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Minchu P, Messner M, Albuquerque F, Newton D, Larson R, Levy M. Outcomes following interval delayed first rib resection for acute axillosubclavian deep venous thrombosis. J Vasc Surg Venous Lymphat Disord 2024; 12:101715. [PMID: 38631801 DOI: 10.1016/j.jvsv.2023.101715] [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] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2023] [Revised: 09/11/2023] [Accepted: 09/26/2023] [Indexed: 04/19/2024]
Abstract
BACKGROUND Current management of axillosubclavian deep venous thrombosis (DVT) often uses thrombolysis for the DVT, prompt first rib removal, and occasional venoplasty or stenting. Our institution has increasingly used anticoagulation alone followed by interval first rib resection. We sought to analyze the effectiveness of this simplified technique. METHODS Between September 2012 and April 2021, 27 patients were identified within the institution's electronic medical record as having undergone first rib resection for upper extremity DVT. Seven of these patients had undergone preoperative thrombolysis before referral and were excluded. Among the remaining 20 patients, preoperative clinic charts were evaluated for age, venous segment involvement, contralateral limb involvement, presence of documented hypercoagulable state, duration of preoperative and postoperative anticoagulation, and postoperative outcomes. RESULTS Of the 20 patients (mean age, 26.2 years; 13 males) presenting with acute axillosubclavian DVT, all patients had right (n = 8) or left (n = 12) arm swelling. Five patients had extremity pain and four had extremity discoloration. Ten had axillosubclavian vein involvement, 9 had subclavian vein involvement, and 1 had axillary vein involvement. Two patients were on oral contraceptives and no patients had any other diagnosed hypercoagulable conditions. The mean duration of preoperative and postoperative anticoagulation was 3.2 ± 2.6 months and 2.1 ± 2.1 months, respectively. Nineteen patients underwent supraclavicular first rib resection and 1 patient underwent transaxillary resection. Twelve patients (60%) demonstrated complete DVT resolution by venous duplex examination during the postoperative period and 8 patients (40%) demonstrated partial recanalization/chronic DVT. Complications included one hemothorax and one thoracic duct injury. All 20 patients remain asymptomatic without arm swelling, with a mean follow-up of 55.1 ± 34.7 months. CONCLUSIONS Among patients presenting with acute axillosubclavian DVT, anticoagulation alone followed by interval first rib resection proved to be successful in providing symptomatic relief in the short to medium term. By eliminating the need for preoperative thrombolysis and postoperative venograms, this potentially cost-saving algorithm simplifies our management for acute venous thoracic outlet syndrome while maintaining good clinical outcomes. Because this study only analyzed our management algorithm's effectiveness in the short to medium term, the long-term effectiveness of this treatment will need to be demonstrated.
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Affiliation(s)
- Prem Minchu
- Virginia Commonwealth University School of Medicine, Richmond, VA
| | - Morgan Messner
- Division of Vascular Surgery at VCU Health, Richmond, VA
| | | | - Daniel Newton
- Division of Vascular Surgery at VCU Health, Richmond, VA
| | - Robert Larson
- Division of Vascular Surgery at VCU Health, Richmond, VA
| | - Mark Levy
- Division of Vascular Surgery at VCU Health, Richmond, VA.
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2
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Patel MS. Novel Percutaneous Mechanical Thrombectomy Device for Treating Upper Extremity Deep Vein Thrombosis in Patient With Paget-Schroetter Syndrome. Vasc Endovascular Surg 2024; 58:235-239. [PMID: 37732898 DOI: 10.1177/15385744231203752] [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] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/22/2023]
Abstract
Paget-Schroetter Syndrome (PSS) is a form of upper extremity deep vein thrombosis (DVT) caused by the external compression of the subclavian vein at the thoracic outlet. Here we describe a complex PSS case in a 43-year-old female who experienced multiple recurrent DVTs and a right-sided hemothorax following two continuous aspiration thrombectomy procedures and a first rib resection. Rapid and complete symptom resolution was achieved with the InThrill Thrombectomy System (Inari Medical), a novel, thrombolytic-free, percutaneous mechanical thrombectomy device that removed all recurrent acute and subacute thrombus in a single session without significant blood loss.
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Affiliation(s)
- Mitul S Patel
- NJ Endovascular Therapeutics, Vascular Surgery, The Valley Hospital, Ridgewood, NJ, USA
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Espitia O, Tissot A, Miossec A, Pistorius MA, Richard R, Raimbeau A, Bénichou A, Espinasse B, Guédon AF. Upper extremity venous thrombosis in hospitalized patients: A prospective epidemiological study. Thromb Res 2024; 233:174-180. [PMID: 38091816 DOI: 10.1016/j.thromres.2023.11.026] [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] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2023] [Revised: 11/08/2023] [Accepted: 11/22/2023] [Indexed: 01/01/2024]
Abstract
BACKGROUND The frequency of upper extremities vein thrombosis (UEVT) is rising with the increasing use of endovenous devices. These thromboses are particularly common among hospitalized patients. The epidemiology and risk factors for UEVT are poorly understood in a hospitalized population. OBJECTIVE To assess the prevalence of UEVT in hospitalized patients and study thrombosis risk factors according to their location. METHODS Prospective evaluation of patients hospitalized in a university hospital with clinical and Doppler ultrasound (DUS) assessment of the upper extremities. RESULTS Of the 400 patients included, 91(22.8 %) had UEVT including 8 (8.8 %) proximal thrombosis, 32 (35.2 %) arm venous thrombosis and 51 (56.0 %) forearm venous thrombosis; 7 (7.7 %) patients with UEVT had a concomitant symptomatic pulmonary embolism. In this population of hospitalized patients, 40 (10 %) had proximal or arm thrombosis and 51 (12.8 %) forearm thrombosis. All patients with UEVT had a venous catheter and 63 (69.2 %) of UEVT patients had therapeutic or prophylactic anticoagulation at the time of DUS evaluation. In multivariate analysis, peripheral intravenous catheter (PIVC) OR 3.71 [1.90; 7.91] (p < 0.001); MID line OR 3.58 [1.46; 8.91] (p = 0.005) and infection disease OR 2.21 [1.26; 4386] (p = 0.005) were associated with UEVT. Central venous catheter OR 66.24 [12.64; 587.03] was associated with proximal UEVT and MID line OR 12.61 [4.64; 35.77] (p < 0.001) with arm UEVT. Forearm UEVT were associated with PIVCOR 10.71[3.14; 67.37] (p = 0.001); infectious disease OR 2.87 [1.48; 5.60] (p = 0.002), iron infusion OR 3.11 [1.23; 7.47] and hospitalization for postpartum OR 4.37 [0.97; 18.06] (p = 0.04). CONCLUSION One in 5 hospitalized patients suffers from UEVT. Proximal venous thrombosis is uncommon. The presence of a catheter and hospitalization for infection are the factors most frequently associated with UEVT.
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Affiliation(s)
- Olivier Espitia
- Nantes Université, CHU Nantes, Department of Internal and Vascular Medicine, F-44000 Nantes, France; Nantes Université, l'institut du thorax, INSERM UMR1087/CNRS UMR 6291, Team III Vascular & Pulmonary Diseases, F-44000 Nantes, France.
| | - Audry Tissot
- Nantes Université, CHU Nantes, Department of Internal and Vascular Medicine, F-44000 Nantes, France
| | - Annaïg Miossec
- Nantes Université, CHU Nantes, Department of Internal and Vascular Medicine, F-44000 Nantes, France
| | - Marc-Antoine Pistorius
- Nantes Université, CHU Nantes, Department of Internal and Vascular Medicine, F-44000 Nantes, France
| | - Rodica Richard
- Nantes Université, CHU Nantes, Department of Internal and Vascular Medicine, F-44000 Nantes, France
| | - Alizée Raimbeau
- Nantes Université, CHU Nantes, Department of Internal and Vascular Medicine, F-44000 Nantes, France
| | - Antoine Bénichou
- Nantes Université, CHU Nantes, Department of Internal and Vascular Medicine, F-44000 Nantes, France
| | - Benjamin Espinasse
- GETBO INSERM 1304 & Department of Vascular Medicine, CHU Brest, F-29000 Brest, France
| | - Alexis F Guédon
- Nantes Université, CHU Nantes, Department of Internal and Vascular Medicine, F-44000 Nantes, France
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Wang TF, Delluc A, Cervi A, Hill D, Kovacs MJ, Séguin C, Ramsay T, Carrier M. A survey of clinician perspectives on the management of catheter-related upper extremity deep vein thrombosis in patients with cancer. Thromb Res 2024; 233:10-13. [PMID: 37984078 DOI: 10.1016/j.thromres.2023.11.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2023] [Accepted: 11/13/2023] [Indexed: 11/22/2023]
Affiliation(s)
- Tzu-Fei Wang
- Department of Medicine, University of Ottawa at The Ottawa Hospital, Ottawa, Ontario, Canada; The Ottawa Hospital Research Institute, Ottawa, Ontario, Canada.
