Management of catheter-related upper extremity deep vein thrombosis in patients with cancer: a systematic review and meta-analysis.

BACKGROUND: Patients with cancer commonly require a central venous catheter, which is associated with an increased risk of venous thromboembolism (VTE). Despite the frequent occurrence, the optimal anticoagulation management and outcomes for patients with cancer and catheter-related upper extremity deep vein thrombosis (DVT) are unclear. OBJECTIVE: We performed a systematic review and meta-analysis to evaluate the rates of recurrent VTE and bleeding in patients with cancer and catheter-related upper extremity DVT. METHODS: We searched MEDLINE, Embase, Scopus, and CENTRAL from inception to June 2, 2023. The primary efficacy outcome was recurrent VTE, and the primary safety outcome was major bleeding. The incidence rates (with 95% CI) of outcomes were pooled using random effects model. RESULTS: We included 29 studies (N = 2,836), among which 5 were prospective. The duration of follow-up and anticoagulation varied considerably. The main long-term anticoagulant used was low molecular weight heparin, followed by direct oral anticoagulants. The pooled 3-month recurrent VTE rate from 14 studies (N = 1,128) was 0.56% (95% CI, 0.10%-3.01%; I2 = 0%). The pooled 3-month major bleeding rate from 10 studies (N = 834) was 2.34% (95% CI, 1.14%-4.76%; I2 = 0%). We were unable to pool event rates beyond 3 months, given high heterogeneity. All studies had serious risk of bias. CONCLUSIONS: Our study demonstrated a relatively low rate of recurrent VTE and moderate rate of major bleeding events within the first 3 months in patients with cancer and catheter-related upper extremity DVT. However, there was significant heterogeneity in the management and reporting after 3 months.

[Two Cases of Catheter-Related Venous Thrombosis Treated with Direct Oral Anticoagulants(DOAC)].

The implantation of a totally implantable central venous(CV)access port is considered a risk factor for venous thromboembolism( VTE). In the treatment of catheter-related thrombosis(CRT), both European and American guidelines recommend anticoagulation therapy with catheters in place. We experienced 2 cases of upper extremity deep vein thrombosis (UEDVT)after the implantation of CV access ports through the left subclavian vein for adjuvant chemotherapy in patients with resected breast cancer. Both patients were successfully treated with direct oral anticoagulants(DOAC) while the port remained in place with a careful follow-up that included monitoring of serum D-dimer levels. The administration of DOAC to CRT that develops in patients undergoing postoperative adjuvant chemotherapy for breast cancer may be relatively safe, with a low potential for adverse events such as bleeding.

Low-dose apixaban or rivaroxaban as secondary prophylaxis of upper extremity deep vein thrombosis.

Upper extremity deep vein thrombosis (UEDVT) may occur without inciting factor or may be secondary to malignancy, surgery, trauma, central venous catheter or related to thoracic outlet syndrome (TOS). International guidelines recommend anticoagulant treatment for at least three months, in particular the use of vitamin K antagonists (VKAs) and direct oral anticoagulants (DOACs). No data on extended anticoagulant therapy and reduced dose of DOACs have been reported in patients affected by UEDVT with persistent thrombotic risk (active cancer, major congenital thrombophilia) or without affected vein recanalization. In our retrospective observational study, including 43 patients, we treated secondary UEDVT with DOACs. In the acute phase of thrombosis (median time of 4 months), we used therapeutic dose of DOACs; the 32 patients with permanent thrombotic risk factors or without recanalization of the UEDVT were shifted to low-dose DOACs (apixaban 2.5 mg twice daily or rivaroxaban 10 mg daily). During therapy with full-dose DOACs, 1 patient presented recurrence of thrombosis; no thromboembolic events were observed during treatment with low-dose DOACs. During full-dose treatment, 3 patients presented minor hemorrhagic complications; no hemorrhagic events were observed during DOACs at low dose. We think our preliminary data could support the indication to extend the anticoagulation with dose reduction of DOACs in patients affected by UEDVT and no-transient thrombotic risk. These data should be confirmed in randomized controlled prospective study.

