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Subclavian DVT: Diagnosis in Seconds with POCUS.

Introduction

In the diagnosis of extremity thromboembolic disease, ultrasound is generally the initial imaging modality. However, access to specialized vascular ultrasound services is often limited. Physicians with experience in lower extremity venous ultrasound should be capable of translating this technique to the less common upper extremity venous thrombosis.

Point of Care Ultrasound (POCUS) for the diagnosis of suspected lower extremity deep venous thrombosis (DVT) is a well-established practice in the medical literature. (1) Ultrasound is non-invasive, saves time, is widely available, and is inexpensive compared to other diagnostic measures. Further, POCUS for DVT is accurate and reliable. (2)

The use of POCUS for upper extremity DVT is not as well described or routine as lower extremity DVT. Upper extremity DVT, while less common than lower extremity DVT, is associated with higher morbidity and mortality. (3-5) Thus, time effective approaches to rapid diagnosis are critical if upper extremity DVT is suspected. Here, we report a case of upper extremity DVT diagnosed in seconds using POCUS and review the typical presentation, sonographic technique and typical findings of upper extremity DVT.

Case Report

A 59-year-old male presented to the emergency department with a chief complaint of right arm swelling. He denied any other symptoms. He had recently been discharged from the hospital with a right sided PICC line for longer term antimicrobial treatment of bacteremia and an abscess. He had multiple comorbid conditions and a 35 pack-year smoking history.

On physical examination, he exhibited mild right upper extremity edema, he was diaphoretic and skin of the affected extremity was warm.

A bedside compression venous ultrasound of the right upper extremity that included the brachial veins, the axillary vein, the subclavian vein, and the internal jugular vein was performed revealing a distended, incompressible right subclavian vein which contained a visible intraluminal thrombus. The patient was started on unfractionated heparin and admitted to the hospital for further management. During his hospitalization, his PICC was removed and he was started on oral warfarin. The remainder of his course was unremarkable.

Discussion

POCUS for Upper Extremity DVT

POCUS has been applied and studied in reference to a multitude of applications, and reports in the literature have shown and described its successful application to lower extremity DVT. However, the literature is sparse regarding the use of POCUS for upper extremity DVT, and there is no consensus on the optimal approach or protocol. The intention of this case report is to demonstrate and describe that POCUS can be successfully applied to diagnosing upper extremity DVT, including the more challenging vasculature such as the subclavian vein.

Contrast venography is considered the reference standard for the diagnosis of upper extremity thrombosis, but is infrequently performed due its invasive nature and the availability of noninvasive alternatives. (2) Ultrasound has been shown to have a high degree of accuracy in identifying upper extremity thrombosis with sensitivity and specificity levels as high as 82% each. (4) Thus, due to its wide availability and noninvasive nature, ultrasound is an efficacious initial imaging modality when upper extremity DVT is suspected. The practicality and safety coupled with the emerging knowledge of ultrasound's efficacy in identifying upper extremity thrombosis leads us to conclude that this approach should be used in the emergency setting when a physician has a suspicion of an upper extremity thrombosis.

It should be emphasized that in high probability cases, a negative ultrasound, POCUS or consultative, should not be used to completely exclude upper extremity, specifically central DVT. While positive findings on ultrasound are sufficient to initiate therapy, a negative ultrasound should be followed by CT or MR venography if the clinical likelihood of DVT is judged to be high. (6) The reported sensitivity and specificity of CT:venography has been reported as high as 95.9% and 95.2% respectively (6). Data is more limited regarding MR:venography and the recommendation for its use comes from American College of Radiology guidelines. (2)

Figure 3 depicts techniques and approaches to performing upper extremity POCUS on patients who are suspected to have an upper extremity DVT and also depict some of the pertinent anatomy when performing ultrasound on the vasculature of the upper extremity.

Epidemiology and background

The prevalence of upper extremity DVT is not accurately known in comparison to lower extremity DVT. Some data has indicated that upper extremity DVT prevalence may account for as many as 2 per 1000 patient hospital admissions. (7) While prevalence is not fully understood, risk factors for upper extremity DVT are well characterized. The most commonly associated predisposition to developing an upper extremity DVT are patients who have indwelling PICC lines. (8-12) It has been reported that as many as 38.5% of the population who has an upper extremity thrombosis also had an indwelling PIC line at the time of the thrombus development. (8) It is likely that underlying conditions associated with the need for PICC placement also contribute significantly to the risk of DVT, including malignancy and inflammatory states. Other risk factors include ovarian hyperstimulation, and chronic illnesses such as heart disease, cancer, or renal failure. (3,9,12-5)

Diagnosis and treatment

Similar to detection of lower extremity thrombosis, the primary finding in upper extremity thrombosis is a lack of venous compressibility. A visible thrombus can often be seen also (see figures 1 and 2). Other findings, such as a loss of phasicity and/or attenuation with spectral Doppler analysis can assist in identifying venous thrombosis. In addition, comparison view of the unaffected side can be helpful in unclear or more difficult cases.