| | - Aurélien Delluc
- Department of Medicine, University of Ottawa at The Ottawa Hospital, Ottawa, Ontario, Canada; The Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
| | - Andrea Cervi
- Department of Oncology, Windsor Regional Cancer Centre, Windsor, Ontario, Canada
| | - Danny Hill
- Sault Area Hospital, Sault Saint Marie, Ontario, Canada
| | - Michael J Kovacs
- Division of Hematology, Department of Medicine, University of Western Ontario, London, Ontario, Canada
| | - Chantal Séguin
- Division of Hematology, Department of Medicine, McGill University, Montreal, Québec, Canada
| | - Tim Ramsay
- The Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
| | - Marc Carrier
- Department of Medicine, University of Ottawa at The Ottawa Hospital, Ottawa, Ontario, Canada; The Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
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Hoexum F, Hoebink M, Coveliers HME, Wisselink W, Jongkind V, Yeung KK. Management of Paget-Schroetter Syndrome: a Systematic Review and Meta-Analysis. Eur J Vasc Endovasc Surg 2023; 66:866-875. [PMID: 37678659 DOI: 10.1016/j.ejvs.2023.08.065] [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] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2022] [Revised: 08/14/2023] [Accepted: 08/29/2023] [Indexed: 09/09/2023]
Abstract
OBJECTIVE Currently, there is no consensus on the optimal management of Paget-Schroetter syndrome (PSS). The objective was to summarise the current evidence for management of PSS with explicit attention to the clinical outcomes of different management strategies. DATA SOURCES The Cochrane, PubMed, and Embase databases were searched for reports published between January 1990 and December 2021. REVIEW METHODS A systematic review and meta-analysis was conducted following PRISMA 2020 guidelines. The primary endpoint was the proportion of symptom free patients at last follow up. Secondary outcomes were success of initial treatment, recurrence of thrombosis or persistent occlusion, and patency at last follow up. Meta-analyses of the primary endpoint were performed for non-comparative and comparative reports. The quality of evidence was assessed using the GRADE approach. RESULTS Sixty reports were included (2 653 patients), with overall moderate quality. The proportions of symptom free patients in non-comparative analysis were: anticoagulation (AC), 0.54; catheter directed thrombolysis (CDT) + AC, 0.71; AC + first rib resection (FRR), 0.80; and CDT + FRR, 0.96. Pooled analysis of comparative reports confirmed the superiority of CDT + FRR compared with AC (OR 13.89, 95% CI 1.08 - 179.04; p = .040, I2 87%, very low certainty of evidence), AC + FRR (OR 2.29, 95% CI 1.21 - 4.35; p = .010, I2 0%, very low certainty of evidence), and CDT + AC (OR 8.44, 95% CI 1.12 - 59.53; p = .030, I2 63%, very low certainty of evidence). Secondary endpoints were in favour of CDT + FRR. CONCLUSION Non-operative management of PSS with AC alone results in persistent symptoms in 46% of patients, while 96% of patients managed with CDT + FFR were symptom free at end of follow up. Superiority of CDT + FRR compared with AC, CDT + AC, and AC + FRR was confirmed by meta-analysis. The overall quality of included reports was moderate, and the level of certainty was very low.
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Affiliation(s)
- Frank Hoexum
- Department of Vascular Surgery, Amsterdam Cardiovascular Sciences, Amsterdam University Medical Centres, Amsterdam, the Netherlands
| | - Max Hoebink
- Department of Vascular Surgery, Amsterdam Cardiovascular Sciences, Amsterdam University Medical Centres, Amsterdam, the Netherlands
| | | | - Willem Wisselink
- Department of Vascular Surgery, Amsterdam Cardiovascular Sciences, Amsterdam University Medical Centres, Amsterdam, the Netherlands
| | - Vincent Jongkind
- Department of Vascular Surgery, Amsterdam Cardiovascular Sciences, Amsterdam University Medical Centres, Amsterdam, the Netherlands
| | - Kak Khee Yeung
- Department of Vascular Surgery, Amsterdam Cardiovascular Sciences, Amsterdam University Medical Centres, Amsterdam, the Netherlands.
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Sen I, DeMartino R, Bjarnason H, Neisen M, Kalra M. Results of a Flexible Patient-Centered Approach to the Timing of Thoracic Outlet Decompression in Paget Schroetter Syndrome. Ann Vasc Surg 2023; 95:210-217. [PMID: 37285964 DOI: 10.1016/j.avsg.2023.05.034] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2023] [Revised: 05/21/2023] [Accepted: 05/28/2023] [Indexed: 06/09/2023]
Abstract
BACKGROUND Treatment algorithms for subclavian vein (SCV) effort thrombosis (Paget-Schroetter syndrome- PSS) are multiple, ranging from thrombolysis (TL) with immediate or delayed thoracic outlet decompression (TOD) to conservative treatment with anticoagulation alone. We follow a regimen of TL/pharmacomechanical thrombectomy (PMT) followed by TOD with first rib resection, scalenectomy, venolysis, and selective venoplasty (open or endovascular) performed electively at a time convenient for the patient. Oral anticoagulants are prescribed for 3 months or longer based upon response. The aim of this study was to evaluate outcomes of this flexible protocol. METHODS Clinical and procedural details of consecutive patients treated for PSS from January 2001 to August 2016 were retrospectively reviewed. Endpoints included success of TL and eventual clinical outcome. Patients were divided into 2 groups-Group I: TL/PMT + TOD; Group II: medical management/anticoagulation + TOD. RESULTS PSS was diagnosed in 114 patients; 104 (62 female, mean age 31 years) who underwent TOD were included in the study. Group I: 53 patients underwent TOD after initial TL/PMT (23 at our institution and 30 elsewhere) with success (acute thrombus resolution) in 80% (n = 20) and 72% (n = 24) respectively. Adjunctive balloon-catheter venoplasty was performed in 67%. TL failed to recanalize the occluded SCV in 11% (n = 6). Complete thrombus resolution was seen in 9% (n = 5). Residual chronic thrombus in 79% (n = 42) resulted in median SCV stenosis of 50% (range 10% to 80%). With continued anticoagulation, further thrombus retraction was noted with median 40% improvement in stenosis including in veins with unsuccessful TL. TOD was performed at a median of 1.5 months (range 2-8 months). Rethrombosis of the SCV occurred in 3 patients 1-3 days postoperatively and was managed with MT/SCV stenting/balloon angioplasty and anticoagulation. Symptomatic relief was achieved in 49/53 (92%) patients at a median follow-up of 14 months. Group II: 51 patients underwent TOD following medical treatment elsewhere with anticoagulation alone for an average 6 months (range 2-18 months) with recurrent SCV thrombosis in 5 (11%). Thirty-nine patients (76%) had persistent symptoms; the remaining had asymptomatic compression of the SCV with maneuvers. SCV occlusion persisted in 4 patients (7%); the indication for TOD being residual symptoms from compression of collateral veins, the median residual stenosis was 70% (range 30-90%). TOD was performed at a median of 6 months after diagnosis of PSS. Open venous reconstruction with endovenectomy and patch was performed in 4 patients and stenting in 2. Symptomatic relief was achieved in 46/51 (90%) at a median follow-up of 24 months. CONCLUSIONS For Paget Schroetter syndrome a management protocol encompassing elective thoracic outlet decompression at a convenient time following thrombolysis is safe and effective, with low risk of rethrombosis. Continued anticoagulation in the interim results in further recanalization of the subclavian vein and may reduce the need for open venous reconstruction.
