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Yang A, Seevanayagam S. Left brachiocephalic venous thrombus initially presenting as acute aortic syndrome. J Surg Case Rep 2023; 2023:rjad461. [PMID: 37564054 PMCID: PMC10411998 DOI: 10.1093/jscr/rjad461] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2023] [Accepted: 07/24/2023] [Indexed: 08/12/2023] Open
Abstract
Upper extremity deep venous thrombosis (UEDVT) is rare but carries significant morbidity. Primary UEDVT presents non-specifically and there are no clear diagnostic or management guidelines, which are essential for early treatment to prevent potentially devastating complications such as pulmonary embolus or post-thrombotic pain syndrome. A patient with left brachiocephalic vein UEDVT initially diagnosed radiographically as an acute aortic syndrome and referred to a cardiothoracic unit is presented. Computed tomography venogram confirmed the diagnosis of UEDVT and therapeutic anticoagulation was started. This case highlights the need for validated diagnostic and management algorithms for UEDVT. Furthermore, this relatively rare condition should be considered for patients with acute chest pain and abnormal imaging referred to surgical units.
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Affiliation(s)
- Amy Yang
- Brian F. Buxton Department of Cardiac and Thoracic Aortic Surgery, Austin Health, Heidelberg 3084, Australia
| | - Siven Seevanayagam
- Brian F. Buxton Department of Cardiac and Thoracic Aortic Surgery, Austin Health, Heidelberg 3084, Australia
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2
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Ligia S, Musiu P, Serrao A, Santoro C, Taglietti A, Capriata M, Faccini A, Molinari MC, Baldacci E, Chistolini A. Low-dose apixaban or rivaroxaban as secondary prophylaxis of upper extremity deep vein thrombosis. J Thromb Thrombolysis 2023:10.1007/s11239-023-02842-6. [PMID: 37341894 DOI: 10.1007/s11239-023-02842-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 06/01/2023] [Indexed: 06/22/2023]
Abstract
Upper extremity deep vein thrombosis (UEDVT) may occur without inciting factor or may be secondary to malignancy, surgery, trauma, central venous catheter or related to thoracic outlet syndrome (TOS). International guidelines recommend anticoagulant treatment for at least three months, in particular the use of vitamin K antagonists (VKAs) and direct oral anticoagulants (DOACs). No data on extended anticoagulant therapy and reduced dose of DOACs have been reported in patients affected by UEDVT with persistent thrombotic risk (active cancer, major congenital thrombophilia) or without affected vein recanalization. In our retrospective observational study, including 43 patients, we treated secondary UEDVT with DOACs. In the acute phase of thrombosis (median time of 4 months), we used therapeutic dose of DOACs; the 32 patients with permanent thrombotic risk factors or without recanalization of the UEDVT were shifted to low-dose DOACs (apixaban 2.5 mg twice daily or rivaroxaban 10 mg daily). During therapy with full-dose DOACs, 1 patient presented recurrence of thrombosis; no thromboembolic events were observed during treatment with low-dose DOACs. During full-dose treatment, 3 patients presented minor hemorrhagic complications; no hemorrhagic events were observed during DOACs at low dose. We think our preliminary data could support the indication to extend the anticoagulation with dose reduction of DOACs in patients affected by UEDVT and no-transient thrombotic risk. These data should be confirmed in randomized controlled prospective study.