Ultrasound examination of proximal upper extremity vasculature is challenging due to the surrounding anatomy. However, with proper technique, most portions of upper extremity vasculature, including the subclavian vein can be visualized based on three key components of the ultrasound exam--gray scale imaging, Doppler wave form analysis, and color Doppler imaging. Because of the superficial nature of the vessels of interest, a high frequency linear transducer should be employed. With the probe placed inferior to the clavicle, indicator directed cephalad, the subclavian vein and artery can be distinguished from one another just inferior to the distal half of the clavicle bone. Proximal to the distal half, Doppler analysis and compressibility can both be used to differentiate between artery and vein. (16)

Examination for upper extremity DVT should proceed in a systematic fashion to effectively visualize the extent of the upper extremity vasculature when thrombus is suspected. First, the brachial veins and artery should be visualized adjacent to one another, with the veins immediately adjacent to and touching the artery. Compressibility can be assessed to confidently distinguish brachial artery and veins. Next, the brachial vein can be followed proximally to the axillary vein. The axillary vein should then be followed as proximal as possible, examining for compressibility all along its course. Next, the subclavian vein should be identified just inferior and deep to the clavicle. The subclavian artery should be adjacent and pleural sliding can also be seen deep to the subclavian artery. Once the subclavian vein has been found, it can be assessed for compressibility and filling by color Doppler. Comparison views to the unaffected side, noting diameter, compressibility, and phasicity may be carried out for unclear findings. Following assessment of the subclavian vein, the internal jugular vein should be examined as well. Lastly, if no DVT is identified, examination of the superficial upper extremity veins, the cephalic and basilic may be carried out, as this may provide a diagnosis and explanation for patient's symptoms. (16)

In specific reference to the subclavian vasculature, an important relationship to appreciate is that of the subclavian vein and subclavian artery. The subclavian vein should be found slightly anterior to the subclavian artery, and this relationship can be quickly confirmed based on color Doppler sonography.

Upon examination of a subclavian vein thrombosis, one would expect to find venous distension. In some instances, intraluminal thrombus may be visible on gray scale imaging. On color Doppler analysis, decreased or absent flow through the vessel would be expected. Finally, on Doppler sonography, one would expect to find decreased pulsatility or absence of signal in the affected vessel.

Once diagnosed, treatment of upper extremity thrombosis is similar to that of lower extremity thrombosis. (8) The standard approach includes unfractionated or low molecular weight heparin bridged to oral warfarin. (6) The newer oral anticoagulants, although not specifically studied for upper extremity may be considered depending on the particular clinical scenario. A review of all patient data should influence the choice of therapy including the presence of indwelling catheters, underlying disease states, and other factors. Initial therapy with unfractionated heparin is the standard approach for inpatient anticoagulation therapy for indwelling catheter-associated upper extremity DVT. (17) Unfractionated heparin is commonly administered initially, which is then eventually converted to oral warfarin therapy. (18)

Removal of the indwelling PICC line is not indicated unless the line is nonfunctional or is no longer needed for patient treatment. (8,19) Careful PICC line management is essential because removal and replacement of the line in a different upper extremity location is associated with up to an 86% increased risk for the patient developing another upper extremity thrombosis. (10) In some cases, more aggressive catheter directed therapies or surgical thrombectomy may be considered, but literature is sparse regarding these therapies in upper extremity DVT (20)

Complications

The most dangerous complication of upper extremity thrombosis is pulmonary embolism (PE).(14,21,22) PE has been reported to complicate up to 36% of all upper extremity vein thrombosis cases, compared to a reported PE incidence rate of 14.5% in lower extremity vein thrombosis. (3,21) PE has a high rate of morbidity and mortality, and thus it is critical that subclavian thrombosis be quickly diagnosed and treated. Another important morbidity associated specifically with upper extremity DVT is propagation of the cerebral vasculature resulting in neurologic complications. (23)

Only a small fraction of diagnosed upper extremity thromboses are found in the subclavian vein, so it is critical to be able to recognize and diagnose this uncommon presentation of upper extremity thrombosis. (9,10) Additionally, it is important for emergency physicians to be aware that this unique presentation of an upper extremity thrombosis can be effectively identified by ultrasound.

As mentioned, the use of ultrasound as a diagnostic tool for emergency physicians in training is a key aspect of their education and professional practice. We believe that this technique can be translated to use in the upper extremity as well. Providers experienced in DVT ultrasound are capable of rapidly completing a systematic sonographic examination for upper extremity DVT, noting typical findings and performing comparison views when necessary. As previously mentioned, any negative ultrasound should be followed with some form of angiography in high risk cases.

In summary, we present a case of subclavian vein thrombosis as a complication of PICC line insertion that was diagnosed in seconds using POCUS. This report clearly demonstrates that POCUS is an approach that can be implemented to rapidly detect this diagnosis. This approach appears to be safe, rapid, cost effective, and may lead to better patient outcomes and lower cost.

References

(1.) Hanley M, Donahue J, Rybicki F, et al. ACR appropriateness criteria [R]: Suspected lower-extremity deep vein thrombosis. Journal of the American College of Radiology. 2014; 1-6.

(2.) Dill K, Bennett S, Hanley M, et al. ACR appropriateness criteria [R] suspected upper extremity deep vein thrombosis. Journal of the American College of Radiology. 2014;1-9.