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Affiliation(s)
- Indrani Sen
- Vascular and Endovascular Surgery, Mayo Clinic Health Systems, EauClaire, WI.
| | - Randall DeMartino
- Division of Vascular and Endovascular Surgery, Mayo Clinic, Rochester, MN
| | - Haraldur Bjarnason
- Division of Vascular and Endovascular Surgery, Mayo Clinic, Rochester, MN
| | - Melissa Neisen
- Division of Vascular and Endovascular Surgery, Mayo Clinic, Rochester, MN
| | - Manju Kalra
- Division of Vascular and Endovascular Surgery, Mayo Clinic, Rochester, MN
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Jenab Y, Tofighi S, Ayati A, Rezvanimehr A, Moosavi NS, Jalaie H, Barbati ME. Single-center experience with catheter-directed thrombolysis and balloon angioplasty for acute upper-extremity deep vein thrombosis: a case series study. BMC Cardiovasc Disord 2023; 23:351. [PMID: 37460994 DOI: 10.1186/s12872-023-03389-3] [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] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2023] [Accepted: 07/11/2023] [Indexed: 07/20/2023] Open
Abstract
BACKGROUND Effective treatment of upper extremity deep vein thrombosis (UEDVT) is crucial to prevent further complications. Various treatments, including percutaneous mechanical thrombectomy (PMT), catheter-directed thrombolysis (CDT), decompression surgery, and venoplasty are suggested for UEDVT. However, no prospective study has yet favored any of these treatments. This study presents a review of our experience with CDT followed by balloon venoplasty in patients with acute primary UEDVT. METHODS We enrolled all patients diagnosed with acute UEDVT from January 2020 to June 2021. Subjects with UEDVT due to secondary causes like malignancies, indwelling catheters, or leads were excluded. CDT was performed through brachial vein access, using a perfusion catheter, and rt-PA administration. Balloon venoplasty was performed if the treated segment had remaining stenosis after CDT. Patients were followed up at the vein clinic for any signs and symptoms in the upper extremity and lifestyle changes. Follow-up ultrasonography was done 12 months after discharge. RESULTS Twelve patients with a mean age of 41.08 ± 14.0 years were included in the study. The mean duration of CDT was 25.00 ± 10.56 h. After CDT, all patients had remaining occlusions, with seven having more than 50% remaining stenosis. However, after balloon venoplasty, no patient had significant (more than 50%) stenosis. There was no serious complication after both procedures. Patients were followed up for a mean duration of twelve months after their admission, with a mean time of maintenance anticoagulation was 10.73 ± 5.77 months. Only one patient had recurrent symptoms in his target limb which required a decompression surgery, while the rest were free of symptoms in their treated extremity. No subject developed pulmonary emboli (PE) during admission or the follow-up period. There was no evidence of hospital readmission for any reason. Upper extremity color-doppler sonography of the patients at twelve months after their procedure showed normal venous flow without any significant stenosis in 8 (66.7%), and partially normal flow with patent target vein in 4 (33.3%) patients. CONCLUSIONS CDT followed by balloon venoplasty may be an effective treatment for selected patients with acute primary UEDVT, providing desirable long-term results and potentially avoiding the need for decompression surgery in the short or long term.
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Affiliation(s)
- Yaser Jenab
- Cardiovascular Diseases Research Institute, Tehran Heart Center, Tehran University of Medical Sciences, Tehran, Iran
| | - Saeed Tofighi
- Cardiovascular Diseases Research Institute, Tehran Heart Center, Tehran University of Medical Sciences, Tehran, Iran.
| | - Aryan Ayati
- Cardiovascular Diseases Research Institute, Tehran Heart Center, Tehran University of Medical Sciences, Tehran, Iran
| | - Ali Rezvanimehr
- Faculty of Medicine, Tehran Medical Sciences Branch, Islamic Azad University, Tehran, Iran
| | - Najme-Sadat Moosavi
- Cardiovascular Diseases Research Institute, Tehran Heart Center, Tehran University of Medical Sciences, Tehran, Iran
| | - Houman Jalaie
- Department of Vascular and Endovascular Surgery, University Hospital Aachen, Aachen, Germany
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de Kleijn RJCMF, Schropp L, van Hattum ES, Ünlu Ç, Middeldorp S, Nijkeuter M, Westerink J, Petri B, de Borst GJ. Post-thrombotic syndrome after upper extremity deep vein thrombosis: An international Delphi consensus study. J Thromb Haemost 2022; 20:1880-1886. [PMID: 35608971 PMCID: PMC9545993 DOI: 10.1111/jth.15767] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2022] [Revised: 04/19/2022] [Accepted: 05/12/2022] [Indexed: 12/03/2022]
Abstract
OBJECTIVES Primary deep vein thrombosis of the upper extremity (UEDVT) is a rare condition but up to 60% of patients may develop post-thrombotic syndrome in the upper extremity (UE-PTS) with significant morbidity and decreased quality of life. However, there is no universally accepted method to diagnose and classify UE-PTS, hampering scientific research on UEDVT treatment. Through this international Delphi consensus study we aimed to determine what a clinical score for diagnosing UE-PTS should entail. METHODS An online focus group survey among 20 patients treated for UEDVT was performed to provide clinical parameters before the start of a four round electronic Delphi consensus study among 25 international experts. The CREDES recommendations on Conducting and Reporting Delphi Studies were applied. Open text questions, multiple selection questions, and 9-point Likert scales were used. Consensus was set at 70% agreement. RESULTS After four rounds, agreement was reached on a composite score of five symptoms and three clinical signs, combined with a functional disability score. The signs and symptom will each be scored on a severity scale of 0-3 and the total score expressed as an ordinal variable; no/mild/moderate/or severe PTS. The functional disability portion measures the impact of the signs and symptoms on the functionality of the patient's arm. CONCLUSION Consensus was reached on a composite score of signs and symptoms of UE-PTS combined with a functional disability score. Clinical validation of the UE-PTS score in a large patient cohort is mandatory to facilitate application in future research.
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Affiliation(s)
| | - Ludo Schropp
- Department of Vascular SurgeryUniversity Medical Center UtrechtUtrechtThe Netherlands
| | - Eline S. van Hattum
- Department of Vascular SurgeryUniversity Medical Center UtrechtUtrechtThe Netherlands
| | - Çagdas Ünlu
- Department of Vascular SurgeryNoordwest‐ZiekenhuisgroepAlkmaarThe Netherlands
| | - Saskia Middeldorp
- Department of Internal Medicine & Radboud Institute of Health Sciences (RIHS)Radboud University Medical CenterNijmegenThe Netherlands
| | - Mathilde Nijkeuter
- Department of Internal MedicineUniversity Medical Center UtrechtUtrechtThe Netherlands
| | - Jan Westerink
- Department of Vascular MedicineUniversity Medical Center UtrechtUtrechtThe Netherlands
| | - Bart‐Jeroen Petri
- Department of Vascular SurgeryUniversity Medical Center UtrechtUtrechtThe Netherlands
| | - Gert J. de Borst
- Department of Vascular SurgeryUniversity Medical Center UtrechtUtrechtThe Netherlands
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9
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Ramadan SM, Kasfiki EV, Kelly C, Ali I. Primary upper extremity deep vein thrombosis (effort thrombosis). Acute Med 2021; 20:151-153. [PMID: 34190744] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/13/2023]
Abstract
Primary spontaneous upper extremity deep vein thrombosis is characterised by thrombosis within deep veins draining the upper extremity due to anatomical abnormalities of the thoracic outlet causing axillosubclavian compression and subsequent thrombosis. It is an uncommon condition that typically presents with unilateral arm swelling in a young male following vigorous upper extremity activity. The diagnosis of this condition is usually made by Doppler ultrasound, but other investigations are mandatory to exclude the secondary causes of upper extremity DVT. Different treatment options are available including anticoagulation, thrombolysis, and surgery. We report the case of a young healthy male with athletic physique who presented with pain and swelling of his dominant arm after weightlifting in the gym.
