Upper extremity deep vein thrombosis

[Ultrasound-guided insertion and the proportion of catheter-associated thrombosis]

Background

Central venous accesses are of great importance in daily medical practice. Insertion into the jugular vein is common due to its accessibility. Catheter-associated venous thrombosis is a relatively common medium-term complication. The use of ultrasound to guide catheterization offers multiple advantages and promises to make vascular access installation a safer technique.

Objective

To compare the proportion of catheter-associated jugular thrombosis when an anatomical landmark technique is used with respect to the ultrasound-guided technique.

Material and methods

An observational, cross-sectional, and analytical study that compares the frequency of thrombosis when the ultrasound-guided technique was used concerning anatomical reference technique in patients in an intensive care unit.

Results

A total of 91 patients were studied: in 44 an ultrasound-guided technique was used, and in 47 anatomical references. A single case of mural thrombosis (2.7%) was observed in the ultrasound-guided insertion group vs. 11 cases (23.4%) in the other group, resulting in a significant association between the anatomical reference insertion technique and thrombosis. Chi squared (1, n = 91) = 8.86, p = 0.004.

Conclusion

The proportion of catheter-associated jugular thrombosis is greater when an anatomical reference technique is used compared to the ultrasound-guided technique.

Recurrence of Upper Extremity Deep Vein Thrombosis Secondary to COVID-19

Infection with SARS-CoV-2 leading to COVID-19 induces hyperinflammatory and hypercoagulable states, resulting in arterial and venous thromboembolic events. Deep vein thrombosis (DVT) has been well reported in COVID-19 patients. While most DVTs occur in a lower extremity, involvement of the upper extremity is uncommon. In this report, we describe the first reported patient with an upper extremity DVT recurrence secondary to COVID-19 infection.

A systematic review and meta-analysis for the management of Paget-Schroetter syndrome

OBJECTIVE

There is currently no general agreement on the optimal treatment of Paget-Schroetter syndrome. Most centers have advocated an interventional approach that is based on the results of small institutional series. The purpose of our meta-analysis was to focus on the safety and efficacy of thrombolysis or anticoagulation with decompression therapy. A detailed description of the epidemiologic, etiologic, and clinical characteristics, along with radiologic findings and treatment option details, was also performed.

METHODS

The current meta-analysis was conducted using the PRISMA guidelines. Studies reporting on spontaneous thrombosis or thrombosis after strenuous activities of axillary-subclavian vein were considered eligible. Analyses of all retrospective studies were conducted, and pooled proportions with 95% confidence intervals of outcome rates were calculated.

RESULTS

Twenty-five studies with 1511 patients were identified. Among these patients, 1177 (77.9%) had thrombolysis, 658 (43.5%) had anticoagulation, and 1293 (85.6%) patients had decompression therapy of the thoracic outlet. Complete thrombus resolution was estimated at 78.11% of the patients after thrombolysis, and the respective pooled proportion for partial resolution of thrombus was 23.72%. Despite thrombolytic therapy, 212 patients underwent additional balloon angioplasty for residual stenosis, although only 36 stents were implanted. After anticoagulation, a total of 40.70% of the patients had complete thrombus resolution, whereas partial resolution was occurred in 29.13% of the patients. During follow-up, a total of 51.75% of the patients with any initial treatment modality had no remaining thrombus, and 84.87% of these patients were free of symptoms. We also estimated that 76.88% of the patients had a Disabilities of the Arm, Shoulder and Hand score of <20, indicating no or mild symptoms after treatment. A subgroup meta-analysis with 20 studies and 1309 patients, showed significantly improved vein patency and symptom resolution in patients who had first rib resection with or without venoplasty, compared with those who had only thrombolysis.

CONCLUSIONS

Although no randomized controlled data are available, our analysis strongly suggested higher rates of thrombus and symptoms resolution with thrombolysis, followed by first rib resection. A prospective randomized trial comparing anticoagulants with thrombolysis and decompression of thoracic outlet is required.