(3.) Shah M, Burke D & Shah S. Upper-extremity deep vein thrombosis. Southern Medical Journal. 2003;96(7):669-672.

(4.) Baarslag HJ, Edwin JR, van Beek EJ, Koopman MMW, Reekers JA. Prospective study of color duplex ultrasonography compared with contrast venography in patients suspected of having deep venous thrombosis of the Upper Extremities. Ann Intern Med. 2002;136:865-872.

(5.) Hingorani, A.; Ascher, E.; Hanson, J, et al. Upper extremity versus lower extremity deep venous thrombosis. The American Journal of Surgery. 1997;174(2):214-217.

(6.) Grant JD, Stevens SM, Woller SC, Lee EW, Kee ST, Liu DM, Lohan DG, Elliott CG. Diagnosis and management of upper extremity deep-vein thrombosis in adults. Thromb Haemost. 2012 Dec;108(6):1097-108.

(7.) Kroger K, Schelo C, Gocke C, Rudofsky G. Colour Doppler sonographic diagnosis of upper limb venous thromboses. Clinical Science. 1998;94:657-661.

(8.) Carr P, & Rippey J. Upper extremity deep vein thrombosis: a complication of an indwelling peripherally inserted central venous catheter. Clinical Case Reports. 2015;3(3):170-174.

(9.) Abdullah B, Mohammad N, Sangkar, J, et al. Incidence of upper limb venous thrombosis associated with peripherally inserted central catheters (PICC). The British Journal of Radiology. 2005;78:596-600.

(10.) Jones M, Lee D, Segall J, et al. Characterizing resolution of catheter-associated upper extremity deep vein thrombosis. Journal of Vascular Surgery. 2010;51(1):108-113.

(11.) Ong B, Gibbs.H, Catchpole I, Hetherington R, Harper J. Peripherally inserted central catheters and extremity deep vein thrombosis. Australian Radiology. 2006;451-454.

(12.) Lee J, Zierler B, Zierler E, et al. The risk factors and clinical outcomes of upper extremity deep vein thrombosis. Vascular and Endovascular Surgery. 2012;46(2):139-144.

(13.) Hingorani A, Ascher E, Markevich, N, et al. Risk factors for mortality in patients with upper extremity and internal jugular deep venous thrombosis. Journal of Vascular Surgery, 2004;41(3):476-478.

(14.) Hingorani A, Ascher E, Lorenson, E, et al. Upper extremity deep venous thrombosis and its impact on morbidity and mortality rates in a hospital-based population. Journal of Vascular Surgery. 1997;26(5):853-860.

(15.) Bar-On S, Cohen A, Levin I, Avni A, Lessing J, Atmog B. Upper extremity deep vein thrombosis following ovarian stimulation.

Harefuah. 2011;150(11):849-851.

(16.) American Institute of Ultrasound in Medicine (AIUM) Practice Parameter for the Performance of Peripheral Venous Ultrasound Examination. Available at: http://www.aium. org/resources/guidelines/peripheralvenous.pdf

(17.) Engelberger R, & Kucher N. Management of deep vein thrombosis of the upper extremity. Circulation. 2012;126:768-773.

(18.) Joffe H, & Goldhaber S. Upper-extremity deep vein thrombosis. Circulation. 2002;106: 1874-1880.

(19.) Crawford J, Liem T, & Moneta, G. Management of catheter-associated upper extremity deep venous thrombosis. Journal of Vascular Surgery: Venous and Lymphatic Disorders. 2016; 4(3):375-379.

(20.) Kucher M. Deep-vein thrombosis of the upper extremities. The New England Journal of Medicine. 2011;364:861-869.

(21.) Goldhaber S, & Tapson V. A prospective registry of 5,451 patients with ultrasound-confirmed deep vein thrombosis. American Journal of Cardiology. 2004;93:259-262.

(22.) Tapson V. Acute pulmonary embolism. The New England Journal of Medicine. 2008;358:1037-1052.

(23.) Kahn S, & Elman E. The post-thrombotic syndrome after upper extremity deep venous thrombosis in adults: A systematic review. Thrombosis Research. 2006;117(6):609-614.

Cody Mullens, MSII

West Virginia University, School of Medicine

Joseph Minardi, MD

West Virginia University, Department of Emergency Medicine

Nicholas Denne, MD

West Virginia University, Department of Emergency Medicine

Nicole Dorinzi, MD

West Virginia University, Department of Emergency Medicine

Erin Setzer, MD

West Virginia University, Department of Emergency Medicine

Corresponding Author: Cody Mullens, MSN, 288 McCullough Rd, Morgantown, WV 26505. Email: cmullen3@mix.wvu.edu

Funding: This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.

Conflicts of Interest: None
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Article Details
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Title Annotation:Case Report; deep vein thrombosis; Point of Care Ultrasound
Author:Mullens, Cody; Minardi, Joseph; Denne, Nicholas; Dorinzi, Nicole; Setzer, Erin
Publication:West Virginia Medical Journal
Article Type:Case study
Date:Sep 1, 2017
Words:2522
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