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Affiliation(s)
- S Ligia
- Hematology, Department of Translational and Precision Medicine, Sapienza University of Rome, Via Benevento 6, Rome, 00161, Italy
| | - P Musiu
- Hematology, Department of Translational and Precision Medicine, Sapienza University of Rome, Via Benevento 6, Rome, 00161, Italy
| | - A Serrao
- Hematology, Department of Translational and Precision Medicine, Sapienza University of Rome, Via Benevento 6, Rome, 00161, Italy
| | - C Santoro
- Hematology, Department of Translational and Precision Medicine, Sapienza University of Rome, Via Benevento 6, Rome, 00161, Italy
| | - A Taglietti
- Hematology, Department of Translational and Precision Medicine, Sapienza University of Rome, Via Benevento 6, Rome, 00161, Italy
| | - M Capriata
- Hematology, Department of Translational and Precision Medicine, Sapienza University of Rome, Via Benevento 6, Rome, 00161, Italy
| | - A Faccini
- Hematology, Department of Translational and Precision Medicine, Sapienza University of Rome, Via Benevento 6, Rome, 00161, Italy
| | - M C Molinari
- Hematology, Department of Translational and Precision Medicine, Sapienza University of Rome, Via Benevento 6, Rome, 00161, Italy
| | - E Baldacci
- Hematology, Department of Translational and Precision Medicine, Sapienza University of Rome, Via Benevento 6, Rome, 00161, Italy
| | - Antonio Chistolini
- Hematology, Department of Translational and Precision Medicine, Sapienza University of Rome, Via Benevento 6, Rome, 00161, Italy.
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3
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Kastora SL, Oduyoye O, Mahmood S. Upper extremity deep venous thrombosis prevalence in the NHS Grampian Medical Ambulatory clinic: diagnostic, therapeutic, and prognostic considerations in oncology patients. Ir J Med Sci 2021; 191:1569-1575. [PMID: 34515987 PMCID: PMC9308609 DOI: 10.1007/s11845-021-02775-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2021] [Accepted: 09/02/2021] [Indexed: 12/05/2022]
Abstract
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.
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Affiliation(s)
| | - Olusegun Oduyoye
- Medical Sciences & Nutrition, University of Aberdeen School of Medicine, Aberdeen, UK.,Emergency Care Centre, Aberdeen Royal Infirmary, Foresterhill Campus, Aberdeen, AB25 2ZN, UK
| | - Shafaq Mahmood
- Emergency Care Centre, Aberdeen Royal Infirmary, Foresterhill Campus, Aberdeen, AB25 2ZN, UK
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4
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Sýkora J, Zeleňák K, Vorčák M, Krkoška A, Vetešková Š, Sýkorová M, Sivák J, Hlinka Ľ, Šinák I. Percutaneous thrombectomy in the management of early rethrombosis in venous thoracic outlet syndrome: two case reports. CVIR Endovasc 2021; 4:61. [PMID: 34357452 PMCID: PMC8346617 DOI: 10.1186/s42155-021-00250-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2021] [Accepted: 07/26/2021] [Indexed: 12/01/2022] Open
Abstract
Background Venous thoracic outlet syndrome resulting in the upper limb deep venous thrombosis is known as Paget–Schroetter syndrome or effort thrombosis. A general treatment algorithm includes catheter-directed thrombolysis followed by surgical thoracic outlet decompression. There are limited data regarding endovascular treatment of rethrombosis presenting early after the surgery. Case presentation Two cases of early rethrombosis successfully treated with percutaneous mechanical thrombectomy by two different techniques are described. In both cases, rethrombosis was diagnosed soon after thrombolysis and first rib resection with scalenectomy. After 12 months, both patients remain symptom-free, with patent subclavian veins confirmed by duplex ultrasonography. Conclusion Percutaneous mechanical thrombectomy devices may offer a safe treatment option for patients with recurrent thrombosis after thoracic outlet surgery, even when thrombolytic therapy is contraindicated.
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Affiliation(s)
- Ján Sýkora
- Clinic of Radiology, Comenius University's Jessenius Faculty of Medicine and University Hospital, Kollárova 2, 036 59, Martin, Slovakia
| | - Kamil Zeleňák
- Clinic of Radiology, Comenius University's Jessenius Faculty of Medicine and University Hospital, Kollárova 2, 036 59, Martin, Slovakia.
