19 year old female with arm swelling

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19 year old female with arm swelling

• Steven Shackford, MD FACS
• 2006

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• 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
• Set the patient up for your next available
  appointment10 days hence.
• Have the patient elevate the RUE call if
  swelling does not resolve.
• Refer the patient to an orthopedist
• See the patient today

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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.
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• You get a venous duplex, which shows loss of
  respiratory phasing and strongly suggests
  obstruction. You should
• Admit the patient and start anticoagulation.
• Get an arteriogram.
• Refer the patient to Hematology.
• Get a venogram.

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You get a venogram
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• Based on this venogram, you
• Admit the patient for anticoagulation
• Refer to Medicine for admission and
  anticoagulation
• Initiate lytic therapy
• Admit patient for trans-axillary first rib
  resection.

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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.
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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)
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First rib resected
Still has obstruction
SVC fills, but less intensely than the vein
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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.
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Post balloon venoplasty
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• Postoperatively, she does well. You now
• Discharge her and tell her to follow up with the
  RN at the student clinic.
• Discharge the patient on coumadin for 3 months.
• Discharge the patient on coumadin and to see you
  in the office in a month for imaging.

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Anatomic vulnerability
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Pathophysiology
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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

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Unusual strenuous effort (L)Repeated work effort
(R)
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Athletics
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Clavicular fracture

• Fracture history is remote
• Hypertrophic nonunion otherwise asymptomatic
• Intermittent obstructive symptoms not uncommon
• Usually an active person

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Symptoms

• ALL will have these to some degree
• Acute gt subacute gt chronic
• Swelling 85-90
• Pain 75-85
• Heaviness, fatigue, aching
• Violaceous discoloration 35-50
• Paresthesias 5-10
• Coldness 0-5

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Signs

• Swelling (not edema)
• Violaceous discoloration
• Dilated superficial collateral veins
• Tender axillary cord
• Normal motor exam
• Normal sensory exam
• May have allodynia

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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

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Treatment Rationale

• No treatment
• Disability 25 (Hughes E, Int Abs Surg 3889,
  1949)
• Pulmonary embolism 12-35
• Usually gt 1 risk factor
• Case fatality rate 10
• SVC syndrome reported rarely
• Venous gangrene
• 16 reported cases (Smith B, Ann Surg 201511,
  1985)
• Amputation 54
• Mortality 31

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Treatment Continuum

• Dependent on acuity
• Gangrene med surg
• Acute med lytics /- surg
• Subacute med /- lytics /- surg
• Chronic /- med /- surg

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Venous Gangrene

• Limb threatening
• Heparin bolus
• Thrombectomy of all major branches
• Esmarch wrap with vein open proximal control
• Coumadin INR 3-4

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Treatment Acute UE DVT

• Early diagnosis imperative
• Collaterals form ? lytic efficacy
• Lytics for 24-72h
• Arm elevation
• Heparin bolus ptt gt2-3x control
• Coumadin INR 2-3 for 3 months
• Interval stress venography
• Timing of 1st rib resection
• Varies 1 day 3months

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axilla
lipoma
subclavian vein
chest wall
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subclavian artery
brachial plexus
subclavian vein
anterior scalene (cut)
1st rib
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Scalene tubercle
lipoma
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Pre-op obstruction Post-lysis
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UEDVT lt10 days old
thrombolytics
success-no stenosis
success-stenosis
1st rib rsn
stress venogram
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angioplasty
anticoag x 3 mos
1st rib rsn
anticoag x 3 mos
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UEDVT gt 10 days
anticoagulation x 3 months
symptomatic
stress venogram
obstructs with stress
obstructed
consider reconstruction
1st rib resection
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Summary

• All UEDVT is secondary
• Virchows Triad
• UEDVT is under-diagnosed
• Delay in treatment worsens outcome
• Treatment depends on clinical presentation
• Acute
• Subacute
• Chronic