Venous gangrene of the upper extremity

Acute Upper Limb Ischemia and Amputation Post Antecubital Fossa Cannulation: A Report of Two Postpartum Patients

Upper extremity arterial thrombosis is less common than that in the lower extremity. Upper extremity arterial thrombosis, when present, is more likely to occur on the ulnar side of the circulation. Severe ischemia resulting from radial artery thrombosis is rare, but iatrogenic cannulation is the most common etiology when it occurs. The risk factors underlying this dreadful presentation are numerous and still under investigation. Pregnancy and the immediate postpartum period are physiological hypercoagulable states. Here we present unusual cases of acute limb ischemia post iatrogenic cannulation in two patients within six weeks postpartum. At four weeks postpartum, a 26-year-old para-1 live-1 female presented to the emergency department with swelling in her right upper limb for four weeks and its blackish discoloration for one week. A 24-year-old primigravida female who had a termination of a blighted ovum 12 days ago presented to the emergency department with gangrenous changes in her right hand and forearm. Both patients reported recent antecubital fossa cannulation within six weeks postpartum, triggering gangrenous hand changes. Both patients had to undergo amputation of the digits and hand ultimately. Thus we postulate the need for extra care and education of healthcare workers in the cannulation of pregnant and post-pregnancy patients to prevent limb-threatening complications.

Long-Term Results of Local Thrombolysis Followed by First Rib Resection: An Encouraging Clinical Experience in Treatment of Subclavian Vein Thrombosis

The purpose of this study was to present the long-term results of our experience, which includes thrombolysis, surgical decompression, and long-term anticoagulation. The medical records of 24 patients who were admitted to Academic Hospital Vrije Universiteit, Amsterdam, the Netherlands, between January 1983 and October 1997, with effort thrombosis of the subclavian vein were reviewed. There were 21 men and 3 women, with a mean age of 30.5 years and an average duration of the symptoms of 2.9 days. Clinical diagnosis was confirmed by phlebography and duplex in all patients. A loading dose of 10,000 units streptokinase was given followed by an infusion at a rate of 10,000 units per hour. Phlebography was repeated daily in order to evaluate the effect of the treatment. Thrombolysis was achieved in 2 to 8 days (mean 5 days). After achievement of complete thrombolysis, anticoagulation with heparin and coumarin derivatives was started; the latter were continued for 3 months.

Six to 12 weeks after the thrombolysis, patients with costoclavicular compression syndrome underwent surgery. A transaxillary first rib resection, partial scalenotomy, and transection of the tendon of subclavian muscle were performed. Thrombolysis was achieved in all patients but one, with a successful lysis percentage of 95.8%. In one patient, the local streptokinase therapy had to be discontinued because of pulmonary embolism. Resection of the first rib was performed on 19 patients. Two patients refused to be operated on. The other three were lost to follow-up, right after the thrombolytic therapy. In long-term evaluation, all the patients who underwent first rib resection were symptom free, whereas the two patients who refused to be operated on had pain and discoloration of the affected arm, although venous patency was achieved.

The subclavian vein thrombosis occurs as a result of repetitive trauma due to anatomic constriction of the vein by the clavicle and the first rib complex. Therefore, we advise addressing the therapy not only to the superimposed thrombus but also to the correction of the underlying anatomic abnormality.

Deep Venous Thrombosis of the Upper Limbs

Deep venous thrombosis of the upper limbs is rare and represents less than 2-3% of all cases of deep venous thrombosis. Reviewing our series of 25 patients we decided that follow-up and symptomatic treatment produce acceptable results, since the disease has a benign natural history. Fibrinolytic agents administered under strict limitations (The Consensus Conference 1980, Ann Int Med) are efficient in early cases, but its ability to change the natural course of the disease has not been proved. Surgical approach should be reserved for cases with secondary ischaemia and/or a resectable extraluminal mass.

