2007 - Current Concepts on Upper Extremity Deep Vein Thrombosis by dfsiopmhy6

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									  Current Concepts on Upper
 Extremity Deep Vein Thrombosis

              Enrico Ascher, MD



The Vascular Institute of New York ®
The Vascular Institute of New York ®
        Brooklyn, New York
         Brooklyn, New York
 PE in the United States
600,000 patients annually

Source of PE
  LEDVT                     88 % - 93 %

Contributes 125,000 to 150,000 deaths
           Clinical Challenge
68 y old male inpatient develops:
  SOB, tachycardia, left upper extremity swelling.
  CT scan: positive for acute PE.
  Venous duplex: negative lower extr. and iliacs,
  positive left upper extr. (subclavian, axillary)
  Adequate heparin therapy fails to avert another
  PE.


                    Next ??
                History
                History
First attempt at surgically removing emboli
from pulmonary artery

    Trendelenburg                     1906

First successful removal of emboli from
pulmonary artery

    Kirschner                         1924
    Extraluminal Interruption
A   Moretz    Smooth clip

B   Spencer   Plication

C   DeWeese Mattress suture

D   Miles     Serrated clip

E   Abdu      Clip
Inventor,
1st Intraluminal Caval
Filtration Device
Bertram D. Cohn, MD, FACS
Maimonides Medical Center
1964 – 1st intraluminal caval filter
        st

    3 tiered conical shape
    4 expanding “wings”
1967 – 1st US patent awarded
        st

                                       (1919 – 2002)
   Mobin-Uddin Umbrella

Kazi Mobin-Uddin, MD (1930 -
1999)
1967 – “1st“ intraluminal caval
filter
   Silastic alloy
   Eighteen 3 mm fenestrations
   Jugular vein route only
      Greenfield Filter

Lazar J. Greenfield, MD, FACS
Introduced 1972
1st device to gain wide
acceptance
Most widely studied
 filtration device
            Indications
  for Superior Vena Cava Filter
Upper Extremity DVT and …
  contraindication to anticoagulation
  failure of anticoagulation
  complication of anticoagulation
      Hemorrhage
      Thrombocytopenia
     General Belief
     General Belief

UEDVT: Benign Process
UEDVT: Benign Process
   Low incidence of pulmonary
   Low incidence of pulmonary
   embolism
   embolism
   Low mortality
   Low mortality
            Previous Studies
            Previous Studies
Study
Study         Year
              Year   Patients
                     Patients   PE
                                PE   %
                                     %
Hughes
Hughes        1949
              1949     320
                       320      1
                                1    0
                                     0
Demeter
Demeter       1981
              1981     16
                       16       0
                                0    0
                                     0
Painter
Painter       1984
              1984     17
                       17       0
                                0    0
                                     0
Donayre
Donayre       1986
              1986     41
                       41       5
                                5    12
                                     12
Gloviczki
Gloviczki     1986
              1986     95
                       95       4
                                4    4
                                     4
Cohen
Cohen         1988
              1988     12
                       12       0
                                0    0
                                     0
Monreal
Monreal       1991
              1991     30
                       30       4
                                4    13
                                     13
Upper Extremity DVT
Upper Extremity DVT

          170 patients
           170 patients
          103 females
           103 females      61 %
                            61 %
          67 males
           67 males         39 %
                            39 %
          Age :: 9 to 101 years
           Age 9 to 101 years
          (mean 68 ± 17)
           (mean 68 ± 17)


            J Vasc Surg
            J Vasc Surg    1997
                           1997
Diagnosis: Duplex
Diagnosis: Duplex
     Upper Extremity DVT
     Pulmonary Embolism
                       7%
                       7%
     0%
     0%   for
           for   outpatients
                  outpatients
     8%
     8%   for
           for   inpatients
                  inpatients

Exclude 3 with lower extremity DVT
Exclude 3 with lower extremity DVT
                       5%
                       5%
Upper Extremity DVT

  Are these patients
   hypercoagulable?
 Upper Extremity DVT
 Upper Extremity DVT

Hypercoagulable State
Hypercoagulable State
  Lower Extremity DVT
  Lower Extremity DVT
   15 % to 22 %
   15 % to 22 %
  Upper Extremity DVT
  Upper Extremity DVT
  ? %
   ? %
          Upper Extremity DVT
          Upper Extremity DVT


                     52 patients over 11
                     52 patients over 11
                     month period
                     month period
                     30
                     30   females
                           females          58 %
                                            58 %
                     22
                     22   males
                           males            42 %
                                            42 %
                     Age :: 9 to 97 years
                     Age 9 to 97 years


