19 year old female with arm swelling19 year old female with arm swelling

Steven Shackford, MD FACSSteven Shackford, MD FACS

20062006

You are called by a RN who staffs the UVM student You are called by a RN who staffs the UVM student health clinic about a 19 y/o female on the swim team health clinic about a 19 y/o female on the swim team who has developed RUE swelling. You should:who has developed RUE swelling. You should:

a)a) Set the patient up for your next available Set the patient up for your next available appointment—10 days hence.appointment—10 days hence.

b)b) Have the patient elevate the RUE— call if swelling Have the patient elevate the RUE— call if swelling does not resolve.does not resolve.

c)c) Refer the patient to an orthopedistRefer the patient to an orthopedistd)d) See the patient todaySee the patient today

You elect to see the patient today. She is a healthyYou elect to see the patient today. She is a healthy college athlete with no prior medical history. She college athlete with no prior medical history. She relates that since swimming practice started she has relates that since swimming practice started she has noticed increased tightness in the RUE. The day you noticed increased tightness in the RUE. The day you saw her was the first time that the arm was swollen. saw her was the first time that the arm was swollen. Exam reveals a swollen RUE with blue discoloration, Exam reveals a swollen RUE with blue discoloration, some dilated veins on the chest wall and normal some dilated veins on the chest wall and normal pulses. There is no palpable cord. You should:pulses. There is no palpable cord. You should:a) Refer the patient to Hematology.a) Refer the patient to Hematology.b) Admit to the hospital and start anticoagulation.b) Admit to the hospital and start anticoagulation.c) Get a venous duplex.c) Get a venous duplex.d) Get an arteriogram.d) Get an arteriogram.

You get a venous duplex, which shows loss of You get a venous duplex, which shows loss of respiratory phasing and strongly suggests respiratory phasing and strongly suggests obstruction. You should:obstruction. You should:

a)a) Admit the patient and start anticoagulation.Admit the patient and start anticoagulation.b)b) Get an arteriogram.Get an arteriogram.c)c) Refer the patient to Hematology.Refer the patient to Hematology.d)d) Get a venogram.Get a venogram.

You get a venogramYou get a venogram

Based on this venogram, you:Based on this venogram, you:a)a) Admit the patient for anticoagulationAdmit the patient for anticoagulationb)b) Refer to Medicine for admission and anticoagulationRefer to Medicine for admission and anticoagulationc)c) Initiate lytic therapyInitiate lytic therapyd)d) Admit patient for trans-axillary first rib resection.Admit patient for trans-axillary first rib resection.

Lytic therapy successfully opens the subclavian vein, Lytic therapy successfully opens the subclavian vein, but there is marked effacement at the point where the but there is marked effacement at the point where the vein crosses the 1vein crosses the 1stst rib. In the “stressed” position rib. In the “stressed” position (arm extended over the head) the lumen completely (arm extended over the head) the lumen completely disappears and the collaterals reappear. You now:disappears and the collaterals reappear. You now:a) Tell the patient to stop swimming and give up her a) Tell the patient to stop swimming and give up her swimming scholarship.swimming scholarship.b) Begin anticoagulation with heparin followed by b) Begin anticoagulation with heparin followed by coumadin and tell the patient to stop swimming and coumadin and tell the patient to stop swimming and give up her swimming scholarship.give up her swimming scholarship.c) Begin anticoagulation with heparin and schedule c) Begin anticoagulation with heparin and schedule her for a supra-clavicular 1her for a supra-clavicular 1stst rib resection ASAP (this rib resection ASAP (this admission).admission).d) Begin anticoagulation with heparin and schedule d) Begin anticoagulation with heparin and schedule her for a trans-axillary 1st rib resection ASAP.her for a trans-axillary 1st rib resection ASAP.

You elect to proceed with a trans-axillary 1You elect to proceed with a trans-axillary 1stst rib rib resection, which goes well. Because of your resection, which goes well. Because of your suspicion that the patient may have chronic suspicion that the patient may have chronic trauma to the vein from her swimming, you turn trauma to the vein from her swimming, you turn her supine and obtain a venogram (next slide)her supine and obtain a venogram (next slide)

First rib resectedFirst rib resected

Still has obstructionStill has obstruction

SVC fills, but less intensely thanSVC fills, but less intensely thanthe veinthe vein

Intra-operatively, you decide to:Intra-operatively, you decide to:a) Quit and put the patient on coumadin.a) Quit and put the patient on coumadin.b) Do a jugular venous turn-down to the distal b) Do a jugular venous turn-down to the distal subclavian vein.subclavian vein.c) Bypass the obstruction with 16mm ringed c) Bypass the obstruction with 16mm ringed Goretex.Goretex.d) Attempt balloon angioplasty of the d) Attempt balloon angioplasty of the obstruction.obstruction.

Post balloon venoplastyPost balloon venoplasty

Postoperatively, she does well. You now:Postoperatively, she does well. You now:a)a) Discharge her and tell her to follow up Discharge her and tell her to follow up

with the RN at the student clinic.with the RN at the student clinic.b)b) Discharge the patient on coumadin for 3 Discharge the patient on coumadin for 3

months.months.c)c) Discharge the patient on coumadin and Discharge the patient on coumadin and

to see you in the office in a month for to see you in the office in a month for imaging.imaging.

