of hemodynamic consequences of positional venous outflow impairment in patients with suspected TOS has never been reported.

Objective

We hypothesized that moving the arms forward (prayer: “Pra” position) while keeping the hands elevated after a surrender/candlestick position (Ca) would allow quantification of 100% upper limb venous emptying (PPGmax) and quantitative evaluation of the emptying observed at the end of the preceding abduction period (End-Ca-PPG), expressed in %PPGmax.

Materials and methods

We measured V-PPG in 424 patients referred for suspected TOS (age 40.9 years old, 68.3% females) and retrieved the results of ultrasound investigation at the venous level. We used receiver operating characteristics curves (ROC) to determine the optimal V-PPG values to be used to predict the presence of a venous compression on ultrasound imaging. Results are reported as a median (25/75 centiles). Statistical significance was based on a two-tailed p < 0.05.

Results

An End-Ca-PPG value of 87% PPGmax at the end of the “Ca” period is the optimal point to detect an ultrasound-confirmed positional venous compression (area under ROC: 0.589 ± 0.024; p < 0.001). This threshold results in 60.9% sensitivity, 47.6% specificity, 27.3% positive predictive value, 79.0% negative predictive value, and 50.8% overall accuracy.

Conclusion

V-PPG is not aimed at detecting the presence of a venous compression due to collateral veins potentially normalizing outflow despite subclavicular vein compression during abduction, but we believe that it could be used to strengthen the responsibility of venous compression in upper limb symptoms in TOS-suspected patients, with the possibility of non-invasive, bilateral, recordable measurements of forearm volume that become quantitative with the Ca-Pra maneuver.

Clinical trial registration

[ClinicalTrials.gov], identifier [NCT04376177].

Upper-Extremity Deep Venous Thrombosis after Whole Blood Donation—A Case Report

Upper-extremity deep venous thrombosis (UEDVT) after whole blood donation is rarely reported. Blood donation has a low rate of complications and is typically safe. A small percentage of blood donors experience donation-related events such as UEDVT, which are extremely rare. We are reporting a rare case of a UEDVT following blood donation. This is an extremely rare event; only five cases were reported to our knowledge. A 22-year-old Caucasian woman with a past medical history of provoked pulmonary embolism completed 6 months of apixaban and negative thrombophilia workup presented to the hospital with complaints of progressive pain and swelling in her right arm. The patient reports donating blood using her right arm in January 2021. Phlebotomy duration for blood donation was approximately 10minutes. She reported pain and swelling several days after blood donation. Subsequently, a duplex ultrasound showed a thrombus in the right brachial vein. The patient was started on apixaban for 6 months. Although most whole blood donors do not experience complications, DVT is a rare complication from whole blood donation with severe consequences. It should be considered in a donor with worsening pain and swelling.

Edoxaban: front-line treatment for brachiocephalic vein thrombosis in primitive mediastinal seminoma: A case report and literature review

RATIONALE

Venous thromboembolism is a feared frequent complication of cancer with a 2-way relationship. Low molecular weight heparin is the mainstay of treatment. The use of direct oral anticoagulants is supported by established evidence for the treatment of deep vein thrombosis also in active cancer and they are prioritized over low molecular weight heparin for cancer-associated thrombosis according to current guidelines. However, upper limb deep vein thrombosis is poorly studied with scant data on the use of direct oral anticoagulants in noncatheter-related deep vein thrombosis. We report the case of a patient with noncatheter-related deep vein thrombosis and a rare tumor site effectively and safely treated with a direct oral anticoagulant, edoxaban, after lack of efficacy with low molecular weight heparin.

PATIENT CONCERNS

A 35-year-old man with primitive mediastinal seminoma presented at our Cardio-Oncology Unit for prechemotherapy assessment.

DIAGNOSIS

Persistent brachiocephalic deep vein thrombosis, despite full-dose enoxaparin, was detected at ultrasonography.

INTERVENTION

We decided to switch the anticoagulant treatment from enoxaparin to edoxaban.

OUTCOME

The 3-month ultrasonography showed almost total regression of the deep vein thrombosis without any adverse effects and a good patient compliance.

LESSONS

We conducted a literature review on upper limb deep vein thrombosis, since its management is challenging due to inconsistency of evidence. This report highlights the benefits of direct oral anticoagulants compared to low molecular weight heparins in cancer-associated thrombosis therapy in terms of efficacy, safety and ease of use.

[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.

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.

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Thromboembolic complications are commonly associated with COVID-19 infection.

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

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

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

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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.