“The Natural History of Upper Extremity Acute DVT” John E. Rectenwald MD, MS Associate Professor of Surgery Associate Professor of Radiology University of Michigan Venous Management of Acute and Chronic DVTs SVS Vascular Annual Meeting 2012 National Harbor, MD

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John E. Rectenwald, MD, MS. Nothing To Disclose

Venous Management of Acute and Chronic DVTs 2012 SVS Vascular Annual Meeting

Overview of Acute UE DVT Incidence Demographics Complications Pathogenesis Diagnosis Management

Incidence of UE acute DVT • Approximately 10% of all cases of DVT involve the upper extremities – 0.4-1 case per 10,000 people

• Incidence is increasing – increased use of central venous catheters, cardiac pacemakers, defibrillators

• Secondary causes are more common than primary • Historically considered a benign and selflimited process

Demographics of UE DVT As compared to patients with lower extremity DVT: • Patients with upper extremity DVT are typically – Younger (Age 64) – Leaner (BMI 28.5) – More likely to have malignancy – Less likely to have acquired or hereditary thrombophilia • Patients with non-CVC associated UE DVT are even younger and leaner (Age 59, BMI 26) Joffe. Circulation 2004;110:1605

Complications of UE DVT As compared to patients with lower extremity DVT:

• Complications are less common in patients with UE DVT – PE approximately 6% (15-30% for LE DVT) – 2-5% recurrence at 12 months (10% LE) – PTS occurs in 5% (up 50% in LE DVT) • Axillary/subclavian location and residual thrombosis at 6 months increases risk • Risk of PTS is less in catheter-related DVT Kucher. NEJM 2011;364:861

Pathogenesis of UE DVT Primary (20% of cases) • Venous thoracic outlet syndrome – Compression of the subclavian vein from 1st rib, clavical, subclavius or anterior scalene muscle

• Effort-related thrombosis (Paget-Schroetter’s) – Microtrauma from repetitive arm movements, vigorous exercise, +/- TOS

• Idiopathic – No relation to TOS or effort

Secondary (80% of cases) • Catheter-related thrombosis – CVCs, pacemaker, defib

• Cancer-associated – Associated hypercoag state, treatment induced coagulopathies, direct tumor involvement of vein

• Surgery or trauma of the arm/shoulder • Pregnancy, OCP, ovarian hyperstim syndrome

Presentation of UE DVT • Presenting symptoms can be vague – Discomfort, pain, parasthesias, and weakness in the arm are common

• Findings on exam – Swelling, edema, discoloration, and visible venous collaterals

• Can present with SVC syndrome – Facial swelling, headache, nausea, dyspnea

• Two-thirds of patients with CVC and pacemaker-related DVT are asymptomatic

Diagnosis of UE DVT • History and physical exam helpful • Pretest clinical prediction scores – Used with variable success

• D-dimer assay – Good for ruling out the diagnosis, but not considered a good screening tool

Diagnosis of UE DVT • Duplex ultrasonography with compression – Proximal subclavian and SVC difficult to visualize and compress due to overlying bony structures – Metaanalysis of 9 studies showed sensitivity of 97%, specificity of 96% for UE DVT

• Conventional venography – Largely replaced by ultrasonography – Reserved for patients with indeterminate duplex studies and helpful in patients with TOS

• CTV/MRV – May be useful but limited data available Di Nisio. J Thromb Hasmost 2010;8:684

Management of Catheter Associated UE DVT • Routine catheter removal is generally not recommended – Difficult access, continued need for further IV access should be considered – Must be able to anticoagulate the patient

• Removal is warranted in – Malfunctioning catheter, infection, contraindication to anticoagulation, persistent signs and symptoms despite treatment Chest Guidelines 2012

Management of UE DVT Anticoagulation Therapy • Management of UE DVT is based on data from trials with LE DVT – No randomized, controlled trial have been done in UE DVT patients

• Metaanalysis of 4 observational studies in patients with UE DVT – 209 patients treated (mainly) with LMWH – Recurrent rate 1.9%, no PE in studies. Kovacs. J Thromb Haemost 2007;5:1650 – Major bleeding rate 2-4% Karabay. J Int Med Res 2004;32:429 Prandoni. BMJ 2004;329:484 Savage. Thromb Haemost 1999;82:1008

Management of UE DVT Anticoagulation Therapy • Initial treatment of UE DVT usually involves LMWH with unfractionated heparin reserved for patients with renal dysfunction • Effects of once vs twice daily tx with LMWH has not been studied • No data for optimal duration of treatment in UE DVT is available – 3-6 months of vitamin K antagonist recommended – Use of LMWH in patients with cancer preferred

Management of UE DVT Thrombolysis • Catheter-directed thrombolysis should be reserved for patients with recent onset, extensive swelling and functional impairment of arm with minimal bleeding risk – Data imputed from studies in LE DVT – Symptoms should be less than 14 days in duration

• One small study in 30 patients with thrombolysis of UE DVT – 97% partial or complete recanalization, major bleeding complication occurred in 9%, rate of mild PTS was 21%

• Mechanical thrombolysis only in patients with persistent, severe symptoms after failure of thrombolysis Vik. Cardiovasc Interv Radiol 2009;32:980

Management of UE DVT Stenting • Venous stents in general have been associated with mixed results – One Study of 49 patients who had venous stents placed – Most had temporary improvement but 62% require reintervention at 2 years

• Stents should not be used to treat residual stenosis at the costocavicular junction – High rates of stent deformation, fracture and recurrent thrombosis Oderich. J Vasc Surg 2000;32:760

Management of UE DVT Surgery • Prospective, randomized trial data for surgical treatment of UE DVT (thrombectomy, venoplasty, venous bypass) are lacking • However, adequate surgical decompression for the venous thoracic outlet appears to improve outcomes – 240 patients in two case series showed a 85% venous patency rate and no PTS after surgical decompression of the thoracic outlet Schneider. J Vasc Surg 2004;40:599.

Management of UE DVT Surgery • Decompression involves first rib resection with or without anterior scalenectomy or resection of the costoclavicular ligament • Preoperative thrombolysis and postdecompression venoplasty are useful adjuncts for treatment of venous TOS

Summary • UE DVT presents with discomfort, swelling of the arm • Risk factors include vigorous arm exercise, CVC, pacemaker, history of DVT or cancer • Presence of a CVC in UE DVT does not mandate removal of the CVC if the patient can be anticoagulated • Anticoagulation with heparin should be initiated followed by vitamin K antagonist for 3-6 months

Summary • Catheter-directed thrombolysis should be reserved for patients with massive swelling and functional impairment of recent onset • Surgery should be reserved for thrombolysis failure or patients with TOS