Table of Contents  
CASE REPORT
Year : 2022  |  Volume : 9  |  Issue : 1  |  Page : 118-122

Aggressive management of upper extremity deep venous thrombosis – A case report and systemic review


Department of Vascular and Endovascular Surgery, Assiut University Hospitals, Asyut, Egypt

Date of Submission03-May-2021
Date of Acceptance27-May-2021
Date of Web Publication23-Mar-2022

Correspondence Address:
Mohammed Shahat
Department of Vascular and Endovascular Surgery, Assiut University Hospitals, Asyut
Egypt
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ijves.ijves_45_21

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  Abstract 


Upper extremity deep vein thrombosis (UEDVT) is rapidly growing health issue. The number of secondary UEDVT is outnumbering the incidence of primary deep vein thrombosis in upper limbs. Central venous catheter, malignancy is the most accused etiology for marked growth in the incidence of upper limb DVT. We are reporting a unique case for UEDVT and its management by thrombolysis in malignant patient with unique complication occurred (arteriovenous fistula) which was managed by covered stent in the artery.

Keywords: Central venous catheter-induced deep vein thrombosis, stent graft in upper limb deep vein thrombosis, thrombolysis in upper extremity deep vein thrombosis, upper limb deep vein thrombosis, upper extremity deep vein thrombosis


How to cite this article:
Shahat M. Aggressive management of upper extremity deep venous thrombosis – A case report and systemic review. Indian J Vasc Endovasc Surg 2022;9:118-22

How to cite this URL:
Shahat M. Aggressive management of upper extremity deep venous thrombosis – A case report and systemic review. Indian J Vasc Endovasc Surg [serial online] 2022 [cited 2022 May 28];9:118-22. Available from: https://www.indjvascsurg.org/text.asp?2022/9/1/118/340503




  Introduction Top


Deep vein thrombosis (DVT) is a global issue with huge socioeconomic burden. In the USA, the incidence of venous thromboembolism (VTE) is estimated to exceed 900,000 cases annually.[1]

Deep vein thrombosis is the formation of a blood clot in one of the deep veins of the body, usually, in the leg, however thrombosis may occur in other sites like upper limb or GIT portal veins. Other rare for thrombosis like cerebral veins may be affected especially in a specific group like a Behect disease.

People at risk for DVT encompass a wide range of patient groups: patients with spinal cord injury, surgical intensive care unit (ICU) patients, critical ill medical ICU patients, thrombophilia patients, and malignancy patients.[2],[3],[4]

Upper limb DVT (ULDVT) is much less frequent than lower limb DVT (LLDVT), but the incidence is increasing due to modern medical practice that increases the use of central venous catheter (CVC) and its related complication.

The anatomy of the upper limb venous system is quite similar to the lower limb venous system, and the veins are classified to deep and superficial.[5] ULDVT can be classified to primary or secondary. Primary is called effort thrombosis or Paget–Schroetter disease. Secondary is either due to CVC or malignancy.

Approximately 20% of all first-time VTE events are associated with malignancy.[6] Malignancy increases the probability of upper limb thrombosis by multiple pathways.

These pathways are venous compression by the tumor mass itself or its metastatic lymph node. Furthermore, the indwelling CVC that frequently used in malignancy patients to infuse its medication. On the other hand, the treatment either by surgery or radio and chemotherapy that increase the liability of DVT. Also, cancer itself produce procoagulant prothrombotic body state as it activates tissue factor TF to bind to VI and Via that activate IX and factor X that activate thrombin.[7] Also, tumor cells secret tumor procoagulant that also initiate factor X activation independent of factor VII. Also, it has a role on platelets activation and many interleukins that produce a prothrombotic state.[8]


  Case Report Top


In our paper we present a case of upper extremity deep vein thrombosis (UEDVT). Female patient known to be diabetiv, hypertensive, inoperable breast cancer on radiotherapy, with lung metastasis, presented to our hospital with painful massive edema of Rt upper limb, redness, and hotness. On physical examination, the patient had swelling of the right upper limb with 7 cm difference from the contralateral side, hottness, and redness, painful abduction of the right arm.

There was no palpable pulses detected in the right hand, but good signals by handheld Doppler were detected. There was no visible masses on the axilla or supraclavicular fossa. There were congested neck veins with flaring collaterals on the chest wall, with noted face congestion. Duplex examination revealed acute thrombosis of the right axillary and subclavian veins with extension into proximal innominate veins, but patent basilic vein, with patent axillary and subclavian arteries with good flow till the hand.

The patient showed a normal coagulation profile, complete blood count, and normal renal function.

Started anticoagulation therapy in therapeutic dose with antiedematous measures and limb elevation. The patient did not respond to our treatment and deteriorated in the following days. Deterioration was in the form of increasing edema, pain and face congestion. This leads us to think about catheter directed thrombolysis (CDT).