A Man in His 50s With an Unusual Network of Small Veins in the Left Infraclavicular Region-Paget-Schroetter Syndrome.

This case report describes a diagnosis of Paget-Schroetter syndrome in a man in his 50s with a network of small veins in the left infraclavicular region discovered after unsuccessful left subclavian vein puncture.

Axillary vein thrombosis 30 h after caesarean section: a case report and literature review.

BACKGROUND: Axillary vein thrombosis is a very rare disorder. However, a case of axillary vein thrombosis shortly after caesarean section has not been reported previously. We report a case of axillary vein thrombosis 30 h after caesarean section due to an unidentified aetiology. CASE: A 37-year-old multiparous woman developed swelling and pain of the forearm and hand 30 h after undergoing a caesarean section. Doppler ultrasonography revealed a 14.9 mm × 5.3 mm thrombosis in the left axillary vein although a prophylaxis of anticoagulation was administrated. After an adjusted-dose of low-molecular-weight heparin (LMWH) was administered, the patient recovered and was discharged. CONCLUSION: Obstetricians should be fully aware of the possibility of upper extremity deep vein thrombosis (DVT) despite its rarity, especially after the surgery. Lying in the lateral decubitus position for long periods postoperatively should be avoided as much as possible.

Preoperative thrombolysis is associated with improved vein patency and functional outcomes after first rib resection in acute Paget-Schroetter syndrome.

INTRODUCTION: Most patients with acute Paget-Schroetter syndrome (PSS) present in one of two manners: (1) thrombosis managed initially with thrombolysis and anticoagulation and then referred for surgery, and (2) initial treatment with anticoagulation only and later referral for surgery. Definitive benefits of thrombolysis in the acute period (the first 2 weeks after thrombosis) over anticoagulation alone have not been well reported. Our goal was to compare patients managed with early thrombolysis and anticoagulation followed by first rib resection (FRR) and later postoperative venography with venoplasty (PTA) with those managed with anticoagulation alone followed by FRR and PTA using vein patency assessed with venography and standardized outcome measures. METHODS: We reviewed a prospectively collected database from 2000 to 2019. Two groups were compared: those managed with early thrombolysis at our institution (Lysis) and those managed with anticoagulation alone (NoLysis). All patients underwent FRR. Venography was routinely performed before and after FRR. Standardized outcome measures included Quick Disability of Arm, Shoulder, and Hand (QuickDASH) scores and Somatic Pain Scale. RESULTS: A total of 50 Lysis and 50 NoLysis patients were identified. Pre-FRR venography showed that thrombolysis resulted in patency of 98% of veins, whereas 78% of NoLysis veins were patent. After FRR, postoperative venography revealed that 46 (92%) patients in the Lysis group and 37 (74%) patients in the NoLysis group achieved vein patency. Thrombolysis was significantly associated with final vein patency (odds ratio: 17 [4-199]; P < .001). Lysis patients had a trend toward lower QuickDASH scores from pre-FRR to post-FRR compared with NoLysis patients with a mean difference of -16.4 (±19.7) vs -5.2 (±15.6) points (P = .13). The difference in reduction of Somatic Pain Scale scores was not statistically significant. CONCLUSIONS: Thrombolysis as initial management of PSS, combined with anticoagulation, followed by FFR and VenoPTA resulted in improved final vein patency and may lead to an improved functional outcome measured with QuickDASH scores. Therefore, clinical protocols using thrombolysis as initial management should be considered when planning the optimal treatment strategy for patients with acute PSS.

Incidence of upper extremity deep vein thrombosis in the retrosternal reconstruction after esophagectomy.

