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UEDVT.ppt

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UEDVT.ppt

  1. 1. Upper Limb DVT… It’s not just for legs anymore Tress Goodwin, SMSIV Surgical ICU, October 2007
  2. 2. Outline <ul><li>Anatomy </li></ul><ul><li>Primary vs. Secondary ULDVT </li></ul><ul><li>Clinical features </li></ul><ul><li>Diagnosis </li></ul><ul><li>Treatment </li></ul><ul><li>Sequelae </li></ul>
  3. 5. Upper vs. Lower DVTs <ul><li>Virchow’s triad (venous stasis, hypercoagulability, endothelial trauma) </li></ul><ul><li>UL: Higher venous flow, less stasis, gravitational effects </li></ul><ul><li>Direct endothelial trauma: effort in primary; iatrogenic in secondary </li></ul>
  4. 6. Spontaneous (Primary) ULDVT <ul><li>First described by Paget and Schroetter </li></ul><ul><li>AKA Paget-Schroetter syndrome, “effort thrombosis” </li></ul><ul><li>Compressive anatomy at thoracic outlet—compression of vein b/w first rib and hypertrophied scalene or tendons </li></ul><ul><li>Can occur after strenuous activity of arms and shoulders </li></ul>
  5. 9. <ul><li>Central venous catheters </li></ul><ul><li>Pacemakers </li></ul><ul><li>Higher incidence: Chemotherapy, TPN via central lines </li></ul><ul><li>Improper placement of catheter tip </li></ul><ul><li>Incidence varies: 1-4% of all DVT’s </li></ul>Secondary ULDVT
  6. 10. Clinical Features <ul><li>Arm swelling, pain, heaviness </li></ul><ul><li>Dilated subcutaneous veins </li></ul><ul><li>JVD </li></ul><ul><li>Upper limb cyanosis </li></ul><ul><li>Can be asymptomatic </li></ul><ul><li>DDx: superficial thrombophlebitis </li></ul>
  7. 11. Associated Conditions <ul><li>Presence of a central venous catheter in (72%) </li></ul><ul><li>Infection (28%) </li></ul><ul><li>Extrathoracic malignancy (22%) </li></ul><ul><li>Thoracic malignancy in (21%) </li></ul><ul><li>Renal failure (21%) </li></ul><ul><li>Prior lower-extremity deep venous thrombosis (18%) </li></ul>Marinella MA, Kathula SK, Markert RJ. Heart Lung. 2000 Mar-Apr;29(2):113-7. Spectrum of upper-extremity deep venous thrombosis in a community teaching hospital.
  8. 12. Spectrum of Manifestations Asymptomatic Massive PE Upper limb complications
  9. 13. ULDVT Sequelae Sajid, M, et al. Upper Limb Deep Vein Thrombosis: A Literature Review to Streamline the Protocol for Management. Acta Haematol 2007; 118.
  10. 14. Diagnosis <ul><li>Duplex ultrasonography </li></ul><ul><li>Aggressive diagnosis: digital subtraction venography, MRV, CTV </li></ul>Sajid, M, et al. Upper Limb Deep Vein Thrombosis: A Literature Review to Streamline the Protocol for Management. Acta Haematol 2007; 118.
  11. 16. Treatment <ul><li>Expectant management </li></ul><ul><li>Removal of offending agent </li></ul><ul><li>Anticoagulation (standard: heparin x 5-7 days, 3 mos of Coumadin) </li></ul><ul><li>Thrombolysis (streptokinase, urokinase, TPA) </li></ul><ul><li>Surgery </li></ul><ul><li>SVC filter </li></ul>
  12. 17. Sajid, M, et al. Upper Limb Deep Vein Thrombosis: A Literature Review to Streamline the Protocol for Management. Acta Haematol 2007; 118. Treatment Protocol
  13. 18. Thrombolysis v Anticoagulation Sajid, M, et al. Upper Limb Deep Vein Thrombosis: A Literature Review to Streamline the Protocol for Management. Acta Haematol 2007; 118.
  14. 19. Surgical management Sajid, M, et al. Upper Limb Deep Vein Thrombosis: A Literature Review to Streamline the Protocol for Management. Acta Haematol 2007; 118.
  15. 20. SVC Filters <ul><li>Ascher, Enrico, Hingorani, Anil, Mazzariol, Fernanda, Jacob, Theresa, Yorkovich, William, Gade, Prasad Clinical Experience with Superior Vena Caval Greenfield Filters. Journal of Endovascular Surgery 1999 6: 365-369 </li></ul><ul><li>Insertion of SVC Greenfield filters is a safe and feasible therapy to prevent recurrent thromboembolism in patients with UEDVT who are refractory to or inappropriate for anticoagulation therapy. </li></ul><ul><li>Ascher E, Hingorani A, Tsemekhin B, Yorkovich W, Gunduz Y.Lessons learned from a 6-year clinical experience with superior vena cava Greenfield filters. J Vasc Surg. 2001 Apr;33(4):907 </li></ul><ul><li>Insertion of SVC-GFs is a safe, efficacious, and feasible therapy and may prevent reccurent thromboembolism in patients with UEDVT who are resistant to anticoagulation or have contraindications to anticoagulation </li></ul>
  16. 21. SVC Filters - Indicated?
  17. 22. Conclusions <ul><li>ULDVT: relatively rare but associated with considerable morbidity and mortality (PE, post-thrombotic syndrome, loss of vascular access) </li></ul><ul><li>Duplex ultrasound sufficient for majority of diagnoses </li></ul><ul><li>Simple anticoagulation suitable for most patients </li></ul><ul><li>Thrombolysis/thrombectomy less frequently used </li></ul><ul><li>Surgery, SVC filters (?) for recurrent cases or where other tx contraindicated </li></ul>
  18. 23. Questions?

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