After infiltration of local anesthesia, Duplex guided the basilic vein puncture performed by micro puncture needle a 6 French introducer sheath was inserted, and diagnostic venography was done. Venography reveled occlusion of axillosubclavian veins and proximal part of the basilica vein [Figure 1] and [Figure 2]. 0.35 Terumo glide wire (Terumo Medical Corporation, Somerset, New Jersey) passed till connection of basilic vein into subclavian vein then trial of the wire passage, and combination of different wires and catheters. Then, avertebral catheter 5f Merit Medical Systems, South Jordan, Utah 130 cm length is used on the wire and the combination wire and catheter passed till the superior vena cava was cannulated and venography showed its freedom of thrombosis [Figure 3]. Then, thrombolytic catheter UniFuse catheter(AngioDynamics, Latham, NewYork) with 10 cm infusion length inserted through the thrombus the catheter was within the thrombus. The used thrombolytic agent was tissue plasminogen activator (tPA; Genentech, Inc., San Francisco, CA). The loading bolus spray dose is applied (10 cm) then maintenance dose by infusion pump by dosage of 0.05 mg. kg. h. After 24 h then control venography revealed residual thrombus in subclavian and innominate with poor recanalization, so we decide to continue the thrombolysis for next 24 h in the same dose without an increase to avoid the risk of bleeding in the malignant patient. Twenty four hours later, another control venography was done and revealed resolution of thrombus with good recanalization of the axilliosubclavian segment. The venography revealed tight underlying Stenosis mostly from external compression of malignant mass in both axillary and subclavian veins which were tried to be dilated by gradual inflation of diameters high pressure balloon 8, 10, 12 in diameter CONQUEST® PTA Dilatation Catheter the stenoses were resilient with inadequate response to balloon dilatation which was a high risk for rethrombosis of the recanalized segment, So we decide to insert a stent through these tight lesions [Figure 4] and [Figure 5]. The stent inserted was wall stent 12 mm × 6 mm and another stent in axillary vein 10 × 6 in telescopic manner with adequate overlap, then completion venography was performed which revealed residual stenosis that was treated by successive inflation of balloons [Figure 6]. Venography then reveled arteriovenous fistula. We think this occurred from overinflation and penetration of the stent into the artery quick brachial access was done with a deployment of a covered stent (fluency 6F on cordis 7|F sheath we used surgical cutdown technique) in the axillary artery. that completely seal the fistula. simultaneous inflation of balloons inside stented artery and vein was done. Then a completion venography angiography was done and showed a satisfactory result [Figure 7].
Figure 1: Thrombus in the upper basalic vein extending to the right subclavian vein

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Figure 2: Complete occlusion of the subclavian vein

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Figure 3: The superior vena cava free of thrombosis

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Figure 4: Tight subclavian lesion mandate stenting

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Figure 5: Residual stenosis after angioplasty

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Figure 6: Insertion of stent in axillary and subclavian veins

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Figure 7: Satisfactory result after venous stenting

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  Discussion Top


DVT of the lower limb is a well studied codition in contrary to UEDVT which has a lower incidence than LLDVT and less studied but fortunately has the same risk factor. The UEDVT risk factor can be classified to endogenous as pregnancy and thrombophilia, exogenous as external compression by rib or CVC, solid malignant mass, at last, it may occur spontaneously.[9] UEDVT can be by classified into two categories primary unprovoked group it also called effort thrombosis related to thoracic outlet syndrome (TOC) and the second group is provoked group either by CVC or cancer this group is the dominant one and represent about 80% of cases.[10],[11],[12] UEDVT occurs mainly in the axillary and subclavian veins usually due to fixed position of subclavian makes it exposed to repetitive trauma and compression during arm motion in the thoracic outlet between the clavicle and first rib in the costoclavicular space. Some activity exaggerate this trauma like above head abduction of the arm or these traumas may be more evident in some positions like exaggerated military position or by certain jobs such as those which need long period sitting on computers desk.[13] The incidence of UEDVT is about 4% only of the patient with venous thrombosis and represent only. Fifteen percent of inpatient. As we mentioned previously these incidences is much lower than LLDVT which can be explained by many factors like fewer number and smaller valves in the upper limb vein when compared with that of the lower limb. High level of fibrinolytic activity in the upper limb than lower limb veins. Restriction of upper limb movement does not occur even in critical ill patient that occur with lower limb in bed ridden patient. Also, lower hydrostatic gradient may contribute in these lower incidence and absence of solial plexus of veins in the upper limb which represent the nidus for thrombus formation in the lower limb.[14] The annual incidence of the UEDVT is estimated by 3.6 people/100,000.[15] Despite all previous explanation the incidence of UEDVT is showing steady increase nowadays because of increase in numbers of patients of malignant diseases and the increase in the frequency in the usage of CVC, pacemakers.[16],[17] The incidence may be underestimated due to missed diagnosis, or many episodes passes asymptomatic. About 80% of thrombosis occurs in the dominant upper limb.[13] Although UEDVT has benign course if treated correctly. On the other side, it may have serious complication mainly pulmonary embolism (PE) and postthrombotic syndrome (PTS). The incidence of PE after UEDVT is about 0%–36%, which is lower than LL DVT, which reaches about 50% of cases. Also, fatal PE is very rare with UEDVT.[18]