| | - Martin Vorčák
- Clinic of Radiology, Comenius University's Jessenius Faculty of Medicine and University Hospital, Kollárova 2, 036 59, Martin, Slovakia
| | - Adam Krkoška
- Clinic of Radiology, Comenius University's Jessenius Faculty of Medicine and University Hospital, Kollárova 2, 036 59, Martin, Slovakia
| | - Štefánia Vetešková
- Clinic of Radiology, Comenius University's Jessenius Faculty of Medicine and University Hospital, Kollárova 2, 036 59, Martin, Slovakia
| | | | - Jozef Sivák
- Middle-Slovak Institute of Cardiovascular Diseases, Cesta k nemocnici 1, 974 01, Banská Bystrica, Slovakia
| | - Ľuboš Hlinka
- Department of Vascular Surgery, University Hospital, Kollárova 2, 036 59, Martin, Slovakia
| | - Igor Šinák
- Department of Vascular Surgery, University Hospital, Kollárova 2, 036 59, Martin, Slovakia
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5
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Higuchi R, Miyawaki M, Yasuga Y, Tomobuchi A, Shigyo H, Nakatani K, Mitsusada N, Hiraoka H, Senzaki N, Tagami N. Paget-Schroetter syndrome accompanied by pulmonary thromboembolism: A case report. J Cardiol Cases 2019; 19:93-96. [PMID: 30949249 DOI: 10.1016/j.jccase.2018.12.004] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2018] [Revised: 11/05/2018] [Accepted: 12/12/2018] [Indexed: 11/16/2022] Open
Abstract
A 17-year-old male, who was involved in a baseball club, presented to our emergency department with the complaint of gradual onset of swelling of his right arm. Contrast-enhanced computed tomography showed obstruction of the proximal portion of the right subclavian vein and pulmonary thromboembolism. Venography confirmed an occluded right subclavian vein. The patient was diagnosed with right subclavian vein thrombosis, which is referred to as Paget-Schroetter syndrome (PSS). An ultrasonography for the affected subclavian vein was helpful not only for making an accurate diagnosis of PSS, but also for verifying dynamic venous flow changes depending on the forearm position. <Learning Objective: This paper aims to describe the usefulness of ultrasonography. A 17-year-old male was diagnosed with Paget-Schroetter syndrome (PSS). In this case, we found ultrasonography is important for verifying dynamic venous flow changes depending on the forearm position. Holding the forearm in a pronated and downward position may have been critical for maintaining good venous flow with prompt resolution of symptoms. Ultrasonography may play a crucial role in assessing an appropriate treatment strategy for PSS.>.
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Affiliation(s)
- Rie Higuchi
- Department of Cardiology, Sumitomo Hospital, Osaka, Japan
| | | | - Yuji Yasuga
- Department of Cardiology, Sumitomo Hospital, Osaka, Japan
| | | | - Hideya Shigyo
- Department of Cardiology, Sumitomo Hospital, Osaka, Japan
| | | | | | | | - Nanae Senzaki
- Department of Ultrasonic Imaging, Sumitomo Hospital, Osaka, Japan
| | - Nobuko Tagami
- Department of Ultrasonic Imaging, Sumitomo Hospital, Osaka, Japan
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6
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Tippit D, Siegel E, Ochoa D, Pennisi A, Hill E, Merrill A, Rowe M, Henry-Tillman R, Ananthula A, Makhoul I. Upper-Extremity Deep Vein Thrombosis in Patients With Breast Cancer With Chest Versus Arm Central Venous Port Catheters. Breast Cancer (Auckl) 2018; 12:1178223418771909. [PMID: 29881287 PMCID: PMC5987887 DOI: 10.1177/1178223418771909] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 09/30/2017] [Accepted: 03/29/2018] [Indexed: 12/31/2022]
Abstract
Most of the patients undergoing treatment for cancer require placement of a
totally implantable venous access device to facilitate safe delivery of
chemotherapy. However, implantable ports also increase the risk of deep vein
thrombosis and related complications in this high-risk population. The objective
of this study was to assess the incidence of upper-extremity deep vein
thrombosis (UEDVT) in patients with breast cancer to determine whether the risk
of UEDVT was higher with chest versus arm ports, as well as to determine the
importance of previously reported risk factors predisposing to UEDVT in the
setting of active cancer. We retrospectively reviewed the medical records of 297
women with breast cancer who had ports placed in our institution between the
dates of December 1, 2010, and December 31, 2016. The primary outcome was the
development of radiologically confirmed UEDVT ipsilateral to the implanted port.