BACKGROUND: Upper extremity deep vein thrombosis (UEDVT) is relatively rare but cannot be negligible because it can cause fatal complications. Although it is reported that the occurrence rate of UEDVT has increased due to central venous catheter (CVC), cancer, and surgical invasion, there is still limited information for esophagectomy. The aim of this study was to evaluate the clinical factors, including CVC placement and thromboprophylaxis approach, as well as retrosternal space's width as a predictive factor for UEDVT in patients receiving esophagectomy. METHODS: This study included 66 patients who underwent esophagectomy with retrosternal reconstruction using a gastric tube. All patients routinely underwent contrast-enhanced computed tomography (CT) on the 4th postoperative day. Low-molecular-weight-heparin (LMWH) was routinely administered by the 2nd postoperative day. To evaluate retrosternal space's width, (a) The distance from sternum to brachiocephalic artery and (b) the distance from sternum to vertebra were measured by preoperative CT, and the ratio of (a) to (b) was defined as the width of retrosternal space. RESULTS: Among all patients, 11 (16.7%) suffered from UEDVT, and none was preoperatively received CVC placement, while 7 were inserted in non-UEDVT cases. Retrosternal space's width in patients with UEDVT was significantly smaller than that in patients without UEDVT (0.17 vs. 0.26; P < 0.0001). A cutoff value of the width was 0.21, which has high sensitivity (87%) and specificity (82%) for UEDVT prediction, respectively. CONCLUSION: The existence of CVC may not affect the development of UEDVT, but preoperative evaluation of retrosternal ratio may predict the occurrence of UEDVT.

Upper extremities deep vein thrombosis treated with oral direct anticoagulants: A prospective cohort study.

BACKGROUND: Limited data are available on the role of direct oral anticoagulants (DOACs) for the treatment of upper extremities deep vein thrombosis (UEDVT). OBJECTIVES: The aim of this study was to assess the effectiveness and safety of DOACs in the treatment of UEDVT. METHODS: Patients with an objectively confirmed acute UEDVT treated with DOACs were merged from prospective cohorts to a collaborative database. Primary study outcomes were recurrent venous thromboembolism (VTE) and major bleeding occurring during DOAC treatment. RESULTS: Overall, 188 patients were included in the study: mean age 52.4 ± 20.4 years, males 43.6%, patients with active cancer 29.2%. Twenty-nine percent of patients had 2 or more risk factors for VTE, 33.0% had catheter-related or pacemaker-related UEDVT. In 13.8% of patients, DOACs were started one month after UEDVT diagnosis or later. Active cancer was an independent predictor for delayed initiation of DOACs (OR 8.1, 95% CI 3.0-22.2). Mean duration of treatment with DOACs was 5.1 ± 2.8 months. During treatment with DOACs, recurrent VTE occurred in 0.9 per 100 patient-year, major bleeding in 1.7 and all-cause deaths in 6.0 per 100 patient-year. No fatal bleeding or fatal VTE recurrence were observed. During 232.1 patient-years of follow-up after DOAC withdrawal, recurrent VTE occurred in 3.0 per 100 patient-year. The 2019 ESC categories for risk of VTE recurrences were able to discriminate patient groups at different risk of events in the on and off-treatment periods. CONCLUSIONS: Our data support the feasibility as well as the effectiveness and safety of DOACs for the treatment of acute UEDVT.

Phlegmasia Cerulea Dolens in the Upper Extremity: A Case Report and Literature Review.

Phlegmasia cerulea dolens (PCD) is a rare condition characterized by deep venous thrombosis with gangrene. It can result in critically severe edema that affects the blood supply to the limbs. PCD generally occurs in the lower rather than upper extremity. We herein present a case report of upper extremity PCD and discuss thrombophilia secondary to low protein S activity as the main cause. Catheter-directed thrombolysis via the occluded end of the artery may be one of the best treatment methods for PCD.

Long-term outcome after nonsurgical management of Paget-Schroetter syndrome.

