Deep venous thrombosis with clinical signs after catheterization of the superior vena cava system

Superior vena caval obstruction in patients with gut failure receiving home parenteral nutrition

Clinical suspicion and venographic conformation were used to diagnose 15 cases of superior vena caval obstruction (SVCO) in 107 home parenteral nutrition (HPN) patients over 379 cumulative years of HPN (3.9 cases/100 patient-years). Patients with SVCO had been on HPN a mean of 51.5 months and had used 6.2 (range 1-50) central catheters, including short- and long-term, before SVCO was diagnosed. The frequency of inflammatory bowel disease (IBD) with SVCO was approximately the same as that in our general HPN population. Positive blood cultures were present immediately preceding the diagnosis of SVCO in 40% (six of 15) of cases. Atypical line placements were noted in two cases. The most common management strategies employed were conversion to enteral feedings in five patients and placement of a new catheter directly into the right atrium by thoracotomy in another five patients. Two of the five with right atrial catheters experienced a postpericardiotomy syndrome (fever, pericardial rub, and pulmonary infiltrates) that responded promptly to indomethacin. The most significant long-term sequela of SVCO was the need for a left jugular vein to right atrial appendage bypass in one patient with chronic venous congestion from her SVCO. Once the SVCO is confirmed, systemic heparinization provides immediate antithrombotic effect and minimizes the risk of pulmonary embolism. The use of streptokinase may result in rapid thrombolysis.

Upper extremity radionuclide venography in the diagnosis and management of venous disease associated with intravenous catheters

The utility of upper extremity radionuclide venography (RNV) in the assessment of suspected catheter-related central venous thrombosis (CRVT) was evaluated in 40 patients with subclavian venous catheters. Twenty normal patients (Group A) served as controls and their venographic patterns were analyzed by using four criteria: (1) delayed tracer transit time, (2) nonuniformity of flow and venous pooling, (3) jugular venous reflux, and (4) collateral venous filling. Control studies displayed no collaterals as a distinguishing characteristic but demonstrated the other three features to a variable degree. Of 106 extremities suspected of CRVT, 67 (Group B) were initially considered to have normal RNV findings (no collaterals). Contrast venography confirmed a normal pattern in 3 but identified CRVT with collaterals in 3 others. Retrospective review of the RNV studies confirmed faint collaterals in these latter 3. The 39 remaining extremities (Group C) showed abnormal RNV findings; contrast venography and postmortem studies confirmed the presence of venous disease in 5 patients. The authors believe that RNV is a reliable, noninvasive procedure for early diagnosis of venous occlusion associated with subclavian venous catheters.