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Affiliation(s)
- S M Ramadan
- SpR Acute Internal Medicine & General Internal Medicine Hull University Teaching Hospitals NHS Trust
| | - E V Kasfiki
- Consultant Acute Medicine, Deputy Director of Clinical Simulation Hull University Teaching Hospitals NHS Trust
| | - Cwp Kelly
- General Practitioner The Old Fire Station Surgery, Beverley
| | - I Ali
- Consultant and Clinical Lead in Acute Medicine, Hull University Teaching Hospitals NHS Trust
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Tanabe H, Miyamori D, Shigenobu Y, Ito Y, Kametani T, Kakimoto M, Kawahara A, Kikuchi Y, Kobayashi T, Otani Y, Kishikawa N, Kanno K, Ito M. Two Patients with Paget-Schroetter Syndrome That Were Successfully Diagnosed by Doppler Ultrasonography: Case Studies with a Literature Review. Intern Med 2020; 59:2623-2627. [PMID: 32581157 PMCID: PMC7662054 DOI: 10.2169/internalmedicine.4349-20] [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] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/05/2022] Open
Abstract
We herein report on two male patients (age, 22 and 44 years) who were referred to our department with swelling of the upper right arm after attending other hospitals. Right subclavian vein thrombosis was demonstrated by ultrasonography and they were then further evaluated by contrast-enhanced computed tomography (CT). Successful treatment involved venous thrombectomy in one patient and anticoagulant therapy in the other. Paget-Schhroetter syndrome was confirmed using standard vascular ultrasonography. Despite the accuracy of this method for diagnosing Paget-Schroetter syndrome, some cases are difficult to confirm. We reviewed 29 previously published case reports of Paget-Schroetter syndrome and analyzed the patient baseline characteristics, time to diagnosis, and the diagnostic methods used.
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Affiliation(s)
- Hiromasa Tanabe
- Department of General Internal Medicine, Hiroshima University Hospital, Japan
| | - Daisuke Miyamori
- Department of General Internal Medicine, Hiroshima University Hospital, Japan
| | - Yuya Shigenobu
- Department of General Internal Medicine, Hiroshima University Hospital, Japan
| | - Yayoiko Ito
- Department of General Internal Medicine, Hiroshima University Hospital, Japan
| | - Takahiro Kametani
- Department of General Internal Medicine, Hiroshima University Hospital, Japan
| | - Masaki Kakimoto
- Department of General Internal Medicine, Hiroshima University Hospital, Japan
| | - Akihiro Kawahara
- Department of General Internal Medicine, Hiroshima University Hospital, Japan
| | - Yuka Kikuchi
- Department of General Internal Medicine, Hiroshima University Hospital, Japan
| | - Tomoki Kobayashi
- Department of General Internal Medicine, Hiroshima University Hospital, Japan
| | - Yuichiro Otani
- Department of General Internal Medicine, Hiroshima University Hospital, Japan
| | - Nobusuke Kishikawa
- Department of General Internal Medicine, Hiroshima University Hospital, Japan
| | - Keishi Kanno
- Department of General Internal Medicine, Hiroshima University Hospital, Japan
| | - Masanori Ito
- Department of General Internal Medicine, Hiroshima University Hospital, Japan
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Chi WK, Tan GM, Yan BP. Urschel's Sign in Paget-Schroetter Syndrome: Multimodality Evaluation by Extravascular and Intravascular Imaging. J Invasive Cardiol 2020; 32:E47-E48. [PMID: 32005794] [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] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/10/2023]
Abstract
Paget-Schroetter Syndrome is potentially life-threatening. In this case, multidisciplinary imaging with extravascular and intravascular evaluation guided the proper diagnosis and treatment planning.
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Affiliation(s)
- Wai Kin Chi
- Division of Cardiology, Department of Medicine and Therapeutics, The Chinese University of Hong Kong, 9/F Clinical Science Building, Prince of Wales Hospital, 30-32 Ngan Shing Street, Shatin, NT, Hong Kong SAR, China.
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Affiliation(s)
- Heather Alva
- 1 Tulane/Ochsner Pediatric Residency, New Orleans, LA, USA
| | | | - Matthew Fletcher
- 3 Ochsner Health Center for Children, New Orleans, LA, USA
- 4 Ochsner Medical Center, New Orleans, LA, USA
| | - Raj Warrier
- 3 Ochsner Health Center for Children, New Orleans, LA, USA
- 4 Ochsner Medical Center, New Orleans, LA, USA
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Umana E, Elsherif M, Binchy J. A Case of Paget-Schroetter Syndrome in a Young Male After Lifting Weights. Ir Med J 2019; 112:873. [PMID: 30892006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/09/2023]
Abstract
Paget-Schroetter Syndrome (PSS) or effort thrombosis of the axillary-subclavian venous axis is a rare disease affecting healthy young adults which requires a high index of suspicion to diagnose. Management often requires not only anticoagulation but also thrombolysis with first rib resection to prevent recurrence and complications. We present a case of a 31-year-old male who presented to our emergency department with pain and swelling of his left upper limb. He was diagnosed with PSS and underwent; anticoagulation, catheter directed thrombolysis and planned for first rib resection.
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Affiliation(s)
- E Umana
- Emergency Department, University Hospital Galway, Ireland
| | - M Elsherif
- Vascular Surgery Department, University Hospital Galway, Ireland
| | - J Binchy
- Emergency Department, University Hospital Galway, Ireland
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Abstract
RATIONALE Thoracic outlet syndrome (TOS) is a rare cause of upper extremity deep vein thrombosis (UEDVT). The treatment usually involves catheter directed thrombolysis followed by systemic anticoagulation. Surgical decompression is frequently recommended after anticoagulation for definitive therapy. PATIENT CONCERNS We report two cases of UEDVT secondary to venous TOS with important clinical presentations. DIAGNOSES Venous TOS. INTERVENTIONS One patient was initially treated conservatively but had a recurrent UEDVT. The second patient had a residual stump from a prior rib resection that was causing compression on the subclavian vein, resulting in recurrent venous symptoms. OUTCOMES Both patients achieved significant improvement in their symptoms at 1 year follow-up. LESSONS UEDVTs can be debilitating, and may limit activities of daily living. Surgical decompression may offer significant improvement in quality of life and symptom relief in such patients.
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Affiliation(s)
- Muharrem Yunce
- Department of Medicine, MedStar Franklin Square Medical Center
| | - Ashwyn Sharma
- Department of Vascular Surgery and Endovascular Therapy
| | - Evan Braunstein
- Department of Medicine Hematology Division, The Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Michael B. Streiff
- Department of Medicine Hematology Division, The Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Ying Wei Lum
- Department of Vascular Surgery and Endovascular Therapy
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15
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Mustafa J, Asher I, Sthoeger Z. Upper Extremity Deep Vein Thrombosis: Symptoms, Diagnosis, and Treatment. Isr Med Assoc J 2018; 20:53-57. [PMID: 29658209] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/08/2023]
Abstract
Upper extremity deep vein thrombosis (UEDVT) is defined as thrombosis of the deep venous system (subclavian, axillary, brachial, ulnar, and radial veins), which drains the upper extremities. It can be caused by thoracic outlet anatomic obstruction, such as Paget-Schroetter syndrome, (primary) or by central intravenous catheters (secondary). UEDVT may be asymptomatic or present with acute severe pain and arm swelling. Clinical suspicion should be confirmed by diagnostic imaging procedures such as duplex ultrasound, computed tomography scan, or magnetic resonance imaging. UEDVT is managed by anticoagulant treatment. In addition to that, early thrombolysis aimed at preventing post-deep vein thrombosis syndrome and thoracic outlet decompression surgery should be given to patients with primary UEDVT. Anticoagulation without thrombolysis is the treatment of choice for patients with catheter-related thrombosis. Mandatory functioning catheters can remain in place with anticoagulant treatment. All other catheters should be immediately removed. The management of patients with UEDVT requires an experience multidisciplinary team comprised of internists, radiologists, hematologists, and vascular surgeons. Understanding the risk factors for the development of UEDVT, the diagnostic procedures, and the treatment modalities will improve the outcome of those patients.
