Thoracic Central Venous Obstruction (T-CVO) A New Look at an Old Problem. (This is what we say about T-CVO!)

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1 Thoracic Central Venous Obstruction (T-CVO) These are ALL examples of T-CVO Paget- Schroetter Syndrome A New Look at an Old Problem Bart Dolmatch, MD, FSIR but each one is a different Cellulitis in swollen arm w/ AVF AVF Dilation There has never been a universal set of reporting standards for T-CVO So we really don t know much about prevalence, natural history, treatment, and outcomes* What if We Didn t Have Reporting Standards for PAD? Would we say, PAD is a complicated problem, intervention gives mixed results, and we don t know what to do? (This is what we say about T-CVO!) *The literature stinks! 1

2 PAD REPORTING SYSTEMS For SYMPTOMS PAD ANATOMIC CLASSIFICATION Why are there are NO Reporting Standards for Thoracic CVO? Birth of the Central Vein work Group (CVWG) Representatives from Interventional Radiology Vascular Surgery Transplant Surgery Nephrology Hematology/Oncology Cardiology Pediatrics Clinical Anatomy 20 members (+/-) 14 Conference Calls 2 yrs 2

3 Members and/or Officers from Soc. Interventional Radiology Soc. Vascular Surgery Am. College of Surgeons Vascular Access Soc. of the Americas Am. Soc. of Diagnostic and Interv. Nephrologists Am. Soc. of Pediatric Hematologists and Oncologists Am. Heart Assoc. and many other org s and societies Do we all Know Thoracic Central Vein Anatomy? Where does the Subclavian Vein begin? 1 st rib * SCV starts here Central IJV s start here SCV starts here Is the Internal Jugular Vein a Central Vein? The «central venous» segment of the Internal Jugular Vein starts at the superior margin of 1st rib Thoracic Central Veins and the suprahepatic IVC) 3

4 Anatomically Important Features of All T-CVO s 1. How obstructed? Stenosis: Up to 99% luminal narrowing Occlusion: 100% obstruction 2. Venous flow or AV access flow? 3. Type of Obstruction? Type 1a Type 1b Type 2a Anatomy of Thoracic CVO Type 2b Type 3 Symptoms Type 4 Type 5 1. Swelling (Yes/No) 2. Pain (Yes/No) 3. Onset of dyspnea (Yes/No) 4. Onset of CNS symptoms (Yes/No) Headache, Dizziness, Altered vision, Altered hearing, Seizure, Other (specify) Type 6 4

5 Signs 1. Swelling measure and record in mm s a. Unilateral b. Bilateral/head-neck 2. Skin changes: a. Skin discoloration of the affected arm b. Lymphatic blistering or weeping c. Stasis ulcers d. Infection (cellulitis, abscess, or purulent drainage) e. Non-healing wounds or incisions 3. Venous findings: a. Ectatic venous collaterals (exam and/or imaging) b. Venous thrombosis (exam and/or imaging) c. Phlebitis (exam) Duration of Symptoms Reported in # of days (not weeks or months) 1-14 days (Acute) days (Sub-acute) >28 days (Chronic) Performance Status Due to T-CVO 3 Functional Limitations 0. Asymptomatic: No change in performance I. Symptomatic: No change in performance II. Symptomatic : Impaired; some restriction in physical exercise, self-care and/or performance of some daily activities but not disabled III. Symptomatic : Disabled; cannot exercise, and capable of only limited self-care and daily activities IV. Symptomatic: Incapacitated; incapable of self-care and daily activities 1. Problems with cannulation of an upper body hemodialysis access 2. Inability to place venous access (venous catheter or AV access) at an intended site. 3. T-CVO that necessitates recanalization or intervention by any method (e.g., guide wire recanalization, angioplasty, stent placement, or surgery) 5

6 T-CVO Reporting Highlights Define Anatomy Stenosis, occlusion Anatomy of Obstruction Symptoms (4) Signs (3) Duration Performance Status Functional Limitation Paget- Schroetter Syndrome Occlusion Unilateral with Venous Flow Type 1b Symptoms: Left Arm Swelling, Pain (no dyspnea or CNS) Signs: Swelling, Plethora (no venous findings) R Arm 102mm L Arm 128mm Duration: 2 Days (Acute) Performance Status: III. Symptomatic : Disabled; cannot exercise, and capable of only limited self-care and daily activities Functional Limitation: None Status of T-CVO Reporting Standards Cellulitis in swollen arm w/ AVF Occlusion Unilateral with AV access flow Type 4 Symptoms: Right Arm Swelling, Pain (no dyspnea or CNS) Signs: Swelling, Erythema, cellulitis (no venous findings) R Arm 134mm L Arm 112mm Duration: 20 Days (Sub Acute) Performance Status: III. Symptomatic : Disabled; cannot exercise, and capable of only limited self-care and daily activities Functional Limitation: Cannot cannulate AVF 1. Endorsed by the Society of Interventional Radiology as a formal Reporting Standards Project 2. Draft manuscript nearly completed 1. Co-publication by JVIR and JVS 2. Many other groups are interested in endorsing this work. 3. Publication planned before summer Further work has begun on lesions, collaterals, etiologies. 4. Nomenclature of T-CVO for EHR and Global Lexicon 6

7 Does this T-CVO make you smile? Catheter Related CVO 7