OBJECTIVE: Paget-Schroetter syndrome (PSS) is an uncommon disease with potentially debilitating long-term effects. The optimal therapy for PSS is unclear, and the role of surgical decompression of the thoracic outlet is still being questioned. In this study, we present long-term results of patients treated with catheter-directed thrombolysis (CDT) and anticoagulation without surgical management. METHODS: This is a retrospective case series of all patients who previously underwent treatment of PSS in our institution between the years 2007 and 2019. Patients were evaluated for clinical signs of post-thrombotic syndrome (PTS) using a modified Villalta scoring scale, including measurements of the circumference of the treated and untreated arms. Duplex ultrasound examination of the treated vein was performed, and quality of life was evaluated using the shortened Disabilities of the Arm, Shoulder, and Hand questionnaire. RESULTS: Eighteen consecutive patients previously treated for PSS with CDT and anticoagulation compose the cohort of this study. None underwent surgical thoracic outlet decompression. All were contacted and invited for clinical and ultrasound evaluation. Follow-up was available for all patients. Mean age at diagnosis was 29 years (range, 16-46 years), and 15 (79%) were male. Mean time from the index event to the follow-up clinic visit was 109 months (range, 37-176 months). Patients were treated with anticoagulation for a mean period of 26 months (range, 6-120 months). Seventeen patients (94%) had a Villalta score of 0 to 3, consistent with nonexistence of PTS. Fourteen patients (78%) were completely asymptomatic. Seven patients (39%) had no difference in arm circumference. A difference in arm circumference between the treated arm and the healthy arm of 1 cm and 2 cm was seen in nine (50%) and two (11%) patients, respectively. Based on the shortened Disabilities of the Arm, Shoulder, and Hand score, none of the patients suffered from impaired quality of life. Duplex ultrasound scanning of the affected veins was performed on 16 of the 18 patients (89%). The vein appeared patent in all examined patients. In three patients, the wall of the examined vein was thickened and irregular. CONCLUSIONS: This study suggests that PSS patients can be treated with anticoagulation and CDT alone, without the need for surgical thoracic outlet decompression. This is based on long-term follow-up of these patients objectively evaluated by means of valid scoring systems. These findings suggest that symptoms or signs of PTS rarely develop, the patients do not suffer from impaired quality of life, and patency of the diseased vein is commonly maintained.

Jugular venous catheter-associated thrombosis and fatal pulmonary embolism: A case report.

INTRODUCTION: Central venous catheters related thrombosis (CRT) insertion has been shown to increase the risk of venous thromboembolism, particularly pulmonary embolism (PE). Nevertheless, deaths cased due to PE have been rarely reported. PATIENT CONCERNS: A central venous catheter was introduced through the right jugular vein during the operation due to severe septic shock from a 57-year-old male patient. Two days after surgery, the hemodynamics was stable. On the 7th day, and low molecular weight heparin calcium (4100 units, once a day) was added for anticoagulation to prevent venous thromboembolism. On the 15th day, during the process of central venous catheter removal, the patient suddenly lost consciousness, suffered cardiac arrest, and received emergency cardiopulmonary resuscitation. DIAGNOSIS: Jugular venous catheter-associated thrombosis and fatal PE. An acute bedside ultrasound showed a thrombus drifting with the blood stream in the right jugular vein. The lower section of the xiphoid process by echocardiography showed decreased systolic amplitude of the right atrium and right ventricle, widened and fixed inferior vena cava, and no variation with respiration. Para-sternal left ventricular long axis section showed that the right ventricular outflow tract was significantly extended, and the contraction amplitude of the anterior and posterior walls of the left ventricle decreased. Left ventricular short axis section indicated a right ventricle enlargement and ventricular septum deviation of left ventricle, showing "D" sign. Apical 4-chamber view showed that the right ventricular ratio increased and the contractile capacity decreased. INTERVENTIONS: One and a half million units of urokinase were immediately given trough intravenous drip. OUTCOMES: Twenty minutes after thrombolysis, the patient's autonomic heart rhythm was recovered, but continued to suffer from hypotension and coma, followed by multiple organ failure, and died 50 hours later. CONCLUSION: Recent clinical practice guidelines recommend against the routine use of any anticoagulant thromboprophylaxis in patients with central venous catheters, but for patients at particularly high risk for CRT, consideration can be given to using higher doses of anticoagulant as prophylaxis, although there are virtually no data to support this approach.

Soccer player with unusual right shoulder and arm pain and swelling.