Ann Vasc Surg 2000
Ann Vasc Surg 2000
                Results
                Results
                             (( n ))
                                n      %%
  AT III
  AT III                        16
                                16     31
                                       31
  Factor V
  Factor V                       6
                                 6     11
                                       11
  Anticardiolipin antibody
  Anticardiolipin antibody       4
                                 4      8
                                        8
  Protein
  Protein   S
            S                    2
                                 2     4
                                       4
  Protein
  Protein   C
            C                    1
                                 1     2
                                       2
Total
Total                          29
                               29      56
                                       56
    Upper Extremity DVT
    Upper Extremity DVT

Jan 1992 to March 2007
Jan 1992 to March 2007
Total 3251 scans (22 %)
Total 3251 scans (22 %)
738 patients with acute UEDVT
738 patients with acute UEDVT
329 females (60%)
329 females (60%)
Age: 9 to 101 years (mean 68 ± 17 y)
Age: 9 to 101 years (mean 68 ± 17 y)
72 Cases
72 Cases   J Vasc Surg 2000
           J Vasc Surg 2000
        204 SVC Filters
        204 SVC Filters
Jan 1994 to March 2007
Jan 1994 to March 2007
204 UEDVT Patients
204 UEDVT Patients
  Greenfield 149
  Greenfield 149
  TrapEase 55
  TrapEase 55
Mean age: 74 years ± 15 years
Mean age: 74 years ± 15 years
Females 60%
Females 60%
              Indications
Anticoagulation:

  Contraindication
  Contraindication    159
                      159   78%
                            78%

  Failure
  Failure             35
                      35    17%
                            17%

  Floating thrombus
  Floating thrombus   10
                      10    5%
                            5%
Combined SVC & IVC Filters
Combined SVC & IVC Filters
       75 Patients (36% ))
       75 Patients (36%

IVC + SVC
 IVC + SVC                   55
                             55   73 %
                                  73 %

IVC
 IVC   SVC
       SVC                   14
                             14   19 %
                                  19 %

SVC
SVC    IVC
        IVC                  6
                             6    8%
                                  8%
Anatomic Considerations
Anatomic Considerations


        SVC length avg. 7 cm
        SVC length avg. 7 cm
        Diameter < 3 cm
        Diameter < 3 cm
        Extent of thrombosis
        Extent of thrombosis
        Anatomic anomalies
        Anatomic anomalies
             Procedure
             Procedure

Selection of Appropriate Sheath
Selection of Appropriate Sheath
   Jugular Insertion -- ““ Femoral ””
   Jugular Insertion       Femoral      kit
                                        kit
   Femoral Insertion -- ““ Jugular ””
   Femoral Insertion        Jugular     kit
                                        kit


SVC Cavogram
SVC Cavogram
   Localization of Release Site
   Localization of Release Site
   Radiologic Confirmation
   Radiologic Confirmation
Superior Venacavagram
Superior Venacavagram
SVC Filter
SVC Filter
Sequential SVC Filter CXRs




   Nov 5, 1995
   Nov 5, 1995   Mar 10, 2002
                 Mar 10, 2002
Migration of
an IVC filter
  into the
 pulmonary
   artery.
Complications (204 cases)
Complications (204 cases)
        5 Patients (2.4%)
        5 Patients (2.4%)

Misplacement
Misplacement                1
                            1
Recurrent PE
Recurrent PE                0
                            0
Migration
Migration                   0
                            0
SVC thrombosis
SVC thrombosis              0
                            0
Cardiac tamponade
Cardiac tamponade           4
                            4
        Death
        Death               1
                            1
SVC Perforation (4 patients)


All men
< 60 years (43, 47, 48, 58)
        SVC Perforation
Demographics      Perforation             %
                                               *
 < 60 years          4 / 39               10
 > 60 years          0 / 165               0
   Male              4 / 82                5 **
  Female             0 / 122               0
                                               ***
 Male < 60           4 / 15               27
Female < 60          0 / 24                0

               * p < 0.002    ** p < 0.03 *** p < 0.02
                    Case Reports
                    Case Reports
  AUTHOR          AGE THROMBOSIS SITE            FOLLOW-UP
 Quang 1985       61       SVC                     > 6 months

 Hoffman 1986     58   L. Subclavian & SVC         > 6 months

 Pais   1987      28    B. Ax-Subclavian           > 3 months

 Owens 1992       75    L. Brachiocephalic           1 year

 Black 1993       67    R. Brachiocephalic   Expired Thrombosed SVC

Lidagaster 1994   67        Unknown          Expired Thrombosed SVC
                            SVC Filters
                            41 patients
                            Follow – up   1 day to
                            221 weeks
                            (median 15    weeks)
                            No clinical   evidence:
                                SVC syndrome
                                filter migration
                                PE due to UEDVT

Spence   Radiology   1999
            Conclusion

SVC filters are safe and effective in the
 prevention of pulmonary embolism.
             Conclusion

SVC filters should not be placed in younger
 (<60 y) male patients since the incidence of
 SVC perforation is exceedingly high (27%)
Thank you

								
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