Phlegmasia Cerulea Dolens in the Upper Extremity

Phlegmasia cerulea dolens (PCD) is a rare form of venous gangrene that arises secondary to occlusion of venous outflow from a limb. Classically described in the lower extremity, it is rare in the upper extremity. We present a case report of upper extremity PCD and a systematic review with data analysis of 37 cases of PCD published in PubMed. Our analysis showed that concurrent lower extremity PCD was a statistically significant marker for worse outcomes in this patient population.

Venous gangrene a rare but dreadful complication of deep venous thrombosis

Venous gangrene is a rare complication of deep venous thrombosis. It is certain from review of literature that there is a significant causative relationship between malignant disease and venous gangrene. Data from the National hospital discharge survey from 1979 to 2006 showed that 0.43% of patients with deep venous thrombosis had gangrene, while 1.39% patients with gangrene had deep venous thrombosis. Toes and fingers are frequent site of venous gangrene in patients with massive deep venous thrombosis, as evident by review of literature. A possible explanation for this occurrence can be the fact that because of the scarcity of subcutaneous fat and the small spaces of fingers and toes, massive edema can generate large compressive forces; these forces may have a compressive effect on the arterioles, which may contribute to the development of venous gangrene. Lower extremities develop venous gangrene more commonly than upper extremities. The condition has an extremely high rate of mortality either from pulmonary embolism or from the serious underlying disease, such as neoplasms.

Hand gangrene following unsuccessful cannulation of the internal jugular vein: a case report and literature review

Hand gangrene following vascular cannula placement is uncommon and is usually the result of thrombotic occlusion of an artery. We describe a case of hand gangrene resulting in wrist disarticulation, following multiple unsuccessful attempts at internal jugular vein cannulation in a critically ill patient.

Upper extremity compartment syndrome in the setting of deep venous thrombosis and phlegmasia cerulea dolens: case report

Forearm compartment syndrome is an uncommon but emergent condition that can threaten limb and life. An uncommon cause of compartment syndrome is deep venous thrombosis, usually in the setting of phlegmasia cerulea dolens of the lower extremity. We present a case of compartment syndrome secondary to venous occlusion of the upper extremity due to phlegmasia cerulea dolens in a patient with metastatic lung cancer.

Three-dimensional gadolinium-enhanced magnetic resonance venography in suspected thrombo-occlusive disease of the central chest veins

STUDY OBJECTIVE

To determine the usefulness of high-resolution three-dimensional (3D) gadolinium-enhanced magnetic resonance venography (MRV) in the evaluation of central venous thrombo-occlusive disease of the chest.

DESIGN

Prospective study.

SETTING

University hospital.

PATIENTS

Sixteen consecutive patients with clinically suspected thrombosis of the superior vena cava, subclavian, brachiocephalic/innominate, internal jugular, or axillary veins. Thirteen patients had a neoplasm, two patients had a connective tissue disease, and one patient had a history of strenuous exercise. Twelve of 16 patients had prior central venous catheter placement. MRI was correlated with color-coded duplex sonography (CCDS) in 7 of 16 patients, digital subtraction angiography (DSA) in 3 of 16 patients, and CT in 2 of 16 patients.

INTERVENTION

Contrast-enhanced MRV was performed in a total of 20 examinations. A 3D data set (gradient echo; time to repeat, 4.6 ms; time to echo, 1.8 ms; flip angle, 30 degrees; time of acquisition, 23 s; 512 matrix/64 partitions; slice thickness, 1.5 mm) was acquired in the arterial and venous phase. Overall image quality was assessed on a 5-point scale. The presence, site, and extent of thrombus, as well as presence of an intravascular device, were determined.

MEASUREMENTS AND RESULTS

Overall image quality was rated very good (1 point) in 7 of 16 cases (44%) and good (2 points) in 9 of 16 cases (56%). Thrombus was detected in 16 of 16 patients, and complete extent of disease could be determined in 15 of 16 patients (94%). MRV did not miss any finding obtained by CCDS, DSA, or CT, and provided additional information in 6 of 16 examinations (38%).

