Role of Ultrasound in the Detection and Management of Upper Extremity Thrombosis

1. Role of Ultrasound in the Detection and Management of Upper Extremity Thrombosis Joseph R. Grajo, M.D.1 and Harsha Nalluri, B.S.2 1University of South Florida, Department of Radiology, Tampa, FL 2Northeast Ohio Medical University, Rootstown, OH Background • Use of a Clinical Prediction Score to Improve Effectiveness of Ultrasound Screening: • A clinical prediction score can improve the accuracy of ultrasound screening for UET • In a clinical prediction score for diagnosing upper extremity thrombosis created by Constans J et al using a multivariate logistic regression: • 64-70% ofpatients with a high probability score had upper extremity venous thrombosis. • Low probability score was still associated with 13% prevalence of UET.13 • A clinical prediction score can be used to identify patients who would most benefit from screening as well as decrease costs • Before a clinical prediction score can be implemented, it must be tested on a large group to assess its strengths and weaknesses • PICC Line Management After a Positive Ultrasound: • In a retrospective study (N=101) of catheter associated UET, it was determined that the duration in which a catheter was left in place did not affect morbidity whether the line was eventually removed or not.14, 15 • If the catheter is no longer necessary, American College of Chest Physicians (ACCP) recommends removal after 3-5 days of starting anticoagulation.5 • If the catheter is necessary, it was suggested to leave it in place and start anticoagulation therapy for three months.11,5, 16 • Immediate indications for removing an indwelling line include: recurring DVT even after starting anticoagulation, catheter malfunction, infection, contraindications to anticoagulation therapy and if the catheter is no longer necessary.11, 5 • Reduction of Upper Extremity Thrombosis by Placement of PICC lines in Basilic and Cephalic Veins: • Placement of PICC lines into basilic and cephalic veins has a lower incidence of deep venous thrombosis. It is suggested that thrombi in the cephalic vein are less likely than thrombi in the basilic vein to propagate into the deep venous system thus less likely to increase the risk of pulmonary embolism.17 • Univariable comparison showed that cephalic insertion of PICC line is associated with a lower incidence of venous thrombosis, but was not demonstrated in a multivariate analysis.17 • . • Ultrasound has been increasingly used to detect venous thrombosis in both the upper and lower extremities in symptomatic patients . It is a potentially advantageous screening tool in detecting upper extremity thrombosis and altering management appropriately. • The risk of developing upper extremity thrombosis is greater in patients with central venous catheters, cardiac pacemakers and defibrillators.1 • Indwelling PICC lines are the single largest risk factor in the development of UE thrombosis.1, 2 • Up to 4% of patients on anticoagulation may still develop venous thrombosis.2, 3 • Classification: • Primary venous thrombosis is not attributable to an underlying condition.1,4Secondary venous thrombi develop in the presence of exogenous or endogenous risk factors. These comprise the majority of upper extremity thrombi and often occur in older patients with multiple co-morbid conditions i.e. indwelling catheters, malignancies, implants and hypercoagulable states.1 • Clinical Features: • Signs and Symptoms are often nonspecific such as extremity swelling, pain, collateral vein enlargement, warmth and tenderness to palpation.5 Compared to thrombi in the lower extremity, upper extremity thrombi often present with fewer symptoms and have a higher mortality outcome.4,6 Venous thrombi in the upper extremity are reported to have a higher three month mortality rate (11%) compared to LEDVTs (7%).1 • Sonographic features often include diminished flow on color Doppler as seen in Figure 3b. The absence of flow and phasicity on color Doppler (as well as subcutaneous edema) is depicted in Figure 4b. • Patients with superficial venous thrombosis (SVT) who also have a history of DVT/PE or SVT in non-varicose veins have an independently higher risk of a underlying DVT than those with isolated SVT. 7 • Relevance: • The impetus to screen patients who are at risk of UET arises from the clinically silent nature of UEV thrombosis, the associated risks, as well as the failure rate of current prophylaxis measures. Upper Extremity Venous Anatomy Normal compressibility, Color Flow and Phasicity Figure 2a Figure 2b Nonocclusive Thrombosis Figure 3a Figure 3b Figure 112 www.iame.com Occlusive Thrombosis Objectives • Understand the classification, etiology and associated complications of upper extremity thrombosis and why screening and treatment are important • Look at current evidence based literature to investigate the utility of ultrasound in screening for upper extremity thrombosis • Discuss options for managing indwelling PICC lines in patients who have upper extremity thrombosis Conclusion • Ultrasound has good sensitivity and specificity in detecting upper extremity thrombosis • Should be interpreted with caution due to small sample sizes and varying methodologies among studies • Technical skill of the examiner plays an important role in the detection of a thrombus; therefore, standardizing user skill across