You are in: eMedicine Specialties > Radiology > VASCULAR/INTERVENTIONAL Deep Venous Thrombosis, Upper ExtremityArticle Last Updated: Apr 5, 2007AUTHOR AND EDITOR INFORMATIONSection 1 of 10
  Author: Craig Greben, MD, Assistant Professor of Radiology, New York University School of Medicine, Chief, Division of Vascular and Interventional Radiology, North Shore University Hospital Craig Greben is a member of the following medical societies: Society of Cardiovascular and Interventional Radiology Coauthor(s): James Naidich, MD, Residency Director, North Shore University Hospital; Professor, Department of Radiology, New York University School of Medicine; Hearns W Charles, MD, Assistant Professor of Radiology, New York University School of Medicine; Consulting Staff, Division of Vascular and Interventional Radiology, New York University Medical Center; Jason J Naidich, MD, Assistant Professor of Radiology, New York University School of Medicine; Attending Physician, Division of Vascular and Interventional Radiology, North Shore University Hospital Editors: Anthony Watkinson, MD, Professor of Interventional Radiology, The Peninsula Medical School; Consultant and Senior Lecturer, Department of Radiology, The Royal Devon and Exeter Hospital, UK; Bernard D Coombs, MB, ChB, PhD, Consulting Staff, Department of Specialist Rehabilitation Services, Hutt Valley District Health Board, New Zealand; Douglas M Coldwell, MD, PhD, Professor of Interventional Radiology, Department of Radiology, Professor of Interventional Radiology, University of Texas Southwestern Medical Center; Robert M Krasny, MD, Consulting Staff, Department of Radiology, The Angeles Clinic and Research Institute; Kyung J Cho, MD, FACR, William Martel Professor of Radiology, Fellowship Program Director, Department of Radiology, Division of Interventional Radiology, University of Michigan Medical School Author and Editor Disclosure Synonyms and related keywords: DVT, effort thrombosis, effort-induced thrombosis, secondary thrombosis, exertional thrombosis, axillary-subclavian vein thrombosis, Paget-von Schrötter syndrome INTRODUCTIONSection 2 of 10
  BackgroundThe 2 forms of upper-extremity deep venous thrombosis (DVT) are (1) effort-induced thrombosis (Paget-von Schrötter syndrome) and (2) secondary thrombosis. Effort induced thrombosis, or Paget-von Schrötter syndrome, accounts for 25% of cases. Paget in England and von Schrötter in Germany independently described effort thrombosis more than 100 years ago. In this primary form of the disease, an underlying chronic venous compressive abnormality caused by the musculoskeletal structures in the costoclavicular space is present at the thoracic inlet and/or outlet. In 75% of patients with secondary thrombosis, hypercoagulability and/or indwelling central venous catheters are important contributing factors. In fact, with the advent of central venous catheters, upper-extremity and brachiocephalic venous thrombosis has become a more common problem. PathophysiologyFactors contributing to upper extremity DVT are controversial, but the disease may be explained with the Virchow triad: stasis, hypercoagulability, and intimal damage. Intimal injury is likely to be more important than the other factors in the etiology of upper-extremity DVT. This mechanism is particularly true of thrombosis of the axillosubclavian vein, compared with that of thrombosis in other large veins. Because of its relatively fixed position in the thoracic inlet or outlet, the axillosubclavian vein is exposed to repeated trauma with arm movement. This repetitive trauma and compression in the fixed costoclavicular space leads to intimal hyperplasia and venous stenosis. Etiologies of secondary venous thrombosis include the following:
FrequencyUnited StatesUpper-extremity DVT now accounts for about 8% of all cases of DVT; this rate is increased from only 2% of all cases prior to 1966. This increased frequency is at least partly due to the increased use of central venous catheters. Mortality/MorbidityThe main complications of upper-extremity DVT are pulmonary embolus and superior vena cava syndrome. If a venous access device is in place and if venous thrombosis is diagnosed, the access device may need to be removed. This removal can seriously affect the care of critically ill patients in whom venous access is difficult to secure.
