1. Vascular Causes: DVT/VVI/SVT
Yung-Wei Chi DO
Associate Professor of Medicine
UC Davis Vascular Center

2. Disclosure Statement of Financial Interest
I, Yung-Wei Chi, DO NOT have a financial interest / arrangement or affiliation with one or more organizations that could be perceived as a real or apparent conflict of interest in the context of the subject of this presentation.

3. Agenda
Intra-vascular causes
Extra-vascular causes

4. Vascular Case 25 YO ♀ with:
2 day history of left thigh / calf swelling
Associated mild dyspnea on exertion
4 days prior had arthroscopic surgery of right knee
Past Medical History
- Gronblad - Strandberg Syndrome
- subretinal hemorrhages of left eye
- intermittent claudication bilateral calves
Medications
- OCP

5. Physical Examination Vital signs: Cardiorespiratory exam: Extremities:
BP: 110 / 80 mmHg, P= 104,
SaO2 = 94% (RA), T= 98.6 F
Cardiorespiratory exam:
- normal
Extremities:
- Left thigh and calf 2+ edema, non tender, pedal
pulses palpable bilaterally

6. 25 YO Female

7. Diagnostic Data
Duplex US
MRV

8. Even More Data
CT pulmonary angiography revealed filling defects in right middle lobe pulmonary artery
TTE revealed normal right ventricular function with RVSP of 33 mmHg
EKG revealed sinus tachycardia
NT- pro BNP was 75 ( ). Troponin I (-)
Urine HCG was negative

9. CTPA
Echo: Normal RVSP

11. 12x40 Zilver
10x60 Zilver

12. Venography

13. Post Hospital Course Discharged on solo aspirin
Prompt resolution of leg swelling over several days
Gradual return of vision to pre-morbid state
Duplex ultrasound at
4-weeks showing widely patent stents
Factor VIII and D – 3 months normal –subsequent filter removal

15. Gronblad - Strandberg Syndrome

16. Pseudoxanthoma elasticum
Rare (1:70,000 – 160,000)
Involves skin, eye and cardiovascular
Xanthomas (neck, groin, popliteal fossa)
Symptoms (CAD or PAD)
Diffuse arterial disease with prominent collaterals

17. May - Thurner (MTS) or Cockett’s Syndrome
Virchow sinistral (left - sided) DVT
Dx in 2% - 5% of pts w/ venous dz
Right CIA/compresses the left CIV against lumbar vertebrae
25% of asymptomatic pts > 50% stenosis
3rd - 5th decade of life / women

18. May - Thurner Syndrome

19. Presentation of Upper Extremity Venous Thrombosis
2% - 4% of all venous thromboses
US - incidence of 50,000 cases annually
Involves brachial, axillary and subclavian veins
Signs / Symptoms
Swelling / discoloration
Pain / discomfort in arm, shoulder, neck
Prominent superficial veins (Urschel’s sign)

21. Clinical Sequelae
Pulmonary embolus ~ 12% symptomatic and up to ~ 36% may remain asymptomatic
Venous hypertension  PTS (severe 13%)
Loss of future vascular access or SVC syndrome
Mortality 15% - 50% (underlying etiology)
Recurrence after Tx ~ 2% - 8%

22. Etiologies of Upper Extremity Venous Thrombosis
Primary axillo - SCV thrombosis
(idiopathic or Paget - Schroetter syndrome)
No associated disease or trauma
Exertion - related
Secondary axillo – SCV thrombosis
Recognized cause
2o to central venous catheters (CVC), ICD, pacemakers
Systemic due to malignancy, thrombophilia, trauma

23. Ms SM 48 yo F presented with right upper extremity swelling HPI PMH
Previously well & active
Woke - up with pain & gross swelling of arm
Heavy lifting & mammogram few days prior
Multiple presentations to OSH
Rx as cellulitis
PMH
HTN
Smoker
No VTE (DVT or PE)

24. Duplex Ultrasound

25. Paget - Schroëtter Syndrome
Leopold-von-Schroëtter,
Vienna ( )
Sir James Paget, London
( )

26. Common anomalies
- Young athlete with hypertrophied muscle
- First or clavicular rib
- Musculofascial bands
- Cervical ribs

27. Renal Cell Carcinoma in IVC
The American Journal of Surgery 183 (2002) 292–299

28. Intravascular Synovial Sarcoma Causing DVT
Curr Oncol Oct;22(5):e387-e390

29. Arterial Aneurysm Compression
J Vasc Surg 1988;8:465-9

30. Conclusion: If a DVT smells or sounds FISHY, think other causes!
Thrombosis in atypical locations