Conservative management of chronic upper extremity venous outflow occlusion

Chronic upper extremity venous outflow occlusion (UEVOO) occurs frequently among hospitalized patients as a result of various anatomical or pathological etiologies. This includes venous thoracic outlet syndrome, catheter-related injury, malignancy, and hypercoagulable states. While open surgical and endovascular therapies have increasingly been utilized in managing UEVOO, many patients can still be successfully managed with non-invasive therapies. In this review, we will discuss how conservative measures such as anticoagulation and compression therapy can be applied to different causes of UEVOO. The optimal treatment of patients with chronic upper extremity occlusion can be accomplished by deciding which patients will be most likely to benefit from conservative management.

Role of Physical Therapists in the Management of Individuals at Risk for or Diagnosed With Venous Thromboembolism: Evidence-Based Clinical Practice Guideline

The American Physical Therapy Association (APTA), in conjunction with the Cardiovascular & Pulmonary and Acute Care sections of APTA, have developed this clinical practice guideline to assist physical therapists in their decision-making process when treating patients at risk for venous thromboembolism (VTE) or diagnosed with a lower extremity deep vein thrombosis (LE DVT). No matter the practice setting, physical therapists work with patients who are at risk for or have a history of VTE. This document will guide physical therapist practice in the prevention of, screening for, and treatment of patients at risk for or diagnosed with LE DVT. Through a systematic review of published studies and a structured appraisal process, key action statements were written to guide the physical therapist. The evidence supporting each action was rated, and the strength of statement was determined. Clinical practice algorithms, based on the key action statements, were developed that can assist with clinical decision making. Physical therapists, along with other members of the health care team, should work to implement these key action statements to decrease the incidence of VTE, improve the diagnosis and acute management of LE DVT, and reduce the long-term complications of LE DVT.

The role of inflammation in post-thrombotic syndrome after pregnancy-related deep vein thrombosis: A population-based, cross-sectional study

Previous studies suggest that inflammation may play a role in the pathophysiology of post-thrombotic syndrome (PTS). The aims of the present study were to evaluate markers of inflammation as possible predictors for PTS after pregnancy-related deep vein thrombosis (DVT). We included 182 women with a pregnancy-related DVT during 1990-2003 and 314 controls. All women answered a questionnaire and donated a blood sample in 2006. PTS was diagnosed when a self-reported Villalta score was above 4. The following predictors of PTS were included: high sensitivity C-reactive protein (hsCRP), interleukin (IL)-6, IL-8, IL-10, monocyte chemotactic protein (MCP)-1, transforming growth factor (TGF)-β1, platelet derived growth factor (PDGF)-BB, and the two adhesion molecules intercellular adhesion molecule (ICAM)-1 and vascular cell adhesion molecule (VCAM)-1. High values were defined as above median value among controls. We found that 41% of cases were diagnosed with PTS 3-16years after index pregnancy. In univariate analyses, high values of hsCRP, IL-6, and IL-10 were significantly associated with PTS with ORs 2.3 (95% CI; 1.2-4.2, p=0.008), 1.9 (1.0-3.5, p=0.04), and 10.8 (1.3-89.8, p=0.01), respectively. Only hsCRP, which has previously been found to be independently associated with PTS, was independently associated with PTS in a multivariate logistic regression model, when adjusting for proximal DVT occurring postpartum, age above 33years, and smoking (adjusted OR 2.4; 95% CI 1.2-4.8, p=0.01). We conclude that hsCRP was associated with PTS 3-16years after pregnancy-related DVT.

Segmental Impedance Thresholds for Early Detection of Unilateral Upper Limb Swelling

BACKGROUND

Detection of early lymphedema is important for effective treatment outcome and reduction of disease burden. The aims of this study were to determine normal inter-limb variance in the hand and four segments of the arm using bioimpedance spectroscopy (BIS) to provide diagnostic thresholds for detection of early lymphedema development, to determine the intra-rater reliability of these measurements, and to compare the inter-limb BIS ratios to differences based on arm circumference measures.

METHODS AND RESULTS

One hundred women, aged 49.1 (SD 13.8) years without history of breast cancer or lymphedema participated. Impedance measures for the hand and four 10 cm length arm segments were used to determine the inter-limb segment BIS ratios. Circumference difference and segment volumes were calculated from circumference measures obtained with a tape measure. A subgroup of women was measured on two occasions, one week apart. Thresholds were determined for the dominant and nondominant limb, based on two and three standard deviations (SD) above the mean. The 2SD and 3SD thresholds for the dominant arm ranged from 1.121 to 1.150 and 1.172 to 1.209, respectively, and for the nondominant limb ranged from 1.057 to 1.107 and 1.103 to 1.169, respectively. Intra-rater reliability was high (ICC: 0.945-0.983). BIS ratio and circumference-based measures did not identify the same segments as being over threshold.

CONCLUSIONS

BIS diagnostic thresholds for the hand and four segments of the arm, based on normative data, taking into consideration arm dominance have been developed. Segmental BIS has been shown to be highly reliable.