INTRODUCTION Paget-Schroetter syndrome, or effort thrombosis, refers to a deep venous thrombosis in an upper extremity. It is most commonly located in the axillary or subclavian veins and is associated with vigorous repetitive movements and anatomic abnormalities. CASE PRESENTATION This case study describes an 18-year-old Division 1 soccer player who presented with worsening axillary swelling and pain. He was found to have subclavian stenosis at the level of the thoracic inlet between the clavicle and first rib, with deep venous thrombosis in his right axillary, subclavian, proximal brachial, and basilic veins. It was diagnosed with ultrasound and confirmed with venography. He was treated initially with enoxaparin and warfarin before having mechanical thrombolysis, balloon venoplasty, infusion of tissue plasminogen activator, and a right first rib resection. CONCLUSION As Paget-Schroetter syndrome is rare, early recognition and management leads to fewer long-lasting sequelae and less morbidity. Left untreated, it can result in pulmonary embolism and residual upper extremity obstruction.

Upper extremity deep vein thrombosis treated with direct oral anticoagulants: a multi-center real world experience.

Upper-extremity deep vein thrombosis (UEDVT) accounts for about 5-10% of all cases of deep vein thrombosis (DVT). It is often associated with cancer and/or presence of a central venous catheter (CVC), but it may also occur in the absence of these favoring conditions. The safety and efficacy of using direct oral anticoagulants (DOACs) in subjects with UEDVT has not been systematically evaluated and the only data available in the literature derive from anecdotal evidence, analysis of registries, and small single-centre studies. In addition, a specific analysis of UEDVT not associated with cancer and/or CVC has never been made. In this study, we specifically focused on patients with no cancer and without a CVC who were diagnosed with a first episode of UEDVT and were treated with a DOAC. We studied 61 patients, treated in six Italian centres between January 2014 and December 2018. Treatment lasted at least 3 months in all patients. In terms of efficacy, no recurrence of thrombosis or pulmonary embolism were recorded, while Doppler ultrasonography, performed after at least three months of treatment, documented in all cases either partial or complete recanalization of obstructed veins. In terms of safety, no cases of major bleedings were recorded. This is the only series available in the literature of patients treated with DOACs for UEDVT not associated with cancer and/or CVC. This small multicenter real world experience supports the concept that DOACs might be safe and effective for treating UEDTV. Further studies are required to better understand the role of DOACs in these patients.

Pediatric CNS Tumor Patients Have Significantly Lower Requirement of Tissue Plasminogen Activator for Episodes of Central Venous Catheter Dysfunction Compared With Other Pediatric Oncology Patients: Results of a Population-based Cohort Study.

PURPOSE: Central venous catheters (CVCs) are an important component of care delivery in pediatric oncology patients. However, CVC dysfunction is a common problem. Tissue plasminogen activator (tPA) is often administered to re-establish function, however, specific experience in pediatric patients with central nervous system (CNS) tumors is lacking. The goal of this study was to investigate the CVC experience and use of tPA for episodes of CVC dysfunction in pediatric patients with CNS tumors in comparison with other patients. METHODS: Medical records of all pediatric oncology patients from the 4 Atlantic provinces in Canada (Nova Scotia, New Brunswick, Prince Edward Island, and Newfoundland and Labrador) were reviewed. Data collected included demographics, treatment, details of CVCs along with CVC dysfunction, and tPA use. RESULTS: The cohort consisted of 1152 pediatric oncology patients, 222 (19.3%) of whom had CNS tumors. CVC dysfunction requiring tPA administration occurred in 12 (5.4%) of patients with CNS tumors compared with 182 (19.6%) of patients with non-CNS tumors (P=0.0001). Multivariate logistic regression analysis showed that administration of tPA for CVC dysfunction was 2.5 times more likely in patients with non-CNS tumors than those with CNS tumors (P=0.012; 95% confidence interval, 1.3-4.9). CONCLUSIONS: Our study showed that pediatric patients with CNS tumors require significantly less frequent administration of tPA for episodes of CVC dysfunction than patients with non-CNS tumors after adjusting for confounding factors. Hypotheses for this include: potential biologic differences of tumors, the role of the blood-brain barrier, or systematic differences in intensity of treatments.