SexEffort-induced thrombosis occurs most frequently in young men younger than 45 years; this disease particularly affects body builders and other individuals after exercise. AnatomyAnatomic causes that contribute to DVT include the following: presence of a cervical rib, posttraumatic deformity of surrounding bony structures, and anomalous musculofascial bands. The most common points of venous entrapment are between the following: the anterior and medial heads of the scalenus muscle of the first rib (scalenus anticus syndrome); the subclavius muscle, the clavicle, and the first rib; an anomalous cervical rib and the scalenus muscle. Clinical DetailsDVT should be suspected in the presence of pain, swelling, and functional impairment of the upper extremity. The neck and shoulder may be painful and swollen. The skin may be mottled, and the superficial collateral veins may be dilated. Thoracic outlet syndrome may occur with arterial (least common), venous, or brachial-plexus symptoms (most common). Preferred ExaminationUpper-extremity venous thrombosis can be diagnosed with color flow duplex imaging, with a sensitivity of 78-100% and a specificity of 90-100%. The central veins cannot always be accurately imaged sonographically; therefore, contrast-enhanced venography remains an important diagnostic tool. In the assessment of effort-induced thrombosis, venographic views include abduction, external rotation, and extension views. RADIOGRAPHSection 3 of 10
FindingsPlain radiographic findings of a clavicle or first rib fracture or presence of a cervical rib can increase the suspicion of thoracic outlet syndrome and venous thrombosis. CT SCANSection 4 of 10
FindingsCT is readily available and widely used. Upper-extremity and central venous thrombosis is often incidentally diagnosed on contrast-enhanced CT scans of the chest. The thrombus is hypoattenuating compared with the hyperattenuating vein. This cross-sectional imaging modality provides excellent information about soft tissue structures (eg, tumor, lymphadenopathy) surrounding the vein that may account for the thrombosis. Degree of ConfidenceWith new 3-dimensional (3D) reconstruction software packages, the image quality is good, and the findings are diagnostic. MRISection 5 of 10
FindingsThe strength of magnetic resonance venography is in the evaluation of the central veins of the chest; the subclavian vein; the brachiocephalic vein; and the superior vena cava, an area poorly visualized with ultrasonography. Thrombosis is diagnosed as a filling defect in the vessel. ULTRASOUNDSection 6 of 10
FindingsUltrasonography is the imaging modality of choice. Real-time ultrasonography and color flow Doppler imaging are rapid, noninvasive means for the diagnosis of DVT. The lack of full compressibility, the absence of color flow signal and augmentation, and visualization of thrombus are used to make the diagnosis. ANGIOGRAPHYSection 7 of 10
FindingsVenography with iodinated contrast enhancement is more costly and invasive than ultrasonography, but it remains the criterion standard in the evaluation of DVT. Patients with effort-induced thrombosis should undergo bilateral upper-extremity venography with provocative maneuvers. For patients with renal insufficiency or allergy to contrast material, carbon dioxide and gadolinium-based materials are alternative contrast agents for venography. These agents can be used for diagnostic venography as well as for guiding catheter-directed thrombolysis. Gadolinium-based contrast agents (gadopentetate dimeglumine [Magnevist], gadobenate dimeglumine [MultiHance], gadodiamide [Omniscan], gadoversetamide [OptiMARK], gadoteridol [ProHance]) have recently been linked to the development of nephrogenic systemic fibrosis (NSF) or nephrogenic fibrosing dermopathy (NFD). For more information, see the eMedicine topic Nephrogenic Fibrosing Dermopathy. The disease has occurred in patients with moderate to end-stage renal disease after being given a gadolinium-based contrast agent to enhance MRI or MRA scans. As of late December 2006, the FDA had received reports of 90 such cases. Worldwide, over 200 cases have been reported, according to the FDA. NSF/NFD is a debilitating and sometimes fatal disease. Characteristics include red or dark patches on the skin; burning, itching, swelling, hardening, and tightening of the skin; yellow spots on the whites of the eyes; joint stiffness with trouble movingor