studies will be necessary to calculate more accurate sensitivity and specificity values • If ultrasound is to be recommended as a screening tool for UET inpatients with indwelling PICC lines, both its accuracy as well as the reduction of risk factors should be further investigated • Conduct larger prospective trials with corresponding methodologies for more accurate sensitivity calculation • Develop and test prediction scales on a larger scale. Effective clinical prediction scales can be useful for screening patients based on individual risk • A prospective study is required to determine whether PICC lines in the basilic and cephalic veins are associated with a lower incidence of UET • There is no evidence supporting the immediate removal of PICC lines each time a thrombus is discovered Figure 4a Figure 4b Figure 5a Methods • A literature review was performed to understand the utility of ultrasound in screening for upper extremity venous thrombosis and how patient management is affected upon detection of a thrombus. • The search was performed on PUBMED to find review articles, clinical studies and case reports on upper extremity venous thrombosis and its subsequent management. Key words used were “upper extremity DVT OR thrombosis,” “ultrasound AND upper extremity DVT OR thrombosis,” and “upper extremity thrombosis AND ultrasound AND management”, “superficial venous thrombosis” • 17 articles were selected based on relevancy of the title, abstract and frequency of citation by other articles Figure 6a Figure 6b Figure 5b • Decreased compressibility on ultrasound is one of the strongest indicators of a thrombus (sensitivity 97%, specificity 96%).1 In Figure 2a, normal compressibility of a patent cephalic vein is seen. In Figures 3a, 3b and 4a, there is little change in compressibility due to thrombosis. • Venous thrombosis on duplex ultrasound will be accompanied with signs of decreased flow. Decreased flow is seen with non-occlusive clots (Figure 3b) while complete lack of flow is associated with occlusive clots (Figure 4b). • Currently, there are no universally accepted guidelines for the screening of UE thrombosis in asymptomatic patients due to the lack of high level evidence based studies. • Sensitivity and Specificity: • The sensitivity and specificity ranges for ultrasound in detecting upper extremity thrombosis in current literature is variable; 78-100% (sensitivity) and 82-100% (specificity).8, 9 , 10 • There was much variability in the methods used. The sample sizes were often small and limited to a couple hundred patients even in the largest studies. • . Discussion • As ultrasound is very user dependent, the skill of the individual user can increase or decrease sensitivities and specificities of any trial.1,11 • Challenges to Using Ultrasound in the Upper Extremity: • Decreased compressibility is the most specific sonographic sign for venous thrombosis. • A large percentage of UEDVTs occur in the axillary and subclavian veins, which are harder to assess with ultrasound as they run beneath the clavicle.1 • Acoustic shadowing from the sternum and clavicle make visualization of the vessels difficult and hinder the assessment of venous compressibility. This is observed in Figures 5a and 5b where there is suboptimal visualization of a nonoccluded subclavian vein and poor rendition of blood flow on color overlay. • In comparison, the internal jugular vein is often better visualized due to the absence of overlying osseous structures • A non-occluded internal jugular vein with normal compression is seen in Figure 6a. In Figure 6b, thenormal phasic waveform of the internal jugular vein is seen with color flow overlay. • Acoustic shadowing from the clavicle decreases the specificity of ultrasound in detecting UET and increases the false positive rate to 18%.1,11 References • 1.) Czihal M, Hoffman U. “Upper Extremity Deep Venous Thrombosis” Journal of Vascular Medicine 2011: 16(3) 191-202 • 2.) Joffe H, Kuchner N, et al. “Upper Extremity DVT, a Prospective Registry of 592 Patients” Circulation 2004, 110:1605-1611 • 3.) Schwarcz T, Matthews M et al “Surveillance Venous Duplex Is Not Clinically Useful after Total Joint Arthroplasty When Effective Deep Venous Thrombosis Prophylaxis is Used” Annals of Vascular Surgery 2004: 18: 193-198 • 4.) Martinelli I, Battagioli T et al. “Risk factors and recurrence rate of primary deep vein thrombosis of the upper extremities” Circulation 2004 Aug 3;110(5):566-70. Epub 2004 Jul 19 • 5.) Baskin JL, Pui C et al “Management of occlusion and thrombosis associated with long term indwelling central venous catheters” Lancet 2009 Jul 11: 374(9684): 159 • 6.) Munoz FJ, Mismetti et al. “Clinical Outcome of Patients with UEDVT: results from the RIETE Registry” Chest 2008; 133:143-148 Epub 2007 Oct 9 • 7.) Quere, Isabelle, and Alain Leizorovicz. "Superficial Venous Thrombosis and Compression Ultrasound Imaging." Journal of Vascular Surgery 56.4 (2012): 1032-037. Print • 8.) Di Nisio M and Van Sluis GL. "Accuracy of Diagnostic Tests for Clinically Suspected Upper Extremity Deep Vein Thrombosis: A Systematic Review." Journal of Thrombosis and Haemostasis 8.4 (2010): 684-92 • 9.) Muhammad S et al “Upper Limb Deep Vein Thrombosis: A literature review to streamline the protocol for management “Acta Haematol 2007;118(1):10-8. Epub 2007 Apr 10 • 10.) 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