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Venous Interventions

Upper Extremity DVT

� Primary Upper Extremity Venous Thrombosis

� Catheter Associated Thrombosis

� Venous Thoracic Outlet Syndrome

The Thoracic

Outlet

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Presentation

� Sudden onset

� Edema

� Pain, “Heaviness”, “Tightness”

� Cyanotic discoloration

� Equally affecting men and women

� Usually between 15-45 yo

Diagnosis

� Traditionally, with US

� Often the first step, even now

� MR or CTV can provide all the info of US as well as much else

� Catheter based venography remains the gold standard

� Provides the immediate ability to proceed with thrombolysis

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Primary Upper Extremity Venous

Thrombosis

� In fact, actually very rare

� Therapy is the same as for UE DVT of secondary cause (etiology is often

understood only in retrospect)

� Heparinoids/Novel Oral Anticoagulants/Coumadin

� Thrombolysis

J Vasc Surg. 1986Oct;4(4):333-7

Axillary-subclavian venous occlusion: the morbidity of a nonlethal disease.

Gloviczki P, Kazmier FJ, Hollier LH.

� To evaluate results of medical and surgical treatment of axillary-subclavian venous occlusion, the clinical courses of 95 patients were reviewed. Twenty-three patients had acute axillary-subclavian venous thrombosis, and 72 patients had chronic occlusion. Thirty-four patients with thoracic outlet syndrome and axillary-subclavian occlusion represented 3.5% of the 969 patients treated for thoracic outlet syndrome during the same period. Nonlethal pulmonary embolization from the axillary-subclavian vein occurred in four patients. Sixty percent of patients were asymptomatic or had mild symptoms during strenuous exercise at last follow-up (mean, 5.4 years). Forty-eight of these 56 patients had received anticoagulation during the acute phase of the disease. Twenty-seven percent of patients had symptoms with moderate exercise and 12.6% had symptoms at rest. Thirteen patients had operations, with improvement demonstrable in 10 patients. All five patients who underwent first rib resection for intermittent venous occlusion or for thoracic outlet syndrome after thrombosis occurred on the contralateral side did well. Axillary-subclavian venous occlusion is a nonlethal disease but late sequelae occur in one third of patients. Early anticoagulation appears to be beneficial and, in some patients with concomitant thoracic outlet syndrome, first rib resection also appears to be helpful. Further data are needed to evaluate results of fibrinolytic treatment, thrombectomy, and venous reconstruction.

Gloviczki et al

� 4% of patients had PE from the upper extremity DVT

� 27% of patients had life limiting symptoms with mild activity

� 13% of those affected had symptoms at rest

� Early intervention with anticoagulation and resolution of the underlying

anatomic defect resolved the symptoms in 90% of those affected

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Post

Thrombotic

Syndrome

� Chronic edema

� Pain

� Cosmetic disfigurement

� Loss of function

� Potential compromise of the ability to remain employed

How Do We

Prevent This?

� Anticoagulation

� Compression

� Thrombolysis

� Angioplasty

� Decompression of the SCV

� Open Venous Reconstruction

Prevention of PTS: Anticoagulation

� Immediate

� -----Heparin

� -----Lovenox

� -----Usually NOT NOADs

� Long term, post intervention

� -----3? 6? 12? months

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Prevention of

PTS:

Compression

� Less of an issue in the upper extremity vs lower

extremity

� Can be life changing for patients who develop

PTS

� Not normally indicated after uncomplicated,

initial UE DVT

� Can be used in the lower extremity soon after a

DVT diagnosis is made

� No custom fitted garments until the initial

edema is resolved

Thrombolysis

� Indicated for virtually all young patients found to have

SCV thrombosis

� Best opportunity to avoid PTS

� Uncovers the underlying cause

� Provides rapid symptom relief

Thrombolysis: Contraindications

� CVA within 90 days

� AVM/Intracranial neoplasm/Recent neurosurgery

� Recent head trauma or facial fractures

� Non-CNS surgery within 3 weeks

� Puncture of “non-compressible vessel” (relative)

� Active bleeding

� Multiple relative, “minor” contraindications

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Thrombolysis:

IDEAL

Thrombolysis:

REAL

Thrombolysis:

REALLY REAL

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Venous

Stenting?

Addressing the Real Problem:

Alteration of the SCV

� Extrinsic Scarring

� Intrinsic Synechiae

� First Rib Deformities

� Anomalous tendons/muscles

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First Rib Resection

� J Vasc Surg Venous Lymphat Disord. 2016 Oct;4(4):485-500. doi: 10.1016/j.jvsv.2016.01.004.

� Diagnosis and treatment of effort-induced thrombosis of the axillary subclavian vein due to venous thoracic outlet syndrome.

� Vemuri C1, Salehi P2, Benarroch-Gampel J3, McLaughlin LN3, Thompson RW4.

� …most frequently occurs in young, active, healthy patients.

