U YETKIN, T GOKTOGAN, A SAHIN, I YUREKLI, A GURBUZ
deep vein thrombosis, ultrasonography., upper extremity
U YETKIN, T GOKTOGAN, A SAHIN, I YUREKLI, A GURBUZ. Idiopathic deep venous thrombosis of the right upper extremity and our medical strategy. The Internet Journal of Thoracic and Cardiovascular Surgery. 2008 Volume 14 Number 1.
Upper extremity deep vein thrombosis is a rare thrombotic disorder. Ultrasonography is the primary imaging modality for the diagnosis of upper extremity thrombosis.In this paper we present an idiopathic deep venous thrombosis of the right upper extremity and our medical strategy.
Upper-extremity thrombosis(UEDVT) appears to be more frequent today, comprising about 2% of all deep venous limb thrombosis. Its severity depends on the type of possible complications, i.e., pulmonary embolism and post-thrombotic sequelae(1).
Our case was a 37-year-old female. She was admitted to our outpatient clinic with complaints of pain, edema, skin discoloration, tenderness and venous distension of her right upper extremity. Time between the onset of clinical signs and diagnosis was 5 days. Physical examination revealed that all the peripheral pulses were palpable. Her arm was significantly swollen with increased skin temperature (Figures 1&2).
Color Doppler ultrasonographic examination of our case showed that, although right internal jugular vein remained patent, there was acute thrombosis within right subclavian, axillary and proximal half of brachial vein. Venous segments distal to the aforementioned parts remained patent (Figures 3&4).
Our patient was then hospitalized and we started to apply our medical treatment strategy. Continuous infusion of the unfractioned heparin was introduced to keep the activated clotting time (ACT) between 200 to 250 seconds. Moreover, her affected arm was elevated. She was administered oral warfarin sodium preparation. Complementary medical treatment included an oral preparation of “Diosmin 450 mg + Hesperidin 50 mg”( 2 tablets each morning), enteric coated tablet of 300 mg acetylsalicylic acid per day, heparinoid(luitpold) 445 mg/100 g gel 2x1 US and a non-steroidal anti-inflammatory drug preparation orally. She has been hospitalized for 4 days. She was investigated for a history of malignancies, venous catheters, thoracic outlet syndrome and protein CS deficiency. After all these investigations, it was decided that this episode of DVT was idiopathic in etiology. She was kept under warfarin sodium anticoagulation therapy for 6 months, targeting the INR levels of 2.20.2. Her outpatient follow-up continues event-free with only oral medication of 300 mg acetylsalicylate per day. She is asymptomatic and her control color Doppler ultrasound showed no recurrence or post-thrombotic sequelae.
Upper extremity deep venous thrombosis (UEDVT) makes up approximately 1-4% of all episodes of deep venous thrombosis (DVT). Risk factors for UEDVT include central venous catheterization, strenuous upper extremity exercise or anatomic abnormalities causing venous compression, inherited thrombophilia, and acquired hypercoagulable states including pregnancy, oral contraceptive use, and cancer. Unexplained or recurrent UEDVT should prompt a search for inherited hypercoagulable states or underlying malignancy(2).
In the study of Sajid et al.,they analysed original studies, review articles and evaluation studies published over the last 25 years. Forty-seven studies on UEDVT encompassing 2557 patients were evaluated. The incidence of UEDVT was quoted 1-4% of the total DVT. Pulmonary embolism (2-35%) and post-thrombotic syndrome (7-46%) were the main sequelae. Anticoagulation was the universal intervention, giving 79% symptom relief (13.2% rethrombosis rate) (3).
Color Doppler ultrasonography may be useful in the diagnosis of the UEDVT (1).
Pulmonary embolism and post-thrombotic syndrome are the most common sequelae of UEDVT (2). Post-thrombotic syndrome is a chronic, potentially debilitating complication of deep vein thrombosis (DVT), yet little is known regarding risk factors and optimal management. A standardized means of diagnosis would help to establish better management protocols. The impact of upper extremity PTS on quality of life should be further quantified (4).
Early detection and treatment of UEDVT decrease complications, morbidity, and mortality (2). Simple anticoagulation is suitable for the majority of patients (3). A minimum of 3 months of warfarin sodium anticoagulant therapy is important with venous decompression(2).
The high rate of complications during thrombolysis and the lack of clinical benefit suggest that conservative treatment may be favoured (5). Chronic anticoagulation is not required in these patients (6).