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Affiliation(s)
- Jaber Mustafa
- Department of Internal Medicine B, Kaplan Medical Center, Rehovot, affiliated with Hebrew University-Hadassah Medical School, Jerusalem, Israel
| | - Ilan Asher
- Department of Internal Medicine B, Kaplan Medical Center, Rehovot, affiliated with Hebrew University-Hadassah Medical School, Jerusalem, Israel
| | - Zev Sthoeger
- Department of Internal Medicine B, Kaplan Medical Center, Rehovot, affiliated with Hebrew University-Hadassah Medical School, Jerusalem, Israel
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Abstract
INTRODUCTION Peripherally inserted central venous catheters (PICC) are widely used in cancer patients and ultrasound-guided PICC insertion could improve success rate. The tip position of the catheter should be located at the border of lower one-third of the superior vena cava (SVC) and cavo-atrial junction. The migration is malposition at the late stage after PICCs were inserted, and catheter malposition was associated with thrombosis and other complications.After patient's informed consent, we report a case of a 66-year-old male with twice catheter migrations resulting in thrombosis after being diagnosed with cardiac cancer. CONCLUSION The correct position of the catheter tip can ensure the normal use of PICC and reduce the complications. For the migrated catheter, it should be removed as soon as possible, and when thrombosis has been developed, standard anticoagulant therapy should be given.
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17
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Lipe DN. Young Woman With a Blue, Painful and Swollen Arm. Ann Emerg Med 2017; 70:922-936. [PMID: 29157693 DOI: 10.1016/j.annemergmed.2017.06.018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2017] [Indexed: 11/18/2022]
Affiliation(s)
- Demis N Lipe
- Martin Army Community Hospital, Fort Benning, GA
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18
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Noyes AM, Dickey J. The Arm is Not the Leg: Pathophysiology, Diagnosis, and Management of Upper Extremity Deep Vein Thrombosis. R I Med J (2013) 2017; 100:33-36. [PMID: 28459919] [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] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/07/2023]
Abstract
Upper extremity deep venous thrombosis (UEDVT) involves thrombosis of the deep veins of the arm as they enter the thorax. They are increasing in frequency, largely due to the rising use of central venous catheters and implantable cardiac devices, and represent more than 10% of all DVT cases, Upper extremity deep venous thrombosis has been historically misunderstood when compared to lower extremity deep vein thrombosis (LEDVT). Their associated disease states may carry devastating complications, with mortality rates often higher than that of LEDVT. Thus, education on recognition, classification and management is critical to avoid long-term sequelae and mortality from UEDVT. [Full article available at http://rimed.org/rimedicaljournal-2017-05.asp].
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Affiliation(s)
- Adam M Noyes
- Department of Medicine, Division of Cardiology, Warren Alpert Medical School of Brown University, Providence, RI
| | - John Dickey
- Department of Medicine, Division of Cardiology, Warren Alpert Medical School of Brown University, Providence, RI
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19
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Pais C, Ferreira J, Sousa P. Paget-Schröetter Syndrome, a rare cause of subclavian vein thrombosis. Rev Port Cir Cardiotorac Vasc 2017; 24:67-70. [PMID: 29898300] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Received: 06/18/2017] [Indexed: 06/08/2023]
Abstract
Paget-Schröetter Syndrome, or effort thrombosis of the subclavian vein, is an uncommon condition that affects young, active, healthy individuals. It's a type of Thoracic Outlet Syndrome (TOS), consequence of compression and repetitive injury of the subclavian vein, between the first rib and the clavicle. This paper reports the case of a 27 year-old female presenting with an acutely swollen right upper limb, with no history of trauma or repeated movement of right arm, taking oral contraceptive pills and no history of venous thromboembolic disease. Duplex ultrasound evaluation confirmed right subclavian venous thrombosis with no evidence of cervical rib or other structural abnormalities, diagnosing Paget-Schröetter Syndrome. Following anticoagulation, catheter directed thrombolysis and balloon angioplasty were performed, with no success due to external compression. Therefore, after the correction of the external compression through first rib resection, the luminal flow was restored and the venous obstruction symptoms disappeared. In these case, a prompt treatment was critical for the achievement of the best results.
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Affiliation(s)
- Carmen Pais
- Department of Internal Medicine, Centro Hospitalar de Trás-os-Montes e Alto Douro, Portugal
| | - Joana Ferreira
- Department of Vascular Surgery, Centro Hospital do Alto Ave, Hospital da Senhora da Oliveira Guimarães, Portugal
| | - Pedro Sousa
- Department of Radiology, Centro Hospitalar de Trás-os-Montes e Alto Douro, Portugal
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Abstract
To identify patient-related risk factors for venous thrombosis in patients with central venous catheters (CVC) or peripherally inserted central catheters (PICC). We performed a systematic review of the literature assessing patient-related risk factors for thrombosis related to CVC or PICC. The databases PubMed, Ovid and the Cochrane library were searched for observational studies pertaining to patient-related risk factors for CVC and PICC-related thrombosis. The initial search through PubMed, Ovid and the Cochrane library yielded 516 results. After 71 duplicates were removed, 445 articles were assessed for eligibility based on title and abstract. Four hundred and eleven articles were then excluded and 33 full text articles were manually assessed for eligibility. Eight articles were eliminated as they did not contain content relevant to the review. Twenty-five studies were then selected to assess 20 risk factors. There were no consistent significant associations for catheter-related thrombosis across the twenty-five studies. Multiple studies identified age, malignancy, diabetes, obesity, chemotherapy, thrombophilia and a history of thrombosis as significant risk factors for catheter-related thrombosis. Inconsistent findings among studies make it difficult to establish which patient-related risk factors are associated with catheter-related thrombosis. Future studies could include larger sample sizes and more cases of catheter-related thrombosis to produce more significant results. Identification of patient-related risk factors could lead to early recognition of upper limb deep vein thrombosis in patients with catheters, thereby preventing complications.
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Affiliation(s)
- Amy Leung
- School of Medicine and Dentistry, James Cook University, Mackay Base Hospital, 475 Bridge Road, Mackay, QLD, 4650, Australia,
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21
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Bleker SM, van Es N, Kleinjan A, Büller HR, Kamphuisen PW, Aggarwal A, Beyer-Westendorf J, Camporese G, Cosmi B, Gary T, Ghirarduzzi A, Kaasjager K, Lerede T, Marschang P, Meijer K, Otten HM, Porreca E, Righini M, Verhamme P, van Wissen S, Di Nisio M. Current management strategies and long-term clinical outcomes of upper extremity venous thrombosis. J Thromb Haemost 2016; 14:973-81. [PMID: 26866515 DOI: 10.1111/jth.13291] [Citation(s) in RCA: 34] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2015] [Accepted: 02/04/2016] [Indexed: 01/17/2023]
Abstract
UNLABELLED Essentials Few data exist on outcome of upper extremity deep and superficial vein thrombosis (UEDVT and UESVT). We followed 102 and 55 patients with UEDVT or UESVT, respectively, for a median of 3.5 years. Risk of recurrent venous thromboembolism was low in both diseases, and the mortality high. Postthrombotic symptoms were infrequent and cancer patients had a higher risk of recurrent VTE. SUMMARY Background There is scant information on the optimal management and clinical outcome of deep and superficial vein thrombosis of the upper extremity (UEDVT and UESVT). Objectives To explore treatment strategies and the incidence of recurrent venous thromboembolism (VTE), mortality, postthrombotic symptoms, and bleeding in patients with UEDVT and UESVT and to assess the prognosis of cancer patients with UEDVT. Patients/methods Follow-up of patients with UEDVT or UESVT, who were enrolled previously in a diagnostic management study. Results We followed 102 and 55 patients with UEDVT and UESVT, respectively, both for a median of 3.5 years. Anticoagulant treatment was started in 100 patients with UEDVT (98%) and in 40 (73%) with UESVT. Nine patients with UEDVT (9%) developed recurrent VTE, 26 (26%) died, 6 (8%) of 72 patients had moderate postthrombotic symptoms, and 5 (5%) experienced major bleeding. One patient with UESVT had a recurrent VTE, 18 (33%) died, none had moderate postthrombotic symptoms, and none had major bleeding. Of the cancer patients with UEDVT, 18% had recurrent VTE vs. 7.5% in non-cancer patients (adjusted hazard ratio 2.2, 95%CI 0.6-8.2). The survival rate was 50% in cancer patients with UEDVT vs. 60% in those without (adjusted HR 0.8, 95%CI 0.4-1.4). Conclusions The risk of recurrent VTE was low in patients with UEDVT, and negligible for UESVT. Mortality was high for both diseases. Postthrombotic symptoms were infrequent and mild. Anticoagulant therapy of UEDVT carried a substantial risk of major bleeding. Cancer patients had a significant risk of recurrent VTE.