CONCLUSION

Contrast-enhanced MRV is a fast and reliable noninvasive procedure with excellent results regarding detection and determination of the extent of thrombo-occlusive disease of the chest veins.

Phlegmasia caerulea dolens and venous gangrene

Phlegmasia caerulea dolens and venous gangrene are rare conditions that tend to occur in association with malignancy. They are characterized by total or near-total occlusion of the venous drainage of the limb, including the microvascular collaterals. Associated mortality and morbidity rates are high, especially when progression to venous gangrene has occurred. Treatment options are limited; elevation and anticoagulation are recommended as first-line management. Experience with thrombolysis has been disappointing although intra-arterial administration of thrombolytic agents may improve results. Thrombectomy cannot be advocated routinely. Little advance in management, or in life and limb salvage, has been made in the past 30 years.

Catheter-directed thrombolysis following vena cava filtration for severe deep venous thrombosis

Massive deep venous thrombosis with marked venous outflow obstruction can result in limb loss or end-organ injury. Systemically administered drugs may not reach thrombi in therapeutic concentrations and surgical and thrombolytic strategies carry a small but real risk of pulmonary embolus--similar to the risks with anticoagulation alone. We therefore developed a strategy in which catheter-directed thrombolysis was used to deliver high concentrations of a plasminogen activator directly to the thrombus combined with placement of a downstream Greenfield filter to protect patients from pulmonary embolus. From 1984 to 1993 six patients were treated with this regimen. All had severe symptoms of less than 4 days' duration. On radiologic evaluation four patients had large iliofemoral and/or inferior vena cava thrombosis, one had subclavian/innominate vein thrombosis, and one had transplant renal vein/iliofemoral/inferior vena cava thrombosis. A Greenfield filter was first placed downstream prior to imbedding an infusion catheter in the greatest mass of thrombus for subsequent infusion of urokinase (n = 4) or streptokinase (n = 2). In four patients the catheter traversed the Greenfield filter. All patients were given bolus lytic therapy followed by maintenance infusions ranging in duration from 24 hours to 12 days. Five patients remained on heparin simultaneously. Clot lysis was achieved in all patients with hemodynamic, symptomatic, and arteriographic improvement. There were no deaths, pulmonary emboli, or complications of filter placement. One patient had minor bleeding at the puncture site and another had catheter-related infection.(ABSTRACT TRUNCATED AT 250 WORDS)

Upper limb venous gangrene, a lethal condition

Venous gangrene of the upper extremity is rare. It was the mode of presentation in a 41-year-old woman who died 10 days later of heart failure due to acute myocardial infarction. There is evidence from this and previous publications that patients with this condition tend to have characteristics in common. Most have either advanced malignant disease or seriously impaired myocardial function and venous gangrene usually occurs as a pre-terminal event. Treatment should be directed primarily at the underlying illness but there may be a case for early amputation if permitted by the general condition of the patient.

Massive venous thrombosis of the extremities

Massive venous thromboses of the extremities, although uncommon, are responsible for many of the long-term sequelae associated with venous disease. The charts of all patients with a diagnosis of iliofemoral venous thrombosis or subclavian vein thrombosis over a 6-year period were reviewed. There were 59 patients with iliofemoral venous thrombosis and 18 patients with subclavian vein thrombosis. Iliofemoral venous thromboses were three times more common, showed the classic leftsided predominance, and were more likely to be idiopathic. Subclavian vein thromboses showed no side or sex predilection and were due to anatomic abnormalities, intravenous lines, or radiation. Iliofemoral venous thrombosis showed poor response to lytic therapy, whereas subclavian vein thromboses were effectively lysed in those patients in whom it could be used. Massive venous thromboses of the extremities, although similar in presentation, have different characteristics depending upon the extremity affected. The cause, frequency, and response to treatment differ, which could ultimately influence outcome and the severity of postphlebitic symptoms.