Risk stratification and incidence of acute

complications in upper extremity deep vein thrombosis (UEDVT)

patients.Dr. Santosh Yatam Ganesh MBBS,

MPH.,Mentors: Dr. Khalid J. Qazi MD, MACP.,

Dr. Paul Anain MD, FACS.

VI.XII.MMXIII

Overview of the presentation

• Purpose of research• Epidemiology• Introduction to Upper extremity deep vein thrombosis

(UEDVT)• Research design• Results• Discussion• Conclusion

Purpose of research

• To understand the risk factors of the UEDVT;

• To identify complications rate due to UEDVT during the hospital stay;

• This study will help optimize patient care and decrease the incidence of UEDVT;

Epidemiology• Annual incidence is 0.4-1 per 10,000 people;

• Of all the deep vein thrombosis cases, nearly 10% involve upper extremity;

• Incidence increasing;– Peripherally inserted central catheter(PICC), – Central venous catheter(CVC), – Malignancy.

• Complications are rare;– Pulmonary embolism, – SVC syndrome, – Post thrombotic venous insufficiency.

Introduction to Upper extremity deep vein thrombosis (UEDVT)

• Defined as a thrombus in any of the upper extremity deep veins.

• Deep veins of upper extremity: Radial, Ulnar, Brachial, Axillary, Subclavian, Internal Jugular.

• Superficial veins of upper extremity: Digital, Metacarpal, Cephalic, Basilic, Median.

Primary Secondary

• Venous thoracic outlet syndrome,

• Effort-related thrombosis (Paget–Schroetter syndrome) or

• Idiopathic.

• PICC, • CVC, • Malignancy.

• The Computerized Registry of Patients with Venous Thromboembolism (RIETE):– Multicenter study involving Spain, France, Italy, Israel, Argentina – Data released by CHEST in 2008– 11564 total. 512 had UEDVT.– Significant findings compared to lower extremity DVT:

• younger age,• Lower BMI, • association with Cancer, • higher overall mortality.

– Also more association with PE compared to without UEDVT.• 9% had PE

• At University of California• Recent article• One year study• Out of 373 patients underwent Ultrasound 94 had DVT• Mean age 51• 46(49%) had malignancy• Pain swelling common symptoms• 11 patients had PE• Subclavian : most common vein

• One year data from 12 hospitals.• Total 483. Out of which 69 had UEDVT

• Significantly associated with Central lines, ICU admissions• No difference in 30 days, 6 months and 1year outcomes• No statistical difference in association to cancer

UEDVT LEDVT

16 per 10,000 71 per 10,000

AGE: 59 66

Research Question

• To find the risk factors in patients with upper extremity deep venous thrombosis;

• To find the incidence of acute complications related to upper extremity deep venous thrombosis;

Methodology• Study populations was identified using ICD9 codes.

• Either admitting diagnosis or diagnosed during the hospital stay.

• Retrospective chart review.

• Data from last three years.

• At Sisters of charity hospital and Mercy hospital of Buffalo.

• Used EMR and paper charts.

Inclusion criteria :

• Adults age above 18.

• Patients with newly diagnosed upper extremity deep vein thrombosis.

• Diagnosis during hospitalization or at admission.

• Confirmatory evidence of diagnosis.

Exclusion criteria :

• Patients without confirmatory evidence in the imaging will be excluded.

• Patients who have chronic deep vein thrombosis with duration greater than 60 days.

• Other thrombosis like in lower extremity.

Total charts : 327

Thrombosis in UE: 272

UEDVT:187

Superficial vein thrombosis:

85

Excluded: 55

Results

Age Distribution for DVT patients only

BMI N %

<18.49 7 3.7

18.5-24.99 60 32.1

25-29.99 55 29.4

30-39.99 65 34.76

Mean Weight 80.8 Kgs

Mean BMI 28.39

3.7

32.1

29.4

34.7

Body Mass Index

<18.4918.5-24.9925-29.9930-39.99

Axillary Subclavian Brachial Internal Jugular0

10

20

30

40

50

60

70

80

90

100

9085 84

42

Veins

Swelling Pain Erythema Other0

20

40

60

80

100

120

140

160

148

59

1724

Presenting Signs/Symptoms

44(24%)

17( 9%)126(67%)