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Affiliation(s)
- S M Bleker
- Department of Vascular Medicine, Academic Medical Center, Amsterdam, the Netherlands
| | - N van Es
- Department of Vascular Medicine, Academic Medical Center, Amsterdam, the Netherlands
| | - A Kleinjan
- Department of Vascular Medicine, Academic Medical Center, Amsterdam, the Netherlands
| | - H R Büller
- Department of Vascular Medicine, Academic Medical Center, Amsterdam, the Netherlands
| | - P W Kamphuisen
- University of Groningen, University Medical Center Groningen, Groningen, the Netherlands
| | - A Aggarwal
- Veterans Affairs Medical Center, George Washington University, Washington, DC, USA
| | - J Beyer-Westendorf
- Division 'Thrombosis Research' and Division 'Angiology', Dresden University Clinic, Dresden, Germany
| | - G Camporese
- University Hospital of Padova, Padova, Italy
| | - B Cosmi
- University of Bologna, Bologna, Italy
| | - T Gary
- Abteilung für Angiologie, Medical University, Graz, Austria
| | - A Ghirarduzzi
- Department of Internal Medicine, Company-Institute for Hospitalization and Care Scientific - Arcispedale Santa Maria Nova, Reggio Emilia, Italy
| | - K Kaasjager
- University Medical Center Utrecht, Utrecht, the Netherlands
| | - T Lerede
- USC Immunoematologia e Medicina Transfusionale, Emostasi e Trombosi, Azienda Ospedaliera Papa Giovanni XXIII, Bergamo, Italy
| | - P Marschang
- Department of Internal Medicine, Medical University of Innsbruck, Innsbruck, Austria
| | - K Meijer
- University of Groningen, University Medical Center Groningen, Groningen, the Netherlands
| | - H-M Otten
- Slotervaart Hospital, Amsterdam, the Netherlands
| | - E Porreca
- Dipartimento di Medicina e Scienze dell'Invecchiamento, Università 'G. D'Annunzio', Chieti, Italy
| | - M Righini
- Geneva University Hospital, Geneva, Switzerland
| | - P Verhamme
- Centre for Molecular and Vascular Biology, University Hospital Leuven, Leuven, Belgium
| | - S van Wissen
- Onze Lieve Vrouwe Gasthuis, Amsterdam, the Netherlands
| | - M Di Nisio
- Department of Vascular Medicine, Academic Medical Center, Amsterdam, the Netherlands
- Dipartimento di Medicina e Scienze dell'Invecchiamento, Università 'G. D'Annunzio', Chieti, Italy
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22
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Lum YW. Diagnosis and treatment of upper extremity deep vein thrombosis and thoracic outlet syndrome. Clin Adv Hematol Oncol 2016; 14:162-164. [PMID: 27058028] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/05/2023]
Affiliation(s)
- Ying-Wei Lum
- Johns Hopkins Medicine Heart & Vascular Institute, Baltimore, Maryland
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23
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Goss SG, Alcantara SD, Todd GJ, Lantis JC. Non-Operative Management of Paget-Schroetter Syndrome: A Single-Center Experience. J Invasive Cardiol 2015; 27:423-428. [PMID: 26332877] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/05/2023]
Abstract
OBJECTIVE The preponderance of existing literature for the treatment of Paget-Schroetter syndrome (PSS) advocates clot lysis followed by thoracic outlet decompression (TOD). We postulate that long-term anticoagulation has equal outcomes to more invasive and costly surgical intervention, and review our experience with non-operative management of PSS. METHODS A retrospective review was conducted, examining patients between 1994-2014. Forty patients were identified with PSS, and 27 of these patients had sufficient follow-up for this analysis. Charts were reviewed for details of clinical presentation, disease course, interventions, duration of oral anticoagulation, ultrasound reports, and symptoms at long-term follow-up. RESULTS With a mean follow-up of 54.3 months, 23/27 patients (85%) were asymptomatic after non-operative therapy. In this cohort, 16/27 patients (59%) underwent catheter-directed thrombolysis. Average treatment course with oral anticoagulation was 8.6 months. Four patients (15%) remained symptomatic at follow-up. Two patients (7%) underwent thoracic outlet decompression at another institution, with good results. At least partial recanalization of vessels was documented in 25/27 patients (93%), although recanalization did not correlate with symptoms at long-term follow-up. CONCLUSIONS Based upon equivalent functional results, non-operative management appears to offer similar outcomes for some patients with PSS. We propose a patient-tailored approach to the treatment of PSS, in which patients presenting acutely undergo catheter-directed thrombolysis, followed by a 6-12 month course of oral anticoagulation. Persistent symptoms, recurrent disease, lengthy duration of symptoms prior to diagnosis, and identifiable structural abnormalities may be factors predictive of poor outcomes after non-operative intervention.
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Affiliation(s)
| | | | | | - John C Lantis
- Dept of Vascular Surgery, St. Luke's-Roosevelt Hospital Center, 1090 Amsterdam Avenue, Suite 7A, New York, NY 10025 USA.
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24
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Rosa-Salazar V, Trujillo-Santos J, Díaz Peromingo JA, Apollonio A, Sanz O, Malý R, Muñoz-Rodriguez FJ, Serrano JC, Soler S, Monreal M. A prognostic score to identify low-risk outpatients with acute deep vein thrombosis in the upper extremity. J Thromb Haemost 2015; 13:1274-8. [PMID: 25980766 DOI: 10.1111/jth.13008] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2015] [Accepted: 04/26/2015] [Indexed: 11/30/2022]
Abstract
BACKGROUND No studies have identified which patients with upper-extremity deep vein thrombosis (DVT) are at low risk for adverse events within the first week of therapy. METHODS We used data from Registro Informatizado de la Enfermedad TromboEmbólica to explore in patients with upper-extremity DVT a prognostic score that correctly identified patients with lower limb DVT at low risk for pulmonary embolism, major bleeding, or death within the first week. RESULTS As of December 2014, 1135 outpatients with upper-extremity DVT were recruited. Of these, 515 (45%) were treated at home. During the first week, three patients (0.26%) experienced pulmonary embolism, two (0.18%) had major bleeding, and four (0.35%) died. We assigned 1 point to patients with chronic heart failure, creatinine clearance levels 30-60 mL min(-1) , recent bleeding, abnormal platelet count, recent immobility, or cancer without metastases; 2 points to those with metastatic cancer; and 3 points to those with creatinine clearance levels < 30 mL min(-1) . Overall, 759 (67%) patients scored ≤ 1 point and were considered to be at low risk. The rate of the composite outcome within the first week was 0.26% (95% confidence interval [CI] 0.004-0.87) in patients at low risk and 1.86% (95% CI 0.81-3.68) in the remaining patients. C-statistics was 0.73 (95% CI 0.57-0.88). Net reclassification improvement was 22%, and integrated discrimination improvement was 0.0055. CONCLUSIONS Using six easily available variables, we identified outpatients with upper-extremity DVT at low risk for adverse events within the first week. These data may help to safely treat more patients at home.