straightening the arms, hands, legs, or feet; pain deep in the hip bones or ribs; and muscle weakness. For more information, see the FDA Public Health Advisory or Medscape. Patients are positioned with their arm in the neutral, extended, and hyperabducted positions. The diagnosis is made when an intraluminal filling defect is seen or when a deep venous structure does not fill and collateral veins are visualized. False Positives/NegativesThe compressive features seen with provocative maneuvers during contrast-enhanced venography can occur in asymptomatic patients; therefore, not all patients with venous compression have venous thrombosis. INTERVENTIONSection 8 of 10
If demonstrated, the thrombus should be treated in a staged, multidisciplinary fashion. The treatment of Paget-von Schrötter syndrome consists of thrombolytic therapy; anticoagulation; surgical decompression; and, occasionally, angioplasty and/or stent placement. Secondary axillosubclavian vein thrombosis can be treated with conservative, surgical, or catheter-directed thrombolytic therapy. Lytic therapy is highly effective when started early. Large strictures of a central vein can be treated with metallic stents. Interventions for primary thrombosis of the axillosubclavian vein In the Machleder algorithm, the basilic vein is the preferred access site. Catheter-directed thrombolysis may be performed. Current mechanical thrombectomy devices can potentially facilitate clot removal and thus shorten the thrombolytic infusion time and reduce the dose. Anticoagulation may be administered for 6-12 weeks. Thoracic-outlet decompression by means of transaxillary or transthoracic resection of the first rib may be indicated if significant disability or vein abnormality persists. Follow-up venography and angioplasty may be performed to correct residual venous stenosis after decompression surgery. The use of vascular stents in this location is relatively contraindicated because long-term patency rates are low. Treatment options for secondary thrombosis of the axillosubclavian vein Traditional conservative therapies include catheter removal, bed rest, heat application, limb elevation, and anticoagulation. Symptomatic improvement after conservative therapy is the result of venous collateral recruitment and the prevention of clot propagation. Invasive surgical therapy includes thrombectomy. Catheter-directed thrombolysis may be appropriate. The median basilic vein is easily accessed with sonographic or venographic fluoroscopic guidance. A vascular sheath is placed, and an upper-extremity venogram is obtained. The extent of the clot is documented. A guidewire is passed through the clotted venous segment (wire traversal test), and a multi–side-hole infusion catheter of appropriate length is embedded in the clotted segment. Thrombolytic therapy with the agent of choice is begun. Most thrombosed veins are recanalized in 24 hours (some as long as 48-72 h). If the underlying vein is normal after completion thrombolysis, short-term anticoagulation is warranted. If the underlying vein is abnormal (eg, with irregularities or stenoses), 10-12 weeks of anticoagulation is advocated. Thrombolytic agents Three thrombolytic agents are currently available for use in the United States: urokinase (Abbokinase, Abbott Laboratories), alteplase (Activase, Genentech), and reteplase (Retavase, Centocor). Absolute contraindications for thrombolytic therapy are the following: (1) active internal hemorrhage; (2) recent gastrointestinal hemorrhage; (3) central nervous system tumor, aneurysm, or arteriovenous malformation; and (4) recent cerebrovascular accident. Relative contraindications include the following: (1) recent major surgery, biopsy, or trauma; (2) postpartum (<10 d) status; (3) uncontrolled hypertension; (4) hemorrhagic retinopathy; and (5) left-sided intracardiac thrombus. Some patients with upper-extremity venous thrombosis should be considered for superior vena caval filtration. Indications for placement of a superior vena caval filter include the following: (1) contraindication to anticoagulation; (2) recurrent pulmonary embolism despite adequate anticoagulation; (3) complications of anticoagulation; (4) chronic, recurrent pulmonary embolism associated with pulmonary hypertension; and (5) massive pulmonary embolism. MULTIMEDIASection 9 of 10
REFERENCESSection 10 of 10
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