DVT Prophylaxis

NOArrivedYES

Frequency % Cumulative %PICC 82 43.9 43.9

CVC/Dialysis/Mediport 34 18.2 62.0

Pacemaker/AICD 14 7.5 69.5

Unidentified 12 6.4 75.9

none 45 24.1

Total 187 100.0 100

Co-Morbidities N Percentage

HTN 121 61.7

Cancer 63 33.7

Dyslipidemia 61 32.6

COPD 58 31

DM 56 29.9

CHF 53 28.3

Sepsis 51 27.3

CAD 46 24.6

Hypothyroidism 38 20.3

CKD 37 19.8

CVA/TIA 20 10.7

H/o Hypercoagulability 18 9.6

Mechanical 7 3.7

N %PE 14 7.5

SVC 9 4.8

Other 2 1.1None 162 86.6Total 187 100

7.5%4.8%

1.1%

86.6%

COMPLICATIONS DURING THE HOSPITAL-IZATION

PESVCOtherNone

Comparing Upper extremity

deep venous thrombosis with superficial venous thrombosis

<40 41-50 51-60 61-70 >71 Total

Deep VT 12 24 31 37 83 187

Superficial VT

9 10 8 15 43 85

Total 21 34 39 52 126 272

Symptoms DVT(%) SVT(%) p Value Relative risk CI

Swelling 148(79) 69(81) 0.699 0.975 .85-1.1

Pain 59(31) 17(20) 0.04 1.57 1.1-2.5

Erythema 17(9) 8(9.4) 0.932 0.96 0.43-2.32

Lines frequency in Deep venous thrombosis and Superficial venous thrombosis patients

PICC CVC/Dialysis/Mediport

Pacemaker/AICD

Unidentified None

DVT 82 34 14 12 45

SVT 25 9 2 2 47

Total 107 43 16 14 92

COMORBIDITY DVT(%) SVT(%) p-value RR CI

HTN 121(65) 51(60) 0.45 1.07 0.88-1.32

SMOKING 92(49) 38(44) 0.492 1.10 0.83-1.45

CANCER 63(33) 10(12) <.0001 2.86 1.54-5.30

DYSLIPIDEMIA 61(33) 26(31) 0.73 1.06 0.729-1.56

COPD 58(31) 21(25) 0.28 1.25 0.81-1.92

DM 56(30) 26(31) 0.91 0.97 0.66-O.852

CHF 53(28) 18(21) 0.21 1.33 0.83-2.14

COMORBIDITY DVT(%) SVT(%) p-value RR CI

SEPSIS 51(27) 19(22) 0.39 1.2 0.77-1.93

CAD 46(24) 16(19) 0.29 1.3 0.78-2.17

H/o DVT 39(20) 7(8) 0.017 2.53 1.18-5.42

HYPOTHYROIDISM

38(20) 8(9) 0.004 2.15 1.05-4.42

CKD 37(20) 5(6) 0.004 3.36 1.37-8.25

CVA/TIA 20(11) 8(9) 0.74 1.1.3 0.522-2.47

H/o Hypercoagulable

18(10) 2(3) .05 4.09 0.97-17.23

Frequency of Complications in hospitals

For Pulmonary embolism comparing DVT and SVT p Value is 0.211 rr: 2.12, CI: 0.62-7.18

p Value: 0.013, rr: 3.78 CI: 1.17-12.2

Complications during hospitalization comparing Deep VT vs. Superficial VT

DiscussionDemographics:

• Age– 65% of patients are above the age of 65.– Mean age is higher compared to RIETE study.

• Gender:– No major difference.

• Race:– More common in Whites.– Results are similar to the study done at University at California.

• BMI:– Increase in BMI increases risk for UEDVT.– Average weight is higher than other studies.

Risk Factors:• Smoking:

– Nearly 50%.• HTN, COPD, Cancer, Dyslipidemia:

– In more than 1/3rd of patients.• CHF, Sepsis, CAD:

– In more than 1/4th of the patients.Investigation tool:• US is the most commonly used diagnostic modality

– Sensitivity75-95%.– Specificity 95-98%.

Symptoms:• Swelling is the most common symptom.Lines: • PICC, CVC, PACEMAKER/AICD: 75%.• 2/3rd of patients were on DVT prevention prophylaxis with anticoagulants.

Comparing UEDVT and Superficial vein:

• Pain is associated with UEDVT;

• Lines are important risk for UEDVT compared to SVT;

• History of previous DVT increases risk for future DVT compared to SVT;

• Cancer, CKD and Hypothyroidism are associated with UEDVT than SVT;

• Overall more complications from UEDVT during hospital stay;

• Study done by Liviu et al (publishes in Chest in 2008) it showed statistically significant association of hypothyroidism and DVT. No studies particularly on UEDVT.

• Daneschvar et al study has shown the association between the UEDVT and CKD. They compared the 268 patients with CKD with 4,307 patients with preserved kidney function. 30% Patient with CKD had UEDVT compared to 10 without ckd.

• A study at University of California by Jung-Ah lee on 373 UEDVT patients cancer was diagnosed in 48% of patients. We had lesser number of patients with cancer however hospitals we conducted study does not have dedicated cancer floors.

Conclusions• Clinical profile of patients with UEDVT and Superficial thrombosis were variable.

• Suspect UEDVT compared to Superficial thrombosis – Swelling– Cancer– CKD– Hypothyroidism– With Lines

• Patients with UEDVT overall experience more complications than Superficial vein thrombosis during the hospital stay.

• First study to find differences in risk factors for Deep vein thrombosis vs Superficial thrombosis in Upper extremity.

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Special thanks

Mentors: Dr. Qazi & Dr. Anain.

Guidance: Dr. Woodman & Dr. Tourbaf.

Acknowledgement

Statistician: Dr. Satchidanand.