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Affiliation(s)
- V Rosa-Salazar
- Department of Internal Medicine, Hospital Clínico Universitario Virgen de la Arrixaca, Murcia, Spain
| | - J Trujillo-Santos
- Department of Internal Medicine, Hospital General Universitario Santa Lucía, Murcia, Spain
| | - J A Díaz Peromingo
- Department of Internal Medicine, Hospital Clínico Universitario de Santiago, Santiago de Compostela, Spain
| | - A Apollonio
- Department of Angiology, Ospedale Belcolle di Viterbo, Viterbo, Lazio, Italy
| | - O Sanz
- Department of Internal Medicine, Hospital Universitario de Gran Canaria Dr. Negrín, Las Palmas, Spain
| | - R Malý
- Department of Cardiovascular Medicine I, Charles University in Prague, Faculty of Medicine in Hradec Kralove, University Hospital Hradec Kralove, Hradec Kralove, Czech Republic
| | - F J Muñoz-Rodriguez
- Department of Internal Medicine, Fundación Privada Hospital de Mollet, Mollet del Vallés, Spain
| | - J C Serrano
- Department of Internal Medicine and Oncology Haematology, Hospital Dr. Patrocinio Peñuela Ruíz, Tachira, Venezuela
| | - S Soler
- Department of Internal Medicine, Hospital d'Olot I Comarcal de la Garrotxa, Garrotxa, Spain
| | - M Monreal
- Department of Internal Medicine, Hospital Universitari Germans Trias i Pujol, Universidad Católica de Murcia, Murcia, Spain
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Robert-Ebadi H, Becker F, Righini M. [Upper extremity deep vein thrombosis: a particular form of venous thromboembolism]. Rev Med Suisse 2015; 11:342-347. [PMID: 25854043] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/04/2023]
Abstract
The incidence of upper extremity deep vein thrombosis (UEDVT) is constantly increasing due to frequent insertion of intravenous devices for various indications. Secondary UEDVT represent more than two thirds of cases. Primary UEDVT generally include UEDVT occurring without any triggering factor and UEDVT following intense or repeated efforts or in association with the thoracic outlet syndrome, with a causative link that may be sometimes very difficult to ascertain. As opposed to lower extremity DVT, data remain very scarce and of limited quality in this setting. Diagnosis is mainly based on clinical probability assessment associated with D-dimer measurement and compression ultrasound as first-line imaging. Treatment still consists of therapeutic anticoagulation in the vast majority of cases.
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26
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De Caridi G, Massara M, Greco M, Villari S, Squillaci D, Spinelli F. Hybrid management of Paget-Schroetter syndrome due to thoracic outlet syndrome. Gen Thorac Cardiovasc Surg 2014; 64:109-12. [PMID: 25005008 DOI: 10.1007/s11748-014-0445-3] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2014] [Accepted: 06/20/2014] [Indexed: 11/28/2022]
Abstract
Paget-Schroetter syndrome due to thoracic outlet syndrome is a rare but potentially disabling condition that generally affects young patients otherwise healthy. The prompt diagnosis and treatment of Paget-Schroetter syndrome is necessary to avoid major morbidity and long-term disability. The more modern treatment paradigm reported in the current literature consists of hybrid procedures with surgical decompression of the thoracic outlet and endovascular techniques to potentially improve long-term vein patency. However, there seems to be no consensus in the literature with regard to the timing and precise nature of active management, and there is presently no agreed protocol for the optimum management of Paget-Schroetter syndrome. Controversy exists partly because no randomised controlled studies are present in literature. We present a case of Paget-Schroetter syndrome due to thoracic outlet syndrome in a young male patient submitted to a multimodal procedure.
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Affiliation(s)
- Giovanni De Caridi
- Cardiovascular and Thoracic Department, University of Messina, Messina, Italy.
- , Via Marina Arenile 57/a, 89135, Reggio Calabria, Italy.
| | - Mafalda Massara
- Cardiovascular and Thoracic Department, University of Messina, Messina, Italy
| | - Michele Greco
- Cardiovascular and Thoracic Department, University of Messina, Messina, Italy
| | - Simona Villari
- Cardiovascular and Thoracic Department, University of Messina, Messina, Italy
| | - Domenico Squillaci
- Cardiovascular and Thoracic Department, University of Messina, Messina, Italy
| | - Francesco Spinelli
- Cardiovascular and Thoracic Department, University of Messina, Messina, Italy
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27
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Zwicker JI, Connolly G, Carrier M, Kamphuisen PW, Lee AYY. Catheter-associated deep vein thrombosis of the upper extremity in cancer patients: guidance from the SSC of the ISTH. J Thromb Haemost 2014; 12:796-800. [PMID: 24548519 DOI: 10.1111/jth.12527] [Citation(s) in RCA: 66] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2013] [Accepted: 02/12/2014] [Indexed: 11/29/2022]
Affiliation(s)
- J I Zwicker
- Division of Hemostasis and Thrombosis, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
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28
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Schleyer AM, Jarman KM, Calver P, Cuschieri J, Robinson E, Goss JR. Upper extremity deep vein thrombosis in hospitalized patients: a descriptive study. J Hosp Med 2014; 9:48-53. [PMID: 24281984 DOI: 10.1002/jhm.2115] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/02/2013] [Revised: 10/04/2013] [Accepted: 10/07/2013] [Indexed: 11/11/2022]
Abstract
Increasingly, there is a focus on the prevention of hospital-acquired conditions including venous thromboembolism. Many studies have evaluated pulmonary embolism and lower extremity deep vein thrombosis, but less is known about upper extremity deep vein thrombosis (UEDVT) in hospitalized patients. The objective of this study was to describe UEDVT incidence, associated risks, outcomes, and management in our institution. Using an information technology tool, we reviewed records of all symptomatic adult inpatients diagnosed with UEDVT at an academic tertiary center between September 2011 and November 2012. Fifty inpatients were diagnosed with 76 UEDVTs. Their mean age was 49 years; 70% were men. Sixteen percent had a history of venous thromboembolism; 20% had a history of malignancy. The mean length of stay (LOS) was 24.6 days (range, 2-91 days); 50% were transferred from outside hospitals. Thirty-eight percent of UEDVTs were in internal jugular veins, 21% in axillary veins, and 25% in brachial veins. Forty-four percent of patients had UEDVT associated with central venous catheters (CVCs). During hospitalization, 78% were fully anticoagulated; 75% of survivors at discharge. Only 38% were discharged to self-care; 10% died during hospitalization. Patients with UEDVT were more likely to have CVCs, malignancy, and severe infection. Many patients were transferred critically ill with prolonged LOS and high in-hospital mortality. Most UEDVTs were treated even in the absence of concurrent lower extremity deep vein thrombosis or pulmonary embolism. Additional research is needed to modify risks and optimize outcomes. Journal of Hospital Medicine 2014;9:48-53. © 2013 Society of Hospital Medicine.
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Affiliation(s)
- Anneliese M Schleyer
- Department of Medicine, University of Washington, Seattle, Washington; Department of Quality Improvement, Harborview Medical Center, Seattle, Washington
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29
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Klitfod L, Broholm R, Baekgaard N. Deep venous thrombosis of the upper extremity. A review. INT ANGIOL 2013; 32:447-452. [PMID: 23903301] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/02/2023]
Abstract
UNLABELLED Upper extremity deep venous thrombosis (UEDVT) occurs either spontaneously, as a consequence of strenuous upper limb activity (also known as the Paget-Schroetter syndrome) or secondary to an underlying cause. Primary and secondary UEDVT differs in long-term sequelae and mortality. This review will focus on the clinical presentation, risk factors, diagnosis, and treatment strategies of UEDVT. In the period from January to October 2012 an electronic literature search was performed in the PubMed/MEDLINE database, and 27 publications were included. CLINICAL PRESENTATION swelling, pain and functional impairment are typical symptoms of UEDVT, although completely asymptomatic cases have been described. However life-threatening, massive pulmonary embolism (PE) can also be a sign of UEDVT. RISK FACTORS for the primary condition anatomical abnormalities (Thoracic Outlet Syndrome, TOS) may dispose to the condition. Malignancy and therapeutic interventions are major risk factors for the secondary deep vein thrombosis in combination with the patient's characteristics, comorbidities and prior history of deep vein thrombosis. COMPLICATIONS recurrent deep venous thrombosis, pulmonary embolism and Post Thrombotic Syndrome (PTS) are the major complications after UEDVT. PTS is a chronic condition leading to significant functional disability and impaired quality of life. DIAGNOSIS compression ultrasonography is noninvasive and the most frequently used objective test with a high accuracy in experienced hands. Treatment modalities and strategies: the treatment modalities include anticoagulation therapy, catheter-directed thrombolysis, surgical decompression, percutaneous transluminal angioplasty and stenting and they may be combined. However, the optimal treatment and timing of treatment remains controversial. Early diagnosis and treatment is essential to prevent PTS in primary UEDVT; however, there is no consensus on which treatment is the best. Anticoagulation is still considered the treatment of choice for at least 3-6 months, until Randomized Controlled Trials may have demonstrated otherwise.
