Transcript Resident Lecture: Venous disease

19 year old female with arm swelling
Steven Shackford, MD FACS
2006
You are called by a RN who staffs the UVM student
health clinic about a 19 y/o female on the swim team
who has developed RUE swelling. You should:
a) Set the patient up for your next available
appointment—10 days hence.
b) Have the patient elevate the RUE— call if swelling
does not resolve.
c) Refer the patient to an orthopedist
d) See the patient today
You elect to see the patient today. She is a healthy
college athlete with no prior medical history. She
relates that since swimming practice started she has
noticed increased tightness in the RUE. The day you
saw her was the first time that the arm was swollen.
Exam reveals a swollen RUE with blue discoloration,
some dilated veins on the chest wall and normal
pulses. There is no palpable cord. You should:
a) Refer the patient to Hematology.
b) Admit to the hospital and start anticoagulation.
c) Get a venous duplex.
d) Get an arteriogram.
You get a venous duplex, which shows loss of
respiratory phasing and strongly suggests
obstruction. You should:
a) Admit the patient and start anticoagulation.
b) Get an arteriogram.
c) Refer the patient to Hematology.
d) Get a venogram.
You get a venogram
Based on this venogram, you:
a) Admit the patient for anticoagulation
b) Refer to Medicine for admission and anticoagulation
c) Initiate lytic therapy
d) Admit patient for trans-axillary first rib resection.
Lytic therapy successfully opens the subclavian vein,
but there is marked effacement at the point where the
vein crosses the 1st rib. In the “stressed” position
(arm extended over the head) the lumen completely
disappears and the collaterals reappear. You now:
a) Tell the patient to stop swimming and give up her
swimming scholarship.
b) Begin anticoagulation with heparin followed by
coumadin and tell the patient to stop swimming and
give up her swimming scholarship.
c) Begin anticoagulation with heparin and schedule
her for a supra-clavicular 1st rib resection ASAP (this
admission).
d) Begin anticoagulation with heparin and schedule
her for a trans-axillary 1st rib resection ASAP.
You elect to proceed with a trans-axillary 1st rib
resection, which goes well. Because of your
suspicion that the patient may have chronic
trauma to the vein from her swimming, you turn
her supine and obtain a venogram (next slide)
First rib resected
Still has obstruction
SVC fills, but less intensely than
the vein
Intra-operatively, you decide to:
a) Quit and put the patient on coumadin.
b) Do a jugular venous turn-down to the distal
subclavian vein.
c) Bypass the obstruction with 16mm ringed
Goretex.
d) Attempt balloon angioplasty of the
obstruction.
Post balloon venoplasty
Postoperatively, she does well. You now:
a) Discharge her and tell her to follow up
with the RN at the student clinic.
b) Discharge the patient on coumadin for 3
months.
c) Discharge the patient on coumadin and
to see you in the office in a month for
imaging.
Anatomic vulnerability
Pathophysiology
History

Classical or common
Unusual strenuous effort
 Repeated movements associated with work or athletics


Frequent
Old clavicle fracture with hypertrophic nonunion
 Situational: back pack use, prolonged position


Uncommon
No contributing etiology
 Think hypercoagulable/hypofibrinolytic state

Unusual strenuous effort (L)
Repeated work effort (R)
Athletics
Clavicular fracture




Fracture history is remote
Hypertrophic nonunion:
otherwise asymptomatic
Intermittent obstructive
symptoms not uncommon
Usually an active person
Symptoms

ALL will have these to some degree



Swelling: 85-90%
Pain: 75-85%




Acute > subacute > chronic
Heaviness, fatigue, aching
Violaceous discoloration: 35-50%
Paresthesias: 5-10%
Coldness: 0-5%
Signs






Swelling (not edema)
Violaceous discoloration
Dilated superficial collateral veins
Tender axillary cord
Normal motor exam
Normal sensory exam

May have allodynia
Diagnosis

Physical exam: suggestive


Objective confirmation needed
Duplex (not B-mode): lab dependent
Sensitivity: 75-100%
 Limited by scanning window, nonocclusive thrombus
 Specificity: 100%


Venography
Gold standard
 Allows for potential endoluminal therapy

Treatment Rationale

No treatment
Disability: 25% (Hughes E, Int Abs Surg 38:89, 1949)
 Pulmonary embolism: 12-35%
 Usually > 1 risk factor
 Case fatality rate: 10%
 SVC syndrome: reported rarely
 Venous gangrene
 16 reported cases (Smith B, Ann Surg 201:511, 1985)

–
–
Amputation: 54%
Mortality: 31%
Treatment Continuum





Dependent on acuity
Gangrene: med + surg
Acute: med + lytics +/- surg
Subacute: med +/- lytics +/- surg
Chronic: +/- med +/- surg
Venous Gangrene





Limb threatening
Heparin bolus
Thrombectomy of all major
branches
Esmarch wrap with vein
open & proximal control
Coumadin: INR 3-4
Treatment: Acute UE DVT

Early diagnosis imperative
Collaterals form:  lytic efficacy
 Lytics for 24-72h






Arm elevation
Heparin bolus: ptt >2-3x control
Coumadin: INR 2-3 for 3 months
Interval stress venography
Timing of 1st rib resection

Varies: 1 day – 3months
axilla
lipoma
subclavian vein
chest wall
subclavian artery
brachial
plexus
subclavian vein
anterior scalene
(cut)
1st rib
Scalene tubercle
lipoma
Pre-op obstruction
Post-lysis
UEDVT <10 days old
thrombolytics
success-no stenosis
success-stenosis
stress venogram
1st rib rsn
+
-
anticoag x 3 mos
1st rib rsn
anticoag x 3 mos
angioplasty
UEDVT > 10 days
anticoagulation x 3 months
symptomatic
stress venogram
obstructs with stress
obstructed
1st rib resection
consider reconstruction
Summary

All UEDVT is secondary




Virchow’s Triad
UEDVT is under-diagnosed
Delay in treatment worsens outcome
Treatment depends on clinical presentation
Acute
 Subacute
 Chronic