Overall, 17 of 297 study subjects (5.7%) were found to have UEDVT. There was 1
documented case of associated pulmonary embolism. Fourteen (9.5%) of 147
subjects with arm ports experienced UEDVT compared with only 3 (2.0%) of 150
subjects with chest ports (P = .0056). Thus, implantation of
arm ports as opposed to chest ports may be associated with a higher rate of
UEDVT in patients with breast cancer.
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Affiliation(s)
- Danielle Tippit
- Department of Internal Medicine, University of Arkansas for Medical Sciences, Little Rock, AR, USA
| | - Eric Siegel
- Fay W. Boozman College of Public Health, University of Arkansas for Medical Sciences, Little Rock, AR, USA
| | - Daniella Ochoa
- Division of Breast Surgical Oncology, Department of Surgery, University of Arkansas for Medical Sciences, Little Rock, AR, USA
| | - Angela Pennisi
- Division of Medical Oncology, Department of Internal Medicine, University of Arkansas for Medical Sciences, Little Rock, AR, USA
| | - Erica Hill
- Division of Breast Surgical Oncology, Department of Surgery, University of Arkansas for Medical Sciences, Little Rock, AR, USA
| | - Amelia Merrill
- Division of Breast Surgical Oncology, Department of Surgery, University of Arkansas for Medical Sciences, Little Rock, AR, USA
| | - Mark Rowe
- Division of Breast Surgical Oncology, Department of Surgery, University of Arkansas for Medical Sciences, Little Rock, AR, USA
| | - Ronda Henry-Tillman
- Division of Breast Surgical Oncology, Department of Surgery, University of Arkansas for Medical Sciences, Little Rock, AR, USA
| | - Aneesha Ananthula
- Department of Internal Medicine, University of Arkansas for Medical Sciences, Little Rock, AR, USA
| | - Issam Makhoul
- Division of Medical Oncology, Department of Internal Medicine, University of Arkansas for Medical Sciences, Little Rock, AR, USA
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7
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Fletcher JJ, Wilson TJ, Rajajee V, Stetler WR, Jacobs TL, Sheehan KM, Brown DL. A Randomized Trial of Central Venous Catheter Type and Thrombosis in Critically Ill Neurologic Patients. Neurocrit Care 2017; 25:20-8. [PMID: 26842716 DOI: 10.1007/s12028-016-0247-9] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
BACKGROUND Observational studies suggest peripherally inserted central venous catheters (PICCs) are associated with a high risk of catheter-related large vein thrombosis (CRLVT) in critically ill neurologic patients. We evaluated the difference in thrombosis risk between PICCs and centrally inserted central venous catheters (CICVCs). METHODS We conducted a pragmatic, randomized controlled trial of critically ill adult neurologic patients admitted to neurological and trauma critical care units at two level I trauma centers. Patients were randomized to receive either a PICC or CICVC and undergo active surveillance for CRLVT or death within 15 days of catheter placement. RESULTS In total, 39 subjects received a PICC and 41 received a CICVC between February 2012 and July 2015. The trial was stopped after enrollment of 80 subjects due to feasibility affected by slow enrollment and funding. In the primary intention-to-treat analysis, 17 (43.6 %) subjects that received a PICC compared to 9 (22.0 %) that received a CICVC experienced the composite of CRLVT or death, with a risk difference of 21.6 % (95 % CI 1.57-41.71 %). Adjusted common odds ratio of CRLVT/death was significantly higher among subjects randomized to receive a PICC (adjusted OR 3.08; 95 % CI 1.1-8.65). The higher adjusted odds ratio was driven by risk of CRLVT, which was higher in those randomized to PICC compared to CICVC (adjusted OR 4.66; 95 % CI 1.3-16.76) due to increased large vein thrombosis without a reduction in proximal deep venous thrombosis. CONCLUSIONS Our trial demonstrates that critically ill neurologic patients who require a central venous catheter have significantly lower odds of ultrasound-diagnosed CRLVT with placement of a CICVC as compared to a PICC.