PTS annoying morbidity especially if occurred in the dominant hand. the estimated incidence about 7%-46% average 15%.[19] Usually through clinical examination can reach a diagnosis of UEDVT, usually patient may suffer from swelling, paresthesia of the upper limb sometimes with pain due to the stretch of the skin by swelling. The examination is critical to differentiate between primary and secondly UEDVT which is crucial in management.by examination patient may have low grade fever high grade with septic thrombophlebitis or malignancy. Examination of arterial tree jugular veins for distention supraclavicular fossa fullness thoracic collaterals is important in proximal massive UEDVT. Also, exclusion of solid masses in the costoclavicular region, and supraclavicular tenderness, some test of TOS as Adson test, Wright maneuver, may be used to exclude TOS. Inpatient with catheter occluded catheter or one port of its ports may be the clinical symptoms of the patient.[20] Although venography is the standard method of diagnosis due to its complication and unavailability the duplex the first investigation to diagnose ULDVT high sensitivity, specificity, safety and availability make it the first choice to use by physician. Non compressibility of the venous part with intraluminal thrombus visualization with flow abnormality detected by color flow is sufficient for diagnosis.[21] Also, X ray should be done to exclude TOS and presence of cervical rib. Also searching for thrombophilia should be done to exclude these as a cause for thrombosis as protein c protein s anti thrombin III.

Management

Usually most of UEDVT cases respond to anticoagulation, and about 50% of cases show symptomatic improvement with anticoagulation; the only disadvantage of UEDVT is the inability to prevent PTS and preserve valve function[22] Usually liberal use of thrombolysis is not the first choice and only used in selected cases not responding to anticoagulation in these cases CDT may be indicated. It also may be used severe cases with near onset from the start. Also, in some selected cases not responding to anticoagulation and CDT other methods like (catheter extraction, surgical thrombectomy, transluminal angioplasty, or a staged approach of lysis followed by a vascular interventional or surgical procedure) can be used if appropriate expertise and resources are available. In patients with contraindication to anticoagulation and manifestation of thrombus progression, PE placement of superior vena cava filter is indicated.[23] Surgery which used to treat UEDVT is either primary treatment by venous thrombectomy but due to its invasiveness and its complication and risks of general anesthesia as also may lead to brachial plexus injury or pneumothorax it should be reserved for refractory cases. Also surgical decompression in vascular TOS is indicated either primary or staged procedures by some surgeon.[20] Indications for CDT are a thrombus age less than two weeks and acute phlegmasia cerulea dolens in patients with no contraindications for thrombolytic therapy.[24] Catheter directed thrombolysis emerged as a revolutionary therapeutic line when comparing risks and benefits. The CDT has many methods either CDT alone or pharmacomechanical CDT. The technique of CDT involves insertion of a catheter under fluoroscopic guidance within the thrombus and prolonged infusion of thrombolytic material within the thrombus by low dose about 1 mg % h in tPA when compared with systemic method this decrease the risk of bleeding and enhance the delivery of the lytic material to the target clot the infusion last at least for 24 h.[25] The main advantages of the CDT early restoration of venous patency with preservation of valve function that will be reflected on reduction of incidence of PTS. It is proven that CDT decrease occurrence of PTS more than anticoagulation alone and if it has occurred it is less severe than when occurring with anticoagulation alone. Also, the incidence is directly correlated to the thrombus load at the end of the procedures.[25],[26],[27] The main disadvantage of the CDT is the risk of bleeding especially intracranial one which is rare when compared with systemic thrombolysis. Also, most frequent type is venous access site which is simple to manage. Although there was previous belief that thrombolysis is increasing the occurrence of PE due to clot disruption this is not proved and routine use of the filter is not recommended.[25]

Absolute contraindications include active internal bleeding and recent (<3 months) stroke, neurosurgery, or intracranial trauma. Relative contraindications include recent cardiopulmonary resuscitation, gastrointestinal bleed, major surgery or trauma, intracranial tumor, thrombocytopenia, uncontrolled hypertension (systolic blood pressure >180 mmHg), and suspicion of infected thrombus.[28] The procedure should be done by experienced vascular surgeon. The access should be done duplex guided to decrease the risk of access site bleeding and infusion of the thrombolytic should by concomitant with heparin infusion and the patient should be under monitoring by experienced nursing staff in ICU. Hematocrit with aPTT every 6 to 8 h and repeated venogram to follow up lysis of the clot.[28]


  Conclusion Top


UEDVT is much lower incidence than LL DVT, but it is increasing incidence require attention. Malignancy is the second most common cause after CVC for secondary UEDVT. CDT is considered the feasible, effective method which prevents some morbid sequel of the disease. This line may be used with caution in a malignant patient without hazards and at last under correction may be acceptable to avoid more morbid complication.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form, the legal guardian has given his consent for images and other clinical information to be reported in the journal. The guardian understands that names and initials will not be published and due efforts will be made to conceal identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
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    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6], [Figure 7]



 

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