Trombosis venosa profunda en extremidad superior como complicación tras luxación de la articulación acromioclavicular / Upper limb deep vein thrombosis as complication of acromioclavicular joint dislocation

Un 5-10% de las trombosis venosas profundas ocurren en el miembro superior. Su causa más frecuente suele ser secundaria a cáncer, catéter venoso central, tratamiento con radio-quimioterapia u hormonal. Con menor frecuencia, los traumatismos en la región del hombro también pueden ser causantes de una trombosis venosa profunda. Su diagnóstico probablemente sea más complejo que en la extremidad inferior debido a su baja frecuencia, así como por la clínica que presenta, siendo un 50% de los casos asintomáticos o presentando tan solo una cervicalgia u omalgia leves. Debido a su infrecuencia, las recomendaciones terapéuticas se basan en la evidencia indirecta de estudios de la trombosis venosa profunda de la extremidad inferior, siendo la anticoagulación oral el mejor tratamiento. Presentamos un caso clínico de trombosis venosa profunda en miembro superior tras sufrir traumatismo directo en el hombro por una caída con bicicleta de montaña, causando una luxación acromioclavicular grado III de Rockwood

Around 5%-10% of deep vein thrombosis occurs in the upper limb. Its most frequent cause is usually cancer, central venous catheter, radio-chemotherapy or hormonal treatment. Less commonly, trauma around the shoulder region can also be a cause of deep vein thrombosis. Its diagnosis is probably more complex than in the lower limb due to its low frequency and clinical suspicion, as well as the clinical presentation, 50% of the cases being asymptomatic or presenting only with mild neck pain or omalgia. Because of their infrequency, therapeutic recommendations are based on indirect evidence from studies of deep vein thrombosis of the lower limb, considering oral anticoagulation the best treatment. We report a case of deep vein thrombosis in the upper limb after trauma to the shoulder causing grade III Rockwood acromioclavicular dislocation

Rivaroxaban in the treatment of upper extremity deep vein thrombosis: A single-center experience and review of the literature.

INTRODUCTION: Direct oral anticoagulants (DOACs) have become widely used to treat patients with venous thromboembolism (VTE), but evidence about their use in the treatment of upper extremity deep vein thrombosis (UEDVT) is lacking. OBJECTIVES: To assess rivaroxaban's efficacy and safety in the treatment of UEDVT. PATIENTS/METHODS: This was a single-center prospective observational study involving patients with their first UEDVT episode confirmed by duplex ultrasound scan. All patients initially received low-molecular-weight heparin for 1 to 2 days and then were switched to rivaroxaban for 3-6 months. The primary endpoint was any symptomatic episode of recurrent VTE. RESULTS: Thirty patients were included in the study, and all patients were followed for 6 months. There were no episodes of recurrent symptomatic venous thromboembolism or asymptomatic UEDVT. No episode of major bleeding was observed. Clinically relevant non-major bleeding occurred in two patients (6.7%, 95% confidence interval [CI]: 1.9-21.4%) with uterine bleeding and large skin hemorrhage. Minor bleeding was observed in two patients (6.7%, 95% CI: 1.9-21.4%) presenting with nasal and gingival bleeding. Recanalization of the upper extremity deep veins was observed in all affected limbs at three months, and it persisted up to 6 months. The signs of upper limb post-thrombotic syndrome (PTS) were found in four patients (13.4%; 95% CI: 5.4-29.8%), and the mean modified Villalta score was 2.1 ±â€¯1.9. CONCLUSION: Treatment of UEDVT with rivaroxaban, preceded by one to two days of LMWH, seems to be safe and effective.

Paget-Schroetter syndrome in a teenager after throwing firecrackers - A case report.

Paget-Schroetter syndrome (PSS), or effort thrombosis, refers to axillary and/or subclavian vein thrombosis associated with repetitive effort of the superior limbs, and is rare in the pediatric population. We report the case of a previously healthy 15-year-old boy who presented with a painful and swollen right arm after throwing firecrackers. Doppler ultrasound showed extensive right subclavian and axillary vein thrombosis. Anticoagulation therapy was started and had favorable evolution. We emphasize that PSS must be included in the differential diagnosis of a swollen arm.