� …pathophysiology is repetitive compression injury of the SCV in the costoclavicular space, resulting in venous scarring, focal stenosis, and eventual thrombosis.

� …After restoration of SCV patency, patients are maintained with anticoagulation and surgical therapy is usually planned within 4 to 6 weeks.

� Surgical management of VTOS …accomplished via different protocols (paraclavicular, transaxillary, infraclavicular). …paraclavicular approach is emphasized in this review, because it affords the surgeon the ability to safely perform complete thoracic outlet decompression (complete anterior and middle scalenectomy, removal of the entire first rib, and resection of the subclavius muscle and costoclavicular ligament), along with definitive management of the damaged SCV (external venolysis, intraoperative venography, and direct vein reconstruction, if needed, using patch angioplasty or bypass grafting), in one operative setting.

� After surgical therapy, interval anticoagulation and a comprehensive physical therapy and rehabilitation program are important in achieving a return to full function. Current protocols on the basis of the paraclavicular surgical approach have thereby routinely provided patients with lasting symptomatic relief, freedom from indefinite anticoagulation, and the ability to return to unrestricted upper extremity activity.

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Paraclavicular Approach

Vein Patch

Venous UE Thrombosis—

--contemporary approach

� Prompt identification

� Anticoagulation

� Thrombolysis

� Address ANY AND ALL underlying anatomic issues

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Primary Thrombosis?

� As noted, quite rare

� Diagnosis of exclusion

� “Am I actually missing the problem here?”

� Additional testing (hypercoagulable syndrome?)

� Long term anticoagulation

Catheter

Associated

Thrombosis

� Far more common than usually appreciated

� --Studies describe an incidence of 2% to 75%

� --Incidence depends upon type of catheter, time

it’s been in place, patient variables, US

surveillance

� Prophylaxis with anticoagulation controversial,

not clearly demonstrated to help (and takes on

the risk of anticoagulation)

� A functioning, necessary indwelling catheter

can be left in place while therapy is ongoing

(although this does raise its own set of issues)

� Treatment with 6 to 12 months of oral

anticoagulation for the DVT is recommended

LOWER EXTREMITY DVT/STENOSIS

(ACUTE AND CHRONIC)

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DVT

� A common problem…as many as 900,000 per year in the US alone

� Therapy has been less than satisfactory

� Between 20 and 50% of DVT patients will develop PTS

� Surely, there is a better answer?

DVT: Therapy

� Prompt Suspicion of the Diagnosis

� Ultrasound for Confirmation

� Anticoagulation

� Compression

� What else?

Post Thrombotic Syndrome

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Venous Percutaneous Thrombolysis

� tPA and or rheolytic catheters

� --AngioJet

� --Pneumbra

� --Others

� Overall, dramatic reduction in PTS but few randomized, prospective studies

� Risk reduced with rheolytic catheters, but nothing is risk free

AngioJet

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Consequently……

� Used for young, otherwise healthy patients

� Iliac venous thrombosis

� Without contraindication to ‘lysis

� Intracranial hemorrhage is the dread complication

� It is NOT the standard of care in the management of LE DVT

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May-Thurner Syndrome

� Stenosis of the Left CIV due to compression by the R CIA

� Often have moderate edema, chronic “aching pain”

� May appear late in life or younger in active athletes

� TIP: Reflux in the left common femoral vein on US

Rouleaux Formation

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May Thurner: Therapy

May Thurner Syndrome

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Bibliography

� Gloviczki P, Kazmier FJ, Hollier LH. Axillary-subclavian venous occlusion: the morbidity of a non-lethal disease. J Vasc Surg 1986; 4 (4): 333-337.

� Vemuri C, Salehi P, Benarroch-Gampel J, mcLaughlini LN, Thompson RW. Diagnosis and treatment of effort-induced thrombosis of the axillary subclavian vein due to venous thoracic outlet syndrome. J Vasc Surg Venous Lymphat Disord. 2016 Oct;4(4):485-500. doi: 10.1016/j.jvsv.2016.01.004.

� Comerota AJ, Kamath V. Thrombolysis for iliofemoral deep venous thrombosis. Expert Rev. Cardiovasc Ther 2013; 11(12): 1631-1638.

� J Vasc Surg Venous Lymphat Disord. 2016 Oct;4(4):485-500. doi: 10.1016/j.jvsv.2016.01.004.

� Diagnosis and treatment of effort-induced thrombosis of the axillary subclavian vein due to venous thoracic outlet syndrome.

� Vemuri C1, Salehi P2, Benarroch-Gampel J3, McLaughlin LN3, Thompson RW4.

� Raju S, Ward M, Davis M. Relative importance of iliac vein obstruction in patients with post-thrombotic femoral vein occlusion. Jvasc Surg: Venous and Lym Dis 2-15; 3: 161-7.

� Osman A, Ng J, Patel M, War d TJ, Wang DS, et al. Endovascular stent placement for May-Thurner syndrome in the absence of acute deep vein thrombosis. J Vasc Interv Radiol 2016; 27: 167-173.