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Affiliation(s)
- L Klitfod
- Vascular Clinic, Gentofte and Rigshospitalet, University of Copenhagen, 2900 Hellerup, Denmark.
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Abstract
An 18-year-old man presented to the emergency department with an acutely swollen right upper limb having spent the previous day canoeing. Venography confirmed right subclavian venous thrombosis at middle one-third of right clavicle with no evidence of cervical rib or other structural abnormalities. Following heparinisation, catheter directed thrombolysis was performed which restored luminal flow. Postprocedure the patient developed spontaneous small-volume haemoperitoneum and acute renal failure. The patient was admitted to the intensive care unit for haemodialysis and supportive management. The patients' renal function improved and he was discharged well following his 28th day of admission. Paget-Schroetter syndrome or effort thrombosis involves subclavian venous thrombosis associated with strenuous activity of upper extremities. In these cases, catheter directed thrombolysis with first rib resection provides greater patency rate than anticoagulation therapy alone. Acute kidney injury following mechanical thrombolysis is rarely reported in the literature.
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Affiliation(s)
- A Dep
- Department of Vascular Surgery, University Hospital Limerick, Limerick, Ireland.
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Kohen D, Hanhan S, Bellah R. Paget-Schroetter syndrome in a lacrosse player. Del Med J 2013; 85:77-79. [PMID: 23631108] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/02/2023]
Abstract
Paget Schroetter Syndrome (PSS) or "effort thrombosis" is a rare form of primary upper extremity deep vein thrombosis often seen in individuals with anatomic variants involving the thoracic outlet and exacerbated by repetitive microtrauma to the subclavian vein. Diagnosis can be made with ultrasound and confirmed with MR venography or conventional venography. We report a case of PSS in a young male athlete who was treated with pharmacologic and mechanical thrombolysis.
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Affiliation(s)
- Denise Kohen
- Christiana Care Health System, Newark, Del., USA
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Drakos N, Gausche-Hill M. A Case Report: A Young Waiter with Paget-Schroetter Syndrome. J Emerg Med 2013; 44:e291-4. [PMID: 23079148 DOI: 10.1016/j.jemermed.2012.07.075] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2012] [Revised: 05/14/2012] [Accepted: 07/30/2012] [Indexed: 11/19/2022]
Affiliation(s)
- Nicholas Drakos
- Department of Emergency Medicine, Harbor-UCLA Medical Center, Torrance, California, USA
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Revel-Vilk S, Brandão LR, Journeycake J, Goldenberg NA, Goldenberg A, Monagle P, Sharathkumar A, Chan AKC. Standardization of post-thrombotic syndrome definition and outcome assessment following upper venous system thrombosis in pediatric practice. J Thromb Haemost 2012; 10:2182-5. [PMID: 23193586 DOI: 10.1111/j.1538-7836.2012.04885.x] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Affiliation(s)
- S Revel-Vilk
- Department of Pediatric Hematology/Oncology, Hadassah Hebrew-University Hospital, Jerusalem, Israel.
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Dwivedi R, Ham-Ying L, Snape J. Problem based review: the patient presenting with an acutely swollen arm. Acute Med 2012; 11:113-116. [PMID: 22685702] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/01/2023]
Abstract
A 69 year old female presented to the Emergency Department with swelling of her right arm and elbow, one week following a fall which resulted in a fracture of the middle third of her right clavicle (Figure 1). The forearm was hot and tender and the arm and hand function were somewhat impaired by swelling, but sensation was intact. Initial bloods were unremarkable, apart from a mild neutrophilia.
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Affiliation(s)
- R Dwivedi
- Kings Mill Hospital, Sutton in Ashfield, Notts, NG17 4JL, UK
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Mitu F, Leon MM, Mitu M. [Upper-extremity deep vein thrombosis: current concepts in diagnosis and treatment]. Rev Med Chir Soc Med Nat Iasi 2011; 115:316-324. [PMID: 21870717] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 05/31/2023]
Abstract
Upper-extremity deep vein thrombosis is a rare manifestation of venous thromboembolic disease. In the past few decades, the clinical importance of upper-extremity deep vein thrombosis has increased because of the wider use of central venous catheters and the development of ultrasonography as a simple and accurate objective diagnostic method. Primary upper-extremity deep vein thrombosis is a rare disorder (2 per 100,000 persons per year), which comprises (1) Paget-Schroetter Syndrome, also known as effort thrombosis, and (2) idiopathic upper-extremity deep vein thrombosis. Secundary upper-extremity deep vein thrombosis develops in patients with upper extremity central venous catheters, pacemakers or cancer and accounts for most cases of upper-extremity deep vein thrombosis. The imaging modes used for diagnosis are: duplex ultrasound, magnetic resonance. Contrast venogram is the standard diagnostic test for characterization of the anatomy. A staged, multimodal approach to Paget-Schroetter Syndrome can effectively restore venous patency, reduce the risk of rethrombosis, and return the patient to normal function. Primary care physicians should be aware of this condition and its atypical presentations, because delayed recognition in a high-functioning persons can be potentially disabling.
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Affiliation(s)
- F Mitu
- Universitatea de Medicină şi Farmacie Gr. T. Popa Iaşi, Facultatea de Medicină, Clinica a VI-a Medicală
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Abstract
Paget-Schroetter's syndrome (PSS) is an effort-related syndrome involving upper extremity deep vein thromboses (UEDVTs) that usually occur in the subclavian or axillary veins. The aetiology is distinct from that of lower extremity DVTs (LEDVTs). Although rare, the syndrome can occur in young, otherwise healthy people who participate in upper extremity activity (Roche-Nagle et al 2007) such as footballer Gary Cahill, a defender at Bolton Wanderers, whose hopes of playing football at international level this season have diminished as a result of developing a UEDVT (BBC Sport 2010). This article discusses the incidence and aetiology, and provides a case study, of the syndrome.
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Abstract
Upper extremities deep venous thrombosis (UEDVT) is a rare condition. According to the literature, approximately 4-10% of all cases of venous thrombosis may involve the subclavian, axillary or brachial veins. In the last few decades, the incidence of UEDVT has increased because of more frequent use of central venous catheters (CVCs) and cardiac pacemaker implantation. In addition, another common risk factor for UEDVT is cancer. UEDVT is classified as primary, approximately one-third of cases, which refers either to effort thrombosis or idiopathic UEDVT, or secondary, due to the presence of overt predisposing causes. The onset of UEDVT is usually characterized by arm swelling and pain, but may also be completely asymptomatic especially in patients with a long-term presence of a CVC. Ultrasonography represents a simple and accurate diagnostic tool to demonstrate the problem. UEDVT has major clinical consequences including pulmonary embolism, recurrences, post-thrombotic syndrome, and death. The role of thromboprophylaxis for those patients with a long-term CVC is still controversial. Unfractionated or low molecular weight heparin, followed by an oral anticoagulant are the most common treatments, with strategy of management similar to that of deep vein thrombosis of the leg. Thrombolysis/thrombectomy and surgical decompression are often successful, but less frequently used. Randomized controlled trials are warranted to clarify the optimal management of UEDVT, and to identify patients at the highest risk of recurrence who might benefit from long-term anticoagulation.
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Affiliation(s)
- Luca Spiezia
- Department of Cardiologic, Thoracic, and Vascular Sciences, 2nd Chair of Internal Medicine, University of Padua Medical School, Via Ospedale 105, 35100, Padua, Italy
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