Blood finds its own way: Axillary vein thrombosis with extensive chest-wall collaterals

Hemodialysis catheters are associated with upper extremity deep vein thrombosis, and chronic venous occlusion leads to the formation of collateral pathways. Knowledge of these pathways aids in accurate interpretation of upper extremity venograms. Arteriovenous fistula is the preferred access for chronic hemodialysis, and long-term use of catheters should be avoided.

Thrombolysis for acute upper extremity deep vein thrombosis

BACKGROUND

About 5% to 10% of all deep vein thromboses occur in the upper extremities. Serious complications of upper extremity deep vein thrombosis, such as post-thrombotic syndrome and pulmonary embolism, may in theory be avoided using thrombolysis. No systematic review has assessed the effects of thrombolysis for the treatment of individuals with acute upper extremity deep vein thrombosis.

OBJECTIVES

To assess the beneficial and harmful effects of thrombolysis for the treatment of individuals with acute upper extremity deep vein thrombosis.

SEARCH METHODS

The Cochrane Vascular Information Specialist (CIS) searched the Specialised Register (29 March 2017), the Cochrane Central Register of Controlled Trials (CENTRAL; 2017, Issue 2), and three trial registries (World Health Organization International Clinical Trials Registry, ClinicalTrials.gov, and ISRCTN registry) for ongoing and unpublished studies. We additionally searched the registries of the European Medical Agency and the US Food and Drug Administration (December 2016).

SELECTION CRITERIA

We planned to include randomised clinical trials irrespective of publication type, publication date and language that investigated the effects of thrombolytics added to anticoagulation, thrombolysis versus anticoagulation, or thrombolysis versus any other type of medical intervention for the treatment of acute upper extremity deep vein thrombosis.

DATA COLLECTION AND ANALYSIS

Two review authors independently screened all records to identify those that met inclusion criteria. We planned to use the standard methodological procedures expected by Cochrane. We planned to use trial domains to assess the risks of systematic error (bias) in the trials. We planned to conduct trial sequential analyses to control for the risk of random errors and to assess the robustness of our conclusions. We planned to consider a P value of 0.025 or less as statistically significant. We planned to assess the quality of the evidence using the GRADE approach. Our primary outcomes were severe bleeding, pulmonary embolism, and all-cause mortality.

MAIN RESULTS

We found no trials eligible for inclusion. We also identified no ongoing trials.

AUTHORS' CONCLUSIONS

There is currently insufficient evidence from which to draw conclusion on the benefits or harms of thrombolysis for the treatment of individuals with acute upper extremity deep vein thrombosis as an add-on therapy to anticoagulation, alone compared with anticoagulation, or alone compared with any other type of medical intervention. Large randomised clinical trials with a low risk of bias are warranted. They should focus on clinical outcomes and not solely on surrogate measures.

Postthrombotic syndrome following upper extremity deep vein thrombosis in children

Upper limb PTS in children depends on DVT pathogenesis (primary vs secondary) and on the age of the patient (neonates vs non-neonates). DVT pathogenesis and thrombus resolution are independent predictors of upper limb PTS in children.

Paget-Schrotter syndrome and complications of management

An 18-year-old man presented to the emergency department with an acutely swollen right upper limb having spent the previous day canoeing. Venography confirmed right subclavian venous thrombosis at middle one-third of right clavicle with no evidence of cervical rib or other structural abnormalities. Following heparinisation, catheter directed thrombolysis was performed which restored luminal flow. Postprocedure the patient developed spontaneous small-volume haemoperitoneum and acute renal failure. The patient was admitted to the intensive care unit for haemodialysis and supportive management. The patients' renal function improved and he was discharged well following his 28th day of admission. Paget-Schroetter syndrome or effort thrombosis involves subclavian venous thrombosis associated with strenuous activity of upper extremities. In these cases, catheter directed thrombolysis with first rib resection provides greater patency rate than anticoagulation therapy alone. Acute kidney injury following mechanical thrombolysis is rarely reported in the literature.