Treatment of acute thrombosis of axillo-subclavian vein

Transcription

1 Treatment of acute thrombosis of axillo-subclavian vein Yang Jin Park Vascular Surgery, Samsung Medical Center Sungkyunkwan University School of Medicine

2 CASE A 32-year-old male patient 3-day history of pain, heaviness, swelling, and functional impairment in his right arm Current active volley ball player in KOVO A swollen and erythematous right arm and visible venous collaterals at shoulder and chest Compression duplex scan reveals an occlusion of axillo-subclavian vein

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9 SCV IJV Scalene m.

10 Further evaluation and management?

11 Acute Upper extremity DVT (AUEDVT) 10% of all cause of DVT case/year per 10,000 people Increased use of central venous catheters, cardiac pacemakers and defibrillators Axillary subclavian veins Secondary forms > primary forms Younger, leaner, cancer-associated, less acquired or hereditary thrombophilia

12 Type of AUEDVT Primary (20% of cases) Venous thoracic outlet syndrome Effort-related thrombosis (Paget-Schroetter syndrome) Idiopathic Secondary (80% of cases) Catheter-associated thrombosis Cancer-associated thrombosis Surgery or trauma of arms or shoulder Pregnancy, oral pills, OHSS OHSS, ovarian hyperstumulation syndrome

13 Paget-Schroetter syndrome Primary acute upper extremity DVT Young, male Pathogenesis Strenuous activity involving force or abduction of dominant arm Repetitive microtrauma of subclavian vein and its surrounding structures Anatomic abnormalities within costoclavicular junction Inflammation Venous intima hyperplasia Fibrosis Acute upper extremity DVT

14 Complications of AUEDVT Upper extremity DVT < Lower extremity DVT Pulmonary embolism 6% 15-32% 12month 2-5% 10% Post-thrombotic syndrome 5% 56% Risk of Post-thrombotic syndrome (PTS) Thrombosis of axillary subclavian veins Residual 6months Catheter-associated thrombosis

15 Clinical diagnosis and evaluation Symptoms Discomfort, pain, paresthesia, weakness Signs Swelling, edema, discoloration, visible venous collaterals Routine screening of thrombosis 2/3 patients with central venous catheter No suggestive symptoms or signs D-dimer

16 D-dimer Negative result is an accurate means of ruling out thrombosis of lower extremity DVT Cannot be recommended for use in screening patients with suspected DVT of upper extremity Many coexisting conditions associated with elevated D-dimer level 52 patients with suspected AUEDVT 23 cancer, 18 implanted catheter D-dimer level (by ELISA) : cutoff 500µg/L 100% sensitivity, 14% specificity Only 5 (10%) patients below cutoff point

17 Compression ultrasonography and duplex ultrasonography Compression ultrasonography Incompressibility of thrombosed vein Preferred imaging test for suspected AUEDVT Difficult to visualize proximal subclavian and brachiocephalic veins 97% sensitivity, 96% specificity Duplex ultrasonography Abnormal Doppler pattern Reduced variability No variability in flow velocity during Valsalva manuever

18 Conventional phlebography Indications Indeterminate ultrasonographic results Before catheter-directed thrombolysis or surgical decompression of venous TOS Positional phlebography Arm abduction Useful for diagnosing residual vein stenosis within costoclavicular junction Disadvantage Use of contrast agents Radiation exposure

19 CT or MR angiography Limited data Useful for imaging proximal arm veins Indeterminate findings on US Suspected concomitant conditions Neoplasms Associated adenopathy Abnormalities at venous thoracic outlet

20 Catheter-associated thrombosis Routine catheter removal is not recommended Considering factors Need for further IV administration of medications or blood sampling Expected difficulties in obtaining venous access Patient s preference Ix of removal Catheter malfunction or infection CIx to anticoagulation therapy Persistent symptoms or signs during initial anticoagulation therapy Catheter is no longer needed

21 Treatment of AUEDVT Anticoagulation alone Catheter-directed thrombolytic therapy Mechanical intervention Aspiration thrombectomy, balloon angioplasty, stenting Pharmaco-mechanical thrombolysis

22 Updated ACCP guideline, 2012

23 Initial Anticoagulation Parenteral anticoagulation (LMWH, fondaparinux, IV or SC UFH) over no Tx LMWH or fondaparinux over IV or SC UFH

24 Thrombolytic therapy Anticoagulation alone over thrombolysis Thrombolysis should be considered: Most axillo-subclavian vein involvement Extensive swelling Functional impairment Symptoms for <14 days Good functional status Life expectancy of 1 year Low risk of bleeding Same intensity and duration of anticoagulation as in similar patients who do not undergo thrombolysis Outcomes Satisfactory recanalization rate compared with anticoagulation alone Unclear whether reduces risk of recurrence, PTE, or PTS

25 Long-term anticoagulation Catheter not routinely be removed if it is functional and there is an ongoing need for the catheter Minimum duration of anticoagulation of 3 months over a shorter period If catheter removed, 3 months of anticoagulation over a longer duration of therapy in patients with/without cancer If not removed, Anticoagulation as long as catheter remains over stopping 3 months of Tx in patients with/without cancer Not-associated with catheter, or cancer, 3 months of anticoagulation over a longer duration

26 Post-thrombotic syndrome (PTS) Prevention against use of compression sleeves or venoactive medications Treatment Compression bandages or sleeves to reduce symptoms against use of venoactive medications

27 Guidelines for Mx of AUEDVT Nils Kucher, NEJM 2011

28 Guidelines for Mx of AUEDVT Nils Kucher, NEJM 2011

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38 head Scalene m. Rt. IJV Phrenic n. Rt. SCV

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43 6 months Rt. SCV

44 Thank you for your attention