Anatomic vulnerabilityAnatomic vulnerability

PathophysiologyPathophysiology

HistoryHistory Classical or commonClassical or common

Unusual strenuous effortUnusual strenuous effort Repeated movements associated with work or athleticsRepeated movements associated with work or athletics

FrequentFrequent Old clavicle fracture with hypertrophic nonunionOld clavicle fracture with hypertrophic nonunion Situational: back pack use, prolonged positionSituational: back pack use, prolonged position

UncommonUncommon No contributing etiologyNo contributing etiology Think hypercoagulable/hypofibrinolytic stateThink hypercoagulable/hypofibrinolytic state

Unusual strenuous effort (L)Unusual strenuous effort (L)Repeated work effort (R)Repeated work effort (R)

AthleticsAthletics

Clavicular fractureClavicular fracture

Fracture history is remoteFracture history is remote Hypertrophic nonunion: Hypertrophic nonunion:

otherwise asymptomaticotherwise asymptomatic Intermittent obstructive Intermittent obstructive

symptoms not uncommonsymptoms not uncommon Usually an active person Usually an active person

SymptomsSymptoms ALL will have these to some degreeALL will have these to some degree

Acute > subacute > chronicAcute > subacute > chronic Swelling: 85-90%Swelling: 85-90% Pain: 75-85%Pain: 75-85%

Heaviness, fatigue, achingHeaviness, fatigue, aching Violaceous discoloration: 35-50%Violaceous discoloration: 35-50% Paresthesias: 5-10%Paresthesias: 5-10% Coldness: 0-5%Coldness: 0-5%

SignsSigns Swelling (not edema)Swelling (not edema) Violaceous discolorationViolaceous discoloration Dilated superficial collateral veinsDilated superficial collateral veins Tender axillary cordTender axillary cord Normal motor examNormal motor exam Normal sensory examNormal sensory exam

May have allodyniaMay have allodynia

DiagnosisDiagnosis Physical exam: suggestivePhysical exam: suggestive

Objective confirmation neededObjective confirmation needed Duplex (not B-mode): lab dependentDuplex (not B-mode): lab dependent

Sensitivity: 75-100%Sensitivity: 75-100% Limited by scanning window, nonocclusive thrombusLimited by scanning window, nonocclusive thrombus

Specificity: 100%Specificity: 100% VenographyVenography

Gold standardGold standard Allows for potential endoluminal therapyAllows for potential endoluminal therapy

Treatment RationaleTreatment Rationale No treatmentNo treatment

Disability: 25% Disability: 25% (Hughes E, (Hughes E, Int Abs Surg 38:89, 1949Int Abs Surg 38:89, 1949))

Pulmonary embolism: 12-35%Pulmonary embolism: 12-35% Usually > 1 risk factorUsually > 1 risk factor Case fatality rate: 10%Case fatality rate: 10%

SVC syndrome: reported rarelySVC syndrome: reported rarely Venous gangreneVenous gangrene

16 reported cases16 reported cases (Smith B, (Smith B, Ann Surg 201:511, 1985Ann Surg 201:511, 1985))– Amputation: 54%Amputation: 54%– Mortality: 31%Mortality: 31%

Treatment ContinuumTreatment Continuum Dependent on acuityDependent on acuity Gangrene: med + surgGangrene: med + surg Acute: med + lytics +/- surgAcute: med + lytics +/- surg Subacute: med +/- lytics +/- surgSubacute: med +/- lytics +/- surg Chronic: +/- med +/- surgChronic: +/- med +/- surg

Venous GangreneVenous Gangrene

Limb threateningLimb threatening Heparin bolusHeparin bolus Thrombectomy of Thrombectomy of allall major major

branchesbranches Esmarch wrap with vein Esmarch wrap with vein

open & proximal controlopen & proximal control Coumadin: INR 3-4Coumadin: INR 3-4

Treatment: Acute UE DVTTreatment: Acute UE DVT

Early diagnosis imperativeEarly diagnosis imperative Collaterals form: Collaterals form: lytic efficacy lytic efficacy Lytics for 24-72hLytics for 24-72h

Arm elevationArm elevation Heparin bolus: ptt >2-3x controlHeparin bolus: ptt >2-3x control Coumadin: INR 2-3 for 3 monthsCoumadin: INR 2-3 for 3 months Interval stress venographyInterval stress venography Timing of 1Timing of 1stst rib resection rib resection

Varies: 1 day – 3monthsVaries: 1 day – 3months

axillaaxilla

chest wallchest wallsubclavian veinsubclavian vein

lipomalipoma

subclaviansubclavian arteryartery

subclavian veinsubclavian vein

anterior scalene anterior scalene (cut)(cut)

11stst rib rib

brachialbrachial plexusplexus

lipomalipoma

Scalene tubercleScalene tubercle

Pre-op obstruction Pre-op obstruction Post-lysisPost-lysis

UEDVT <10 days oldUEDVT <10 days old

thrombolyticsthrombolytics

success-no stenosissuccess-no stenosis

stress venogramstress venogram

++

anticoag x 3 mosanticoag x 3 mos

11stst rib rsn rib rsn

success-stenosissuccess-stenosis

--

anticoag x 3 mosanticoag x 3 mos

11stst rib rsn rib rsn

angioplastyangioplasty

UEDVT > 10 daysUEDVT > 10 days

anticoagulation x 3 monthsanticoagulation x 3 months

symptomaticsymptomatic

stress venogramstress venogram

obstructs with stressobstructs with stress

11stst rib resection rib resection

obstructedobstructed

consider reconstructionconsider reconstruction

SummarySummary All UEDVT is secondaryAll UEDVT is secondary

Virchow’s TriadVirchow’s Triad UEDVT is under-diagnosedUEDVT is under-diagnosed Delay in treatment worsens outcome Delay in treatment worsens outcome Treatment depends on clinical presentationTreatment depends on clinical presentation

AcuteAcute SubacuteSubacute ChronicChronic