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Affiliation(s)
- Jeffrey J Fletcher
- Department of Neurosurgery, University of Michigan, 1500 East Medical Center Drive, Room 3552 TC, Ann Arbor, MI, 48109-5338, USA. .,Department of Neurosurgery, Bronson Methodist Hospital, Kalamazoo, MI, USA.
| | - Thomas J Wilson
- Department of Neurosurgery, University of Michigan, 1500 East Medical Center Drive, Room 3552 TC, Ann Arbor, MI, 48109-5338, USA
| | - Venkatakrishna Rajajee
- Department of Neurosurgery, University of Michigan, 1500 East Medical Center Drive, Room 3552 TC, Ann Arbor, MI, 48109-5338, USA.,Department of Neurology, University of Michigan, Ann Arbor, MI, USA.,Department of Stroke Program, University of Michigan, Ann Arbor, MI, USA
| | - William R Stetler
- Department of Neurosurgery, University of Michigan, 1500 East Medical Center Drive, Room 3552 TC, Ann Arbor, MI, 48109-5338, USA
| | - Teresa L Jacobs
- Department of Neurosurgery, University of Michigan, 1500 East Medical Center Drive, Room 3552 TC, Ann Arbor, MI, 48109-5338, USA.,Department of Neurology, University of Michigan, Ann Arbor, MI, USA.,Department of Stroke Program, University of Michigan, Ann Arbor, MI, USA
| | - Kyle M Sheehan
- Department of Neurosurgery, University of Michigan, 1500 East Medical Center Drive, Room 3552 TC, Ann Arbor, MI, 48109-5338, USA
| | - Devin L Brown
- Department of Neurology, University of Michigan, Ann Arbor, MI, USA.,Department of Stroke Program, University of Michigan, Ann Arbor, MI, USA
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8
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Abstract
Paget-Schroetter syndrome (PSS) is thrombosis of the deep veins draining the upper extremity due to anatomic abnormalities of the thoracic outlet that cause subclavian compression and subsequent thrombosis, leading to thrombus formation in the subclavian vein. Vigorous arm activity in sports is a known risk factor. Here, we report a case of Paget-Schroetter syndrome in a 31-year-old male non-professional baseball pitcher.
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Affiliation(s)
- Shusuke Yagi
- Department of Cardiovascular Medicine, Tokushima University Graduate School of Biomedical Sciences.,Department of Internal Medicine, Shikoku Central Hospital
| | - Minoru Mitsugi
- Department of Internal Medicine, Shikoku Central Hospital
| | | | - Masashi Akaike
- Department of Medical Education, Tokushima University Graduate School of Biomedical Sciences
| | - Masataka Sata
- Department of Cardiovascular Medicine, Tokushima University Graduate School of Biomedical Sciences
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Koury JP, Burke CT. Endovascular management of acute upper extremity deep venous thrombosis and the use of superior vena cava filters. Semin Intervent Radiol 2012; 28:3-9. [PMID: 22379271 DOI: 10.1055/s-0031-1272975] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
Upper extremity deep venous thrombosis (UEDVT), though less common than lower extremity DVT, is a significant problem with several possible etiologies. The incidence of UEDVT is on the rise, primarily from the increasing use of central venous access devices. However, there are other causes of UEDVT, including primary venous thrombosis (Paget-Schroetter syndrome) and hypercoagulable states associated with underlying malignancy. The morbidity and mortality associated with UEDVT is largely from pulmonary embolism and the postphlebitic syndrome. Nevertheless, many UEDVTs are asymptomatic or patients may present with nonspecific clinical symptoms; therefore, a high index of suspicion is often necessary to make a correct diagnosis. Currently, there is no standard treatment algorithm for UEDVT. Treatment options may range from systemic anticoagulation to surgical correction depending on the etiology of the thrombus, as well as the patient's associated comorbidities, life expectancy and expected quality of life following treatment.
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Affiliation(s)
- Joseph P Koury
- Department of Radiology, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
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