Upper Limb DVT

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Upper Limb DVTIts not just for legs anymore
Tress Goodwin, SMSIV Surgical ICU, October 2007
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Outline

• Anatomy
• Primary vs. Secondary ULDVT
• Clinical features
• Diagnosis
• Treatment
• Sequelae

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Upper vs. Lower DVTs

• Virchows triad (venous stasis,
  hypercoagulability, endothelial trauma)
• UL Higher venous flow, less stasis,
  gravitational effects
• Direct endothelial trauma effort in primary
  iatrogenic in secondary

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Spontaneous (Primary) ULDVT

• First described by Paget and Schroetter
• AKA Paget-Schroetter syndrome, effort
  thrombosis
• Compressive anatomy at thoracic
  outletcompression of vein b/w first rib and
  hypertrophied scalene or tendons
• Can occur after strenuous activity of arms and
  shoulders

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Secondary ULDVT

• Central venous catheters
• Pacemakers
• Higher incidence Chemotherapy, TPN via central
  lines
• Improper placement of catheter tip
• Incidence varies 1-4 of all DVTs

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Clinical Features

• Arm swelling, pain, heaviness
• Dilated subcutaneous veins
• JVD
• Upper limb cyanosis
• Can be asymptomatic
• DDx superficial thrombophlebitis

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Associated Conditions

• Presence of a central venous catheter in (72)
• Infection (28)
• Extrathoracic malignancy (22)
• Thoracic malignancy in (21)
• Renal failure (21)
• Prior lower-extremity deep venous thrombosis (18)

Marinella MA, Kathula SK, Markert RJ. Heart Lung.
2000 Mar-Apr29(2)113-7. Spectrum of
upper-extremity deep venous thrombosis in a
community teaching hospital.
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Spectrum of Manifestations
Massive PE
Asymptomatic
Upper limb complications
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ULDVT Sequelae
Sajid, M, et al. Upper Limb Deep Vein Thrombosis
A Literature Review to Streamline the Protocol
for Management. Acta Haematol 2007 118.
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Diagnosis

• Duplex ultrasonography
• Aggressive diagnosis digital subtraction
  venography, MRV, CTV

Sajid, M, et al. Upper Limb Deep Vein Thrombosis
A Literature Review to Streamline the Protocol
for Management. Acta Haematol 2007 118.
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Treatment

• Expectant management
• Removal of offending agent
• Anticoagulation (standard heparin x 5-7 days, 3
  mos of Coumadin)
• Thrombolysis (streptokinase, urokinase, TPA)
• Surgery
• SVC filter

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Treatment Protocol
Sajid, M, et al. Upper Limb Deep Vein Thrombosis
A Literature Review to Streamline the Protocol
for Management. Acta Haematol 2007 118.
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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.
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Surgical management
Sajid, M, et al. Upper Limb Deep Vein Thrombosis
A Literature Review to Streamline the Protocol
for Management. Acta Haematol 2007 118.
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SVC Filters

• Ascher, Enrico, Hingorani, Anil,
  Mazzariol, Fernanda, Jacob, Theresa,
  Yorkovich, William, Gade, PrasadClinical
  Experience with Superior Vena Caval Greenfield
  Filters. Journal of Endovascular Surgery 1999 6
  365-369

• 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.

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SVC Filters - Indicated?
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Conclusions

• ULDVT relatively rare but associated with
  considerable morbidity and mortality (PE,
  post-thrombotic syndrome, loss of vascular
  access)
• Duplex ultrasound sufficient for majority of
  diagnoses
• Simple anticoagulation suitable for most patients
• Thrombolysis/thrombectomy less frequently used
• Surgery, SVC filters (?) for recurrent cases or
  where other tx contraindicated

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Questions?