Acute Upper Extremity and Catheter-Related Venous Thrombosis

Introduction

Acute upper extremity deep venous thrombosis (DVT) characterizes a disease process that ranges from an acutely swollen and painful extremity to one that is asymptomatic. This condition can be classified as either primary or secondary. Primary upper extremity DVT is related to either effort thrombosis (i.e. Paget–Schroetter syndrome – see Ch. 126 , Thoracic Outlet Syndrome: Venous) or an idiopathic cause. Secondary upper extremity DVT develops in patients with either a cancer or an indwelling central venous catheter. As the prevalence of central venous catheter placement increases, secondary thromboses are increasingly outnumbering those related to primary causes.

The prevalence of acute upper extremity DVT, based on a prospectively collected registry – The Computerized Registry of Patients with Venous Thromboembolism (RIETE) – is approximately 4.4% of all DVTs. Almost half of the cases in that registry are catheter-related. Furthermore, studies have documented that in comparison with lower extremity DVT, patients who suffer from upper extremity DVT have a higher mortality rate (up to 48% vs. 13% at 6 months). The high mortality rates in this population are reflective of the associated severe comorbidities rather than the central catheter or the thrombosis itself. ^, Subsequent data have demonstrated similar outcomes between upper extremity DVT and lower extremity DVT. ^,

In the United States alone, greater than five million catheters are inserted yearly to administer fluids, antibiotics, nutrition, and provide hemodialysis needs. With an increasing number of central venous catheters inserted, the overall incidence of catheter-related venous complications including thrombosis, sepsis, pulmonary embolism (PE) and death is simultaneously becoming a considerable issue. There is clearly an elevated incidence of thrombosis in cannulated veins versus noncannulated veins. This was demonstrated in an autopsy study as the risk of venous thrombosis among cannulated versus noncannulated vessels was 36% vs. 1.6%, respectively. ^, This chapter focuses on acute upper extremity catheter-related deep venous thrombosis.

Clinical Findings

Most patients with catheter-related upper extremity DVT are asymptomatic. For example, in a study documenting catheter-related thrombosis in cancer patients, the authors demonstrated that asymptomatic thrombi were present in 29% of patients (range 5% to 62%) vs. symptomatic thrombi in 12% of patients (range 5% to 54%).

Erythema, pain or swelling located at neck, chest or arm are a few of the common symptoms, if present. In patients with significant disease, there is often tremendous engorgement of the veins along the chest wall or the extremity. In rare instances, phlegmasia cerulean dolens has been reported. ^,

Pulmonary embolism is known to occur in 5% to 20% of patients with upper extremity DVT. A prospective study of patients with upper extremity DVT routinely performed ventilation–perfusion scans to determine the prevalence of PE among all patients with upper extremity DVT. The scans demonstrated that 13 out of 86 (15.1%) patients developed a PE. The most common underlying comorbidity for these patients was cancer (31.4%). Additionally, Monreal et al., found that the higher incidence of PE (20%) occurred in the patients that had DVT associated with an underlying indwelling catheter. ^,

Post-thrombotic syndrome, consistent with a painful and swollen extremity after the acute episode, is also known to occur after upper extremity DVT. In a retrospective study by Hingorani et al., 13-month follow-up of 170 patients yielded 4% prevalence of symptoms associated with PTS. However, others have reported the incidence of post-thrombotic syndrome to be as high as 35%.

Diagnostic Strategies

Duplex ultrasonography is the mainstay for diagnosis of most upper extremity DVT. It is noninvasive and more cost-effective than other diagnostic modalities. The diagnosis is confirmed with augmentation maneuvers without appropriate response, noncompressibility of the venous segment, or the signal echogenicity in B-mode along a venous segment.

A 2009 review article demonstrated duplex ultrasonography to be 86% to 100% specific and 78% to 100% sensitive in the diagnosis of upper extremity DVT. The thromboses that diminished the sensitivity of the duplex ultrasonography were those that incompletely assessed the veins, or located at the proximal subclavian or brachiocephalic veins. Furthermore, a prospective study in 66 patients with leukemia evaluated the role of ultrasonography and venography to evaluate patients with asymptomatic upper extremity DVT. These patients underwent bilateral venography and duplex ultrasound evaluation. The authors found an overall prevalence of 29% upper extremity DVT in this cohort. They then concluded that the sensitivity of their ultrasound (37%) was far inferior to venography (79%). It was also determined by these authors that the most common missed thrombotic sites were internal jugular vein during venography and subclavian vein during duplex ultrasonography. It was also their recommendation that in those patients with suspected thrombosis, but without a confirmed diagnosis based on one test, additional testing with or without the use of adjunctive maneuvers should be performed (see Chapter Algorithm).

We recommend that if the duplex ultrasound fails to reveal a thrombus and clinical suspicion is elevated for acute upper extremity DVT, one should obtain venography by either computer tomography (CT) or magnetic resonance (MR). Although catheter-directed venography is seldom used, it remains the gold standard to determine central thrombosis.