Upper Extremity Thrombosis: dx and rx

Heather E. Gunter, Ph.D., HMS IIIGillian Lieberman, M.D. July, 2003

Visualizing the Venous System: Upper Extremity & Thorax

Heather E. Gunter, Harvard Medical School Year IIIGillian Lieberman, M.D.

Heather E. Gunter, Ph.D., HMS IIIGillian Lieberman, M.D.

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Some of the imaging options

Distinguished by• Image capabilities• Cost• +/- radiation, contrast

www.brighamrad.harvard.edu

Butty et al, 2002 Cosgrove, 2002

Contrast venography

magnetic resonance

ultrasound


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Patient H.V. will guide our discussion

• 52 year old woman with end stage renal failure • Dialysis access through a catheter placed in the

left internal jugular vein since August, 2002

indication: Confirm catheter location in SVC

study:

Chest X-ray

Ultrasound

Trad. venography

MRI


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Plain film assessment of central line

• Images are appropriate• Venous anatomy is

implied by catheter path• Catheter contrasts with

surroundings in thorax

• Methods are appropriate• Inexpensive• Readily available• Not operator dependent

cephalic

axillary

subclavian

I. jugular E. jugular

brachiocephalic

SVC

basilicbrachial

Venous drainage of upper armPath of IJ central line


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Catheter is well placed in R. atrium

PA Lateral

Images from BIDMC PACS


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Pt. H.V.’s dialysis access is changed

• AV fistula placed in January, 2003

• AV fistula connects• End of L cephalic v.• Side of L brachial a.

cephalic

Venous drainage of upper arm

brachial A.AV fistula


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Pt. H.V. has new onset L upper extremity edema

• DDx local edema• Venous obstruction• Lymphatic obstruction• Peripheral/ Central

• Clinical history guidance• Long term catheter

placement is associated with stenosis of vessels

• Flow disturbances in AV fistula predispose to thrombosis

cephalic


brachial A.


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First look for peripheral occlusion

• Turbulence in brachiocephalic AV fistula may have led to thrombotic occlusion

• Catheter placement may have led to stenosis along its path (i.e. left internal jugular vein-)

indication: Evaluate for peripheral venous occlusion

study:

Chest X-ray

Ultrasound

Trad. venography

MRI


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Ultrasound evaluation of peripheral vessels

• images are appropriate• Fluid contrasts with

surrounding soft tissue• Flow is represented

• methods are appropriate• Inexpensive• Readily available• No ionizing radiation

• notes• Operator dependent

cephalic


brachial A.

Region not evaluated by US


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Blood is flowing through the fistula

Konner, 2003

Mixed reds and blues indicates turbulent flow

Structural data is black and white

Flow data is colored (doppler)


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Fistula flow has decreased in past two months

April, 2003 June, 2003



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Left upper extremity veins are patent

• Compression with transducer collapses low pressure vessels

• Doppler demonstrates flow in non-occluded vessels



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Left jugular is not patent

• Vein does not compress• Either high pressure or not

patent

• Vein does not have flow• Not patent

Visualization of collaterals (not in these images) points to a chronic processImages from BIDMC PACS


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Second, look for central occlusion

• Distal obstruction ruled out with US• US demonstrated blockage in peripheral path of

catheter, which may continue centrally

indication: Evaluate for central venous occlusion

study:

Chest X-ray

Ultrasound

Trad. venography

MRI


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MRI evaluation of venous flow

• Images are appropriate• Vessels in thorax visible• Flow is represented• Soft tissue anatomy

visible• Volumetric images

• Methods are appropriate• No ionizing radiation• Gadolinium contrast (non

iodinated)• Note

• Lengthy study, expensive

L. Subclavian VL. I. Jugular VL. Brachiocephalic V

SVC V

Image from BIDMC PACS


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MRV confirms filling defect of LIJV

Image from BIDMC PACS


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L. brachiocephalic is occluded (reaction to catheter)

• Proximal left brachiocephalic artery is not visualized with intervenous contrast



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15.5mm

8.5mm

SVC stenosis (reaction to catheter)

• Filling defect in SVC is quantified with transverse slices

• Appearance is consistent with stenosis due to fibrous sheath

a. arch

a. aorta

SVC

a. arch



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Recanalization of LBCV to improve circulation

Fibrous reaction to previous catheter placement has resulted in a L. brachiocephalic occlusion and SVC stenosis.

indication: Recanalize the obstructed vein

study:

Chest X-ray

Ultrasound

Trad. venography

MRI


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Contrast venography for stenosis dilation

• Images are appropriate• Real time display• Vessels visualized• Interventions visualized

• Methods are appropriate• Compatible with

intervention

• Notes• Iodinated contrast• Ionizing radiation• Operator dependent• Expensive

cephalic

brachial A.

femoral veinsvenous catheter placement


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Angio demonstrates obstuction and collaterals

• Digital subtraction enhances contrast, but minimizes appearance of anatomical landmarks

• Dye injected into upper extremity venous access does not pass through left brachiocephalic vein

Digital subtractionRaw imagecatheters

Contrast injection



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SVC is dilated in order to access obstruction

Contast demonstrates stenosis in SVC

Ballon inflation dilates SVC

Stented vessel permits instrument passage



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Brachiocephalic V. flow is restored

• Prior to treatment contrast does not pass through BC obstruction and fills collateral vessels

• Following treatment contrast passed through patent BC and does not fill collateral vessels

1. Sharp recanalization

2. Balloon angioplasty

3. Stent placement



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Patient H.V. follow up

• L upper extremity edema resolved following recanalization procedure


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Menu of tests and their distinguishing features

US MRI venography

Cost $ $$ $$

Flow imaging yes yes yes

Tissue imaging some extensive some

Real time yes no yesAnatomic restrictions yes no no

Ionizing radiation none none yes

Contrast no yes (gad) yes (I)

Operator dependent yes no yes


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Additional approaches (not in wide spread use)

Nuclear studies of thrombosis• radiolabelled fibrinogen• radiolabelled apcitide

Lawler, 2003

Radionuclide venographyCT venography

Krishnan, 2002


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References

• (1999). The diagnostic approach to acute venous thromboembolism. Clinical practice guideline. Am J Respir Crit Care Med 160:1043

• Butty, S. et al. (2002). Body MR venography. Rad Clin N Am. 40 (4) 899- 919.

• Konner, K. (2003). The arteriovenous fistula. J Am Soc Nephrol. 14(6): 1669-80.

• Krishnan, P. (2002). Venous dilatation seen on routine mammography: a clue to superior vena cava obstruction. Chest 121(4): 1361-3.

• Lang, E. et al. (2003). Sharp racanalization for chronic central venous occlusions. In From Bench to Bedside: Emergency Revascularization.

• Lawler, L.P. (2003). Thoracic venous anatomy: multidetector row CT evaluation. Radiol Clin North Am. 41(3): 545-60.

• Meire, H., & Cosgrove D., (2001). Vascular Ultrasound. in Cosgrove in Grainger & Allison’s Diagnostic Radiology: A Textbook of Medical Imaging, 4th Ed. pp. 59-80.


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Acknowledgements

• Phoebe Lewit Olhava, M.D.• Elvira Lang, M.D.• Pamela Lepkowski• Larry Barbaras

Documents

Upper